FILING A CLAIM

Time Limits

You, your eligible dependent or an authorized representative may request plan benefits by filing a claim with the Fund Office within 1 year from the date on which a claim arose, namely the date that health benefits or services were incurred, the date of disability with respect to weekly income benefits or the date of death with respect to death benefits. The deadline may be earlier for specific benefits as described in the applicable benefit sections of the Summary Plan Description. The deadline is later for Cafeteria Benefits

Claim Determinations

If you make a claim for benefits that is denied, you must receive notification in writing in accordance with the requirements for Urgent Care, Concurrent Service, Pre-Service, Post-Service, Disability and Death Claims as explained below. If your claim is denied because more information is needed to make a decision, you must be notified of what information is needed.

Please note that Blue Cross is also subject to the time restrictions below with respect to medical benefits administered by Blue Cross. You should notify the Fund Office in the event that your claim with Blue Cross is not processed in a timely fashion.

Urgent Care Claims

An urgent care claim is involved if, in the opinion of your physician, you would be subject to severe unmanageable pain absent the care or treatment for which you are claiming coverage. An urgent care claim is also involved if your life or health would be seriously jeopardized if the Plan’s determination with respect to your claim were made in the time period allowed for non-urgent treatment decisions.

You will be notified of the Plan’s benefit determination as soon as possible, taking into account the medical emergencies of the case, but not later than 72 hours after receipt of the claim by the Plan, unless the claimant (or representative of the claimant) fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan. In the case of such failure, you will be notified as soon as possible, but not later than 24 hours after receipt of the claim by the Plan, of the specific information necessary to complete the claim. The claimant shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. The Plan Participant will be notified of the Plan’s benefit determination as soon as possible, but in no case later than 48 hours after the earlier of the Plan’s receipt of the specified information, or the end of the period afforded the claimant to provide the specified additional information.

Concurrent Care Decisions

Concurrent care decisions are those that are made in connection with an approved course of treatment that is provided over a period of time or through a number of treatments. You will be notified of any reduction or termination involving concurrent care or ongoing treatment with sufficient time to allow you to appeal the reduction or termination before it is implemented. Special rules apply where the Plan has approved an ongoing course of treatment either for a specific period of time or for a specific number of treatments.

A reduction or termination of the course of treatment before the approved time period or number of treatments will be considered a claim denial, except if it occurs due to a Plan amendment or termination. In this case, a Plan Participant will be notified in advance so that the claimant can appeal the decision before the benefit is reduced or terminated.

The claimant may request to extend the course of treatment beyond the approved time period or number of treatments. If this involves urgent care, the Plan will notify the Plan Participant whether the claimant’s request has been approved or rejected within 24 hours of receiving the claimant’s request, as long as the claimant makes the request at least 24 hours before the approved time period for reduction or number of treatments expires.

Pre-Service Claims

A “pre-service claim” is any claim or request for approval of a benefit with respect to which the terms of the Plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care.

A Plan Participant will be notified of the Plan’s benefit determination within a reasonable period of time appropriate to the circumstances, taking into account any pertinent medical circumstances, but not later than 15 days after receipt of the claim by the Plan. This period may be extended by the Plan for up to 15 days provided that the extension is necessary due to matters beyond the control of the Plan and the claimant is notified prior to the expiration of the initial 15-day period. The notice to the Plan Participant will state the reason for the extension and the date by which the Plan expects to render a decision. If the extension is necessary due to the failure of the claimant to submit the information necessary to decide the claim, the notice of extension must describe the required information. The Plan Participant will then have 45 days from receipt of the notice within which to provide the specific information.

In the case of a failure by a claimant or an authorized representative of a claimant to follow the Plan’s procedures for filing a pre-service claim, the Plan Participant or representative shall be notified of the failure and the proper procedures to be followed in filing a claim for benefits. This notification shall be provided to the Plan Participant or representative as soon as possible, but not later than 5 days (24 hours in the case of a failure to file a claim properly involving urgent care) following the failure. Notification may be oral, unless the Plan Participant or authorized representative request written notification.

Post-Service Claims

“Post-service claims” are any claims that are not pre-service claims. A Plan Participant will be notified of the Plan’s benefit determination with a reasonable period of time appropriate to the circumstances, taking into account any pertinent medical circumstances, but not later than 30 days after receipt of the claim by the Plan. This period may be extended by the Plan for up to 15 days provided that the extension is necessary due to matters beyond the control of the Plan and the claimant is notified prior to the expiration of the initial 30-day period. The notice to the Plan Participant will state the reason for the extension and the date by which the Plan expects to render a decision. If the extension is necessary due to the failure of the claimant to submit the information necessary to decide the claim, the notice of extension must describe the required information. The claimant will then have 45 days from receipt of the notice within which to provide the specified information.

Disability Benefits

Notification of denied claims with regard to disability benefits shall occur within a reasonable period of time, but no later than 45 days after receipt of the claim. The processing period may be extended by up to 60 days by notice to a claimant. You are also notified of any extension including the reason why the extension is necessary and the date by which the Plan expects to make a decision, prior to the expiration of the initial 45-day period. The notice will explain the standards used by the Plan in determining whether a Plan Participant is entitled to a disability benefit, the unresolved issues preventing a decision on your claim, and any additional information needed to resolve those issues. If the additional extension is due to the need for more information, you will have 45 days in which to provide the additional information.

Death Benefits

Notification of denied claims with regard to death benefits shall occur within 90 days of the date the claim was filed. If special circumstances require an extension of time for processing the claim, written notice of this extension of time will be sent to the claimant within the initial 90-day period. Such extension will not exceed 180 days from the date the claim is filed.

Manner And Content Of Notification Of Benefit

Determination

If the Plan issues a benefit denial, the denial will be in writing to the Plan Participant in plain language. In the case of a benefit denial involving a claim for urgent care, the information may be provided to the Plan Participant orally within the time frame prescribed, with a written or electronic notification furnished to the Plan Participant not later than 3 days after such oral notification, and a description of the expedited review process applicable to such claims will be provided.

Appealing A Denied Claim

You may appeal a benefit denial in writing within 180 days after you receive the denial. You have the right to have the Plan Administrator review and reconsider your claim.

Any appeal that does not involve urgent care must be in writing, and can be made by you or a duly authorized representative. It must set out the reasons for the appeal and your dissatisfaction or disagreement with the original determination. Any evidence, comments, or documentation to support your position should be submitted with your written appeal.

Upon request and free of charge, you will be afforded reasonable access to, and copies of, all documents, records, and other information relevant to the claim. A claim review on appeal will not afford deference to the initial adverse benefit determination. The review will be conducted by an appropriately named fiduciary who is neither the individual nor subordinate of the individual who made the initial adverse determination. All comments, documents, records, and other information submitted by the claimant relating to the claim will be considered on appeal, regardless of whether or not such information was submitted or considered in the initial adverse benefit determination.

If an appeal involves medical judgment, including determinations with regard to medical necessity and whether a particular treatment, drug, or other item is experimental or investigational, the Board of Administration will consult with an independent health care professional with appropriate training and experience in the field of medicine involved. This health care professional will be someone who was neither an individual who was consulted in the initial adverse benefit determination or the subordinate of such individual. All medical or vocational experts whose advice was obtained in the initial adverse benefit determination will be identified by the Plan, regardless of whether or not the individual’s advice was relied upon in making the initial adverse benefit determination.

Notice of the Plan’s decision on review may be provided in written or electronic form and will contain the reason for the adverse determination, reference to specific plan provisions on which the determination was based (including any internal rule or guideline relied upon in making the determination), and a statement that the claimant is entitled to receive upon request and free of charge reasonable access to, and copies of, all documents, records, and other information relevant to the claim for benefits.

If the adverse benefit determination is based on medical necessity or experimental treatment or similar exclusion or limit, the Plan’s notice on review will contain either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the claimant’s medical circumstances, or a statement that such explanation will be provided free of charge upon request.

If you submit a claim to Blue Cross and disagree with the decision by Blue Cross, you must first appeal to Independence Blue Cross or Pennsylvania Blue Shield directly. Blue Cross is also subject to the requirements for Urgent Care, Concurrent Service, Pre-Service, and Post-Service Appeals as explained below. You should notify the Fund Office in the event that your appeal with Blue Cross is not processed in a timely fashion.

You may continue to work with Blue Cross in accordance with the Blue Cross procedures. However, you must also file an appeal directly with the Plan after you have completed one level of appeal with Blue Cross or if Blue Cross does not process your appeal on a timely basis. You do not have to exhaust all Blue Cross or Blue Shield procedures or state insurance remedies in order to file a lawsuit under ERISA.

The Plan may request additional information to clarify any matters it deems appropriate. The time period in which the Plan will review your appeal and notify you of its decision varies depending on the type of treatment or services to which your appeal relates as follows:

Urgent Care Appeals

In case of urgent care, there is an expedited review process where you can call or write the Plan Administrator and where all necessary information regarding the review will be provided to you promptly. You will be notified of a decision on appeal with respect to a claim involving urgent care as soon as possible but no later than 72 hours after the appeal request has been received.

Concurrent Care Appeals

In case of concurrent care decisions, you will be notified of a decision on appeal with respect to a claim involving concurrent care prior to the termination of the benefit if the appeal is received prior to such event, or within a reasonable period of time but no later than 30 days after the appeal request has been received if the benefit has been terminated.

Pre-Service Appeals

You will be notified of a decision on appeal with respect to a pre-service claim within a reasonable period of time but no later than 30 days after the appeal request has been received.

Post-Service Appeals

You will be notified of a decision on appeal with respect to a post-service claim within a reasonable period of time but no later than 60 days from the date the request has been received.

Disability Benefit Appeals

You will be notified of a decision on appeal with respect to a claim involving disability benefits within a reasonable period of time but no later than 45 days from the date the request has been received.

Death Benefit Appeals

The Board of Administration normally will consider an appeal of a death benefit claim determination at their regular meeting scheduled at least 30 days after the appeal is received absent other notice. Special circumstances may require an extension of time for consideration of an appeal to no later than the third meeting of the Board following the Plan’s receipt of the review request. You will be notified in writing of any such extension prior to the commencement of the extension. This notice will include the special circumstances for which the extension is required and the date by which the Plan expects to render a decision on the appeal. You will be notified of the Plan’s decision on appeal in writing as soon as possible but not later than 5 days after the determination is made.

Manner And Content Of Notification Of Benefit

Determination On Review

In the event that an appeal is denied, the claimant will be notified electronically or in writing. If the Plan Administrator fails to follow the claims appeals procedures as outlined above, you will have the right to bring a civil action in court.

The Board of Administration can establish rules and regulations for administration of the Plan consistent with its obligations. The Board of Administration’s construction, interpretation or application of the Plan and Plan documents, including factual determinations and eligibility determinations, is final, conclusive and binding on all persons.

The Board of Administration makes the final decisions on participant benefit eligibility and on claims for benefits paid by the Plan.

Lawsuits And Limitations Period

A claimant who is dissatisfied with an eligibility determination or benefit awarded, or who is otherwise adversely affected by any action of the Board must exhaust the Plan remedies before any lawsuit. The Plan has no voluntary mediation or arbitration procedures and is not subject to nor bound by arbitration awards under collective bargaining agreements. A claimant who has exhausted Plan remedies may proceed with a lawsuit in accordance with federal law.

The Plan has a uniform three (3) year limitations period on lawsuits, regardless of the state in which the lawsuit is filed, except to the extent that a uniform and controlling federal statute of limitation applies to a claim for benefits under the Plan or prohibited by law. This rule applies to any administrative proceedings, arbitration, lawsuit or other legal action on such a claim or other action or for any amount claimed to be payable from the Plan or its fiduciaries in connection with a claim or other action (including without limitation, monetary remedies or awards for failure to respond to a request for documents or retroactive payments) against the Plan or its fiduciaries.

The limitations period ends three (3) years after the date of a service, delivery of a product, or other event (including, without limitation, a date of death or disability or a request for plan documents) giving rise to a claim for payment or reimbursement from the Plan or its fiduciaries. Notwithstanding the general rule, no administrative proceedings, arbitration, lawsuit or other legal action amount shall be instituted after the last day on which the Participant or Plan can sue an insurer or other claims administrator handling or paying any benefit under the Plan and no amount shall be payable from the Plan or its fiduciaries on any such barred claim.