(800) 922-9902 dc16info@hsba.com

Claims Review & Appeals

Claims Review Procedures

The information in this section applies to the benefits provided under the Blue Cross Prudent Buyer Network (PPO) and the Blue Cross Advantage Network (APPO) Plans and the Mental Health and Chemical Dependency Plan benefits that are paid directly by the Trust Fund.

The PPO Dental Plan is administered by Delta Dental and the Vision Care Plan is administered by VSP.  You must first complete the claims appeals procedures of Delta Dental or VSP before making a voluntary appeal directly to the Board of Trustees as described in his section.

If you are in Kaiser (HMO), Kaiser/Smart Choices (HMO), DeltaCare USA or UHC Dental, any applicable procedures for filing claims will be described in the Evidence of Coverage booklet provided by Kaiser, DeltaCare USA or UHC Dental. Those organizations also have their own review and appeals procedures, which are described in their materials and which you must follow.

Please note that all questions and appeals regarding eligibility for coverage should be submitted to the Trust Fund Office.

 

Guide to Using This Section for Retirees Eligible for Medicare

or Retirees’ Dependents Eligible for Medicare

If you are enrolled in the Blue Cross Network (PPO) Plan and you are a Retiree eligible for Medicare or a Retiree’s Dependent eligible for Medicare:

  • The claims involving prior approval (pre-service or urgent care claims) and the concurrent claims discussed below apply to you only for vision care.
  • The post-service claims discussed below (claims for health care services already received) do apply to you. Note, however, the following points regarding medical claims:
    • You must submit your post-service medical claims to Medicare before submitting them to the Trust Fund.
    • The Trust Fund will provide medical benefits only as the secondary payer of medical benefits that have been paid primarily by Medicare.
    • The post-service claims procedures discussed below will apply to these secondary-payment benefits.
    • A claim regarding a rescission of coverage will be treated as a Post-Service Claim.

Types of Claims

Pre-service claims: A pre-service claim is a request for authorization of care or treatment that requires approval in whole or in part before the care or treatment is obtained (also called “prior authorization”).

Under this Trust Fund, prior approval of services is required for:

  • non-emergency hospital admissions (unless the stay is for childbirth, in which case no prior approval is required for a stay of up to 48 hours following a vaginal delivery or 96 hours following a cesarean section, or the Trust Fund is the secondary payer of benefits),
  • all inpatient mental health or chemical dependency treatment, and
  • contact lenses to be covered on a “necessary” basis.

If you fail to obtain prior approval for these services, your benefits may be reduced.

Urgent care claims: Your request for a required prior authorization will be considered an urgent care claim if it needs expedited handling—if applying the time frames allowed for a pre-service claim (generally 15 – 30 days for a request submitted with sufficient information) as determined by your Health Care Practitioner:

  • could seriously jeopardize your life or health or your ability to regain maximum function; or
  • in the opinion of a Health Care Practitioner with knowledge of your medical condition, would subject you to severe pain that could not be adequately managed without the care or treatment that is the subject of the claim.

The applicable urgent care claim reviewer, applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine, will determine whether your claim is an urgent care claim. Alternatively, any claim that a Physician with knowledge of your medical condition determines is an urgent care claim within the meaning above will be treated as an urgent care claim.

Concurrent care (ongoing treatment) decisions:  A concurrent care decision is a decision that is reconsidered after an initial approval was made, resulting in a reduction, termination, or extension of a benefit. (For example, an inpatient hospital stay originally prior approved for 5 days is subjected to concurrent review at 3 days to determine if the full 5 days are appropriate.)  In this situation, a decision to reduce, terminate, or extend treatment is made concurrently with the provision of treatment. This category also includes requests by you or your provider to extend care or treatment approved as an urgent care claim.

Post-service claims: Any other type of health care claim is considered a post-service claim—for example, a claim submitted for payment after health care services and treatment have been obtained. A claim regarding rescission of coverage will be treated as a post-service claim.

 

What is NOT a “Claim”

The following are not considered claims and are thus not subject to the requirements and time frames described in this section:

  • Simple inquiries about a Plan’s provisions that are unrelated to any specific benefit claim.
  • A request for an advance determination regarding this Trust Fund’s coverage of a treatment or service that does not require prior authorization.
  • A prescription you present to a pharmacy to be filled. (However, if your request for a prescription is denied, in whole or in part, you may file a claim and appeal regarding the denial by using the procedures in this section).

Filing Claims

Information on how to file claims is included in the chapters covering each Plan of benefit described in this booklet. The information is summarized below.

  • Pre-service claims for hospital admissions not involving mental health or chemical dependency: Have your physician call Anthem Blue Cross at 800-274-7767 to request pre-authorization. If your physician thinks your condition warrants handling of your request as an urgent care claim, make sure the representative who takes your call is advised of this.
  • Pre-service claims for hospital admissions involving mental health or chemical dependency treatment: Call BEAT IT at 800-828-3939 or Anthem Blue Cross at 800-774-7767 to request prior authorization. If your condition warrants handling of your request as an urgent care claim, make sure the representative who takes your call is advised of this.

 

“Urgent Care Claim” Does Not Mean Emergency Care or Care at an Urgent Care Facility

Urgent care claims should not be confused with emergency care or treatment at an urgent care facility, which do not require prior authorization.  See Urgent Care Claims under Types of Claims above for an explanation of when a request for prior authorization might need to be handled as an urgent care claim.

  • Pre-service claims for contact lenses to be covered on a “necessary” basis: VSP providers will have a prior authorization form they can use for this purpose. Non-VSP providers should contact VSP to find out what information they need to submit to VSP.
  • Post-service claims for medical benefits: All claims for medical benefits should be submitted directly to Anthem Blue Cross electronically.  For services rendered outside the state of California, claims should be submitted to the local Blue Cross in the state where the service is rendered.
  • Post-service chiropractic benefits for Kaiser (HMO) and Kaiser/Smart Choices (HMO) participants: if you have received services for chiropractic care, have your provider send the bill to the following address:

District Council 16 Northern California Health and Welfare Trust Fund
4160 Dublin Boulevard, Suite 400
Dublin, CA 94568-7756

  • Post-service claims for prescription drugs: (necessary only if you do not present your WellDyne ID card when you have prescriptions filled or you use a non-participating pharmacy). Send your claim with a prescription receipt (not just a cash register receipt) to the following address:

WellDyne Rx
PO Box 4517
Englewood, Colorado 80155-4517

  • Post-service claims for mental health or chemical dependency benefits: Check with your provider; he or she may submit claims to Anthem Blue Cross or Beat-IT on your behalf. If not, send the claim to the following address:

District Council 16 Northern California Health and Welfare Trust Fund
4160 Dublin Boulevard, Suite 400
Dublin, CA 94568-7756

  • Post-service claims for dental benefits under the PPO Dental Plan: Obtain a claim form from Delta Dental, the Trust Fund Office, or your dentist’s office. After you and your dentist have completed it, it should be sent to the following address:

Delta Dental Plan of California
P.O. Box 7736
San Francisco, CA 94120

  • Post-service health care claims for vision care benefits: No claim form will be necessary if you use a VSP provider. If you use a non-VSP provider, send your Out-of-Network Reimbursement Form (available at vsp.com or 800-877-7195) with your itemized receipt to the following address:

Vision Service Plan
Attn: Out-of-Network Provider Claims
P.O. Box 997105
Sacramento, CA 95899-7105

  • Death Benefit claim. Your beneficiary should contact the Trust Fund Office to obtain a death benefit claim form. The form should be completed and returned with a certified copy of the death certificate.

Using an Authorized Representative

An authorized representative, such as your Spouse, may complete a claim submission for you if you have previously designated the individual to act on your behalf (you can obtain a form from the Trust Fund Office to designate an authorized representative). The Trust Fund may request additional information to verify that this person is authorized to act on your behalf.

In the case of an urgent care claim, a Physician with knowledge of your condition may act on your behalf even without written authorization.

When Claims Must Be Filed

Your claim will be considered to have been filed as soon as it is received by the applicable review authority:  Anthem Blue Cross for pre-service/urgent care claims, and concurrent care decisions involving medical benefits, and post-service claims, BEAT IT for pre-service/urgent care claims, concurrent care decisions and post-service claims involving mental health and chemical dependency benefits, VSP for pre-service claims for necessary contact lenses, the Trust Fund Office for Kaiser chiropractic claims, WellDyne for post-service prescription drug claims, Delta Dental for post-service dental claims, VSP for post-service vision care claims, the Trust Fund Office for life insurance claims.

Pre-service and urgent care claims must be filed before services are obtained. (Remember that an urgent care claim is not to be confused with emergency care or care received at an urgent care facility.)

You must submit all other medical, prescription drug, mental health, chemical dependency, and disability claims within 90 days of the date of service or for disability claims the date of the onset of the disability, and all other vision care claims within 180 days of the date of service. Dental claims must be submitted within 6 months of the date of service. Benefits will not be paid for any claims not filed within 12 months from the later of the date the expense was incurred or the date of payment under another plan that is primary payer.

Claims for death benefits should be submitted to the Trust Fund Office to allow sufficient time for processing within 90 days of the death or as soon thereafter as reasonably possible but not later than one year. Benefits will not be paid for any claims not filed within 12 months from the date of the death.

Notification That Your Pre-Service or Urgent Care Claim Has Not Been Properly Filed

If your pre-service health care claim has been improperly filed, Anthem Blue Cross, BEAT IT, or VSP will notify you as soon as possible but no later than 5 days after receipt of the claim of the proper procedures to be followed in filing a claim.

If your urgent care claim has been improperly filed, Anthem Blue Cross or BEAT IT will notify you as soon as possible but no later than 72 hours after receipt of the claim of the proper procedures to be followed in filing a claim. Unless the claim is re-filed properly, it will not constitute a claim.

You or your provider will receive notice that you have improperly filed your claim only if the claim includes your name, your specific condition or symptom, and a specific treatment, service, or product for which approval is requested. Unless the claim is re-filed properly, it will not constitute a claim.

Timing of Initial Claims Decisions

To ensure that the persons involved with adjudicating medical, prescription drug, and disability claims (effective for disability claims filed on or after April 1, 2018) and appeals (such as claim adjudicators and medical or vocational experts) act independently and impartially, decisions regarding  hiring, compensation, promotion, termination or retention or other similar matters with respect to those individuals, will not be made based upon the likelihood that the individual will support the denial of benefits.  A determination on your claim will be made within the following time frames:

  • Pre-service claims: If your pre-service health care claim has been properly filed, Anthem Blue Cross, BEAT IT, or VSP will notify you of its decision within 15 days from the date your claim is received, unless additional time is needed. The time for response may be extended by up to 15 days if necessary due to matters beyond the control of Anthem Blue Cross, BEAT IT, or VSP. If an extension is necessary, you will be notified before the end of the initial 15-day period of the circumstances requiring the extension and the date by which Anthem Blue Cross, BEAT IT, or VSP expects to make a decision.If an extension is needed because Anthem Blue Cross, BEAT IT, or VSP needs additional information from you, Anthem Blue Cross, BEAT IT, or VSP will notify you as soon as possible, but no later than 15 days after receipt of the claim, of the specific information necessary to complete the claim. In that case you and/or your doctor will have 45 days from receipt of the notification to respond. During the period in which you are allowed to supply additional information, the normal period for making a decision on the claim will be suspended. The deadline is suspended from the date of the extension notice until either 45 days or the date you respond to the request (whichever is earlier). Anthem Blue Cross, BEAT IT, or VSP then has 15 days to make a decision and notify you of the determination.
  • Urgent care claim: You will be notified of a determination by telephone as soon as possible, taking into account the exigencies of your situation, but no later than 72 hours after receipt of the claim by Anthem Blue Cross or BEAT IT. The determination will also be confirmed in writing.If your urgent care claim is received without sufficient information to determine whether or to what extent benefits are covered or payable, Anthem Blue Cross or BEAT IT will notify you as soon as possible, but no later than 72 hours after receipt of the claim, of the specific information necessary to complete the claim. You and/or your doctor must respond to this request within 48 hours. Notice of a decision will be provided no later than 48 hours after Anthem Blue Cross or BEAT IT receives your response, but only if it is received within the required time frame.
  • Concurrent care decision: A reconsideration that involves the termination or reduction of payment for a treatment in progress (other than by Plan amendment or termination) will be made by Anthem Blue Cross or BEAT IT as soon as possible, but in any event early enough to allow you to have an appeal decided before the benefit is reduced or terminated.A request by you to extend approved urgent care treatment will be acted upon by Anthem Blue Cross or BEAT IT within 72 hours of receipt of the claim, provided the claim is received at least 24 hours prior to the expiration of the approved treatment.
  • Post-service claims: Ordinarily, you will be notified of the decision on your post-service health care claim within 30 days of the date the Trust Fund Office, WellDyne, BEAT IT, Delta Dental, or VSP receives the claim. This period may be extended one time by up to 15 days if the extension is necessary due to matters beyond the control of the Trust Fund Office, WellDyne, BEAT IT, Delta Dental, or VSP. If an extension is necessary, you will be notified before the end of the initial 30-day period of the circumstances requiring the extension and the date by which the Trust Fund Office, WellDyne, BEAT IT, Delta Dental, or VSP expects to make a decision.If an extension is needed because the Trust Fund Office, WellDyne, BEAT IT, Delta Dental, or VSP needs additional information from you, the Trust Fund Office, WellDyne, BEAT IT, Delta Dental, or VSP will notify you as soon as possible, but no later than 30 days after receipt of the claim, of the specific information necessary to complete the claim. You and/or your doctor or dentist will have 45 days from receipt of the notification to respond. During the period in which you are allowed to supply additional information, the normal period for making a decision on the claim will be suspended. The deadline is suspended from the date of the extension notice until either 45 days have passed or the date you respond to the request (whichever is earlier). The Trust Fund Office, WellDyne, BEAT IT, Delta Dental, or VSP then has 15 days to make a decision on your post-service claim and notify you of the determination.
  • Death Benefit claims: The Trust Fund will ordinarily make a decision on a claim for death benefits within 90 days of receipt of the claim. This period may be extended by up to 90 days if the extension is necessary due to matters beyond the control of the Trust Fund. If an extension is necessary, you will be notified before the end of the initial 90-day period of the circumstances requiring the extension and the date by which the Trust Fund expects to make a decision.

Denied Claims (Adverse Benefit Determinations)

It is not unusual that some of the charges submitted for a particular claim are not payable by this Trust Fund. Some examples of reasons for denial are: (1) the expense is incurred during a month the Participant is not covered by this Trust Fund, (2) the expense is related to an on-the-job injury, or (3) the expense is not recognized as a Covered Charge under the Plan. Of course, these are not all the possible reasons a claim may be denied; they are only examples.
You will be provided with written notice of an adverse benefit determination, whether your claim is denied in whole or in part. This notice will include the following:

  • identify the claim involved (e.g. date of service, health care provider, claim amount if applicable);
  • state that, upon request and free of charge, the diagnosis code and/or treatment code, and their corresponding meanings, will be provided. However, a request for this information will not be treated as a request for an internal appeal or an external review;
  • the specific reason(s) for the determination, including the denial code and its corresponding meaning as well as any Plan standards used in denying the claim;
  • reference to the specific Plan provision(s) on which the determination is based
  • contain a statement that you are entitled to receive upon request, free access to and copies of documents relevant to your claim;
  • a description of any additional material or information needed to perfect your claim and an explanation of why the material or information is needed
  • a description of the Trust Fund’s internal appeal procedures and external review process and the time limits applicable to such procedures
  • if an internal rule, guideline, protocol, or other similar criterion was relied upon, a copy of the rule, guideline, protocol, or criterion or a statement that it is available upon written request at no charge
  • if the decision was based on the absence of Medical Necessity or the treatment’s being Experimental or Investigational or other similar exclusion, an explanation of the scientific or clinical judgment for the decision, applying the terms of the Plan to your claim, or a statement that such an explanation is available upon written request at no charge;
  • disclose the availability of, and contact information for, any applicable ombudsman established under the Public Health Services Act to assist individuals with internal claims and appeals and external review processes.
  • (Effective for claims filed on or after April 1, 2018) For disability claims, the notice will also include a discussion of the decision, including the basis for disagreeing with or not following:
  1. The views of a treating physician or vocational professional who evaluated the claimant;
  2. The views of medical or vocational experts obtained by the plan, and
  3. Any disability determination by the Social Security Administration.

If you do not understand English and have questions about a claim denial, contact the Trust Fund Office to find out if assistance is available.

  • SPANISH (Español): Para obtener asistencia en Español, llame 800-922-9902.
  • TAGALOG (Tagalog): Kung kailangan niyo ang tulong sa Tagalog tumawag sa 800-922-9902.
  • CHINESE (中文): 如果需要中文的帮助,请拨打这个号码 800-922-9902.
  • NAVAJO (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ 800-922-9902.

For urgent care claims, the notice will describe the expedited review process applicable to urgent care claims. For urgent care claims, the required determination may be provided orally and followed with written notification.

For pre-service and urgent care claims, you will receive notice of the determination even when the claim is approved.

Participants and beneficiaries may request documents and plan instruments regarding whether the plan is providing benefits in accordance with Mental Health Parity and Addiction Equity Act (MHPAEA) and copies must be furnished within 30 days of a request. This may include documentation that illustrates how the health plan has determined that any financial requirement, quantitative treatment limitation, or non-quantitative treatment limitation is in compliance with MHPAEA.

Disability claims: A disability claim is a claim for which the Plan must make a determination of disability in order for the participant to receive the benefit.

Filing Claims

Information on how to file disability claims is summarized below.

Disability claims (effective for claims filed on or after April 1, 2018): Send the claim plus proof of disability to the following address:

District Council 16 Northern California Health and Welfare Trust Fund
4160 Dublin Boulevard, Suite 400
Dublin, CA 94568-7756

When Claims Must Be Filed

You must submit disability claims within 90 days of the date of service or for disability claims the date of the onset of the disability.  Benefits will not be paid for any claims not filed within 12 months from the later of the date the expense was incurred or the date of payment under another plan that is primary payer.

Timing of Initial Claims Decisions

To ensure that the persons involved with adjudicating disability claims (effective for disability claims filed on or after April 1, 2018) and appeals (such as claim adjudicators and medical or vocational experts) act independently and impartially, decisions regarding  hiring, compensation, promotion, termination or retention or other similar matters with respect to those individuals, will not be made based upon the likelihood that the individual will support the denial of benefits.  A determination on your claim will be made within the following time frames:

Disability claims (effective for claims filed on or after April 1, 2018):  Ordinarily, you will be notified of the decision on your disability claim within 45 days of the date the Trust Fund Office receives the claim.  This period may be extended one time by up to 30 days if the extension is necessary due to matters beyond the control of the Trust Fund Office.  If an extension is necessary, you will be notified before the end of the initial 45-day period of the circumstances requiring the extension and the date by which the Trust Fund Office expects to make a decision.

If, prior to the end of this first 30-day extension, the Trust Fund Office determines that due to matters beyond its control a decision cannot be rendered within the first 30-day extension period, the determination period may be extended for up to an additional 30 calendar days provided you are notified prior to the first 30-day extension period of the circumstances requiring the second extension and the date a decision is expected to be rendered.  A Notice of Extension will explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision and the additional information needed to resolve those issues. If the Trust Fund office needs additional information from you to make its decision, you will have at least 45 calendar days to submit the additional information.  During the period in which you are allowed to supply additional information, the normal period for making a decision on the claim will be suspended. The deadline is suspended from the date of the extension notice until either 45 days have passed or the date you respond to the request (whichever is earlier). The Trust Fund Office then has 15 days to make a decision on your post-service claim and notify you of the determination.

Denied Claims (Adverse Benefit Determinations)

It is not unusual that some of the charges submitted for a particular claim are not payable by this Trust Fund. Some examples of reasons for denial are: (1) the expense is incurred during a month the Participant is not covered by this Trust Fund, (2) the expense is related to an on-the-job injury, or (3) the expense is not recognized as a Covered Charge under the Plan. Of course, these are not all the possible reasons a claim may be denied; they are only examples.

You will be provided with written notice of an adverse benefit determination, whether your claim is denied in whole or in part. This notice will include the following:

  • identify the claim involved (e.g. date of service, health care provider, claim amount if applicable);

state that, upon request and free of charge, the diagnosis code and/or treatment code, and their corresponding meanings, will be provided. However, a request for this information will not be treated as a request for an internal appeal or an external review;

  • the specific reason(s) for the determination, including the denial code and its corresponding meaning as well as any Plan standards used in denying the claim;
  • reference to the specific Plan provision(s) on which the determination is based
  • contain a statement that you are entitled to receive upon request, free access to and copies of documents relevant to your claim;
  • a description of any additional material or information needed to perfect your claim and an explanation of why the material or information is needed
  • a description of the Trust Fund’s internal appeal procedures and external review process and the time limits applicable to such procedures
  • if an internal rule, guideline, protocol, or other similar criterion was relied upon, a copy of the rule, guideline, protocol, or criterion or a statement that it is available upon written request at no charge
  • if the decision was based on the absence of Medical Necessity or the treatment’s being Experimental or Investigational or other similar exclusion, an explanation of the scientific or clinical judgment for the decision, applying the terms of the Plan to your claim, or a statement that such an explanation is available upon written request at no charge;
  • disclose the availability of, and contact information for, any applicable ombudsman established under the Public Health Services Act to assist individuals with internal claims and appeals and external review processes.
  • (Effective for claims filed on or after April 1, 2018) For disability claims, the notice will also include a discussion of the decision, including the basis for disagreeing with or not following:
    1. The views of a treating physician or vocational professional who evaluated the claimant;
    2. The views of medical or vocational experts obtained by the plan, and
    3. Any disability determination by the Social Security Administration.

If you do not understand English and have questions about a claim denial, contact the Trust Fund Office to find out if assistance is available.

  • SPANISH (Español): Para obtener asistencia en Español, llame al 800-922-9902.
  • TAGALOG (Tagalog): Kung kailangan niyo ang tulong sa Tagalog tumawag sa 800-922-9902.
  • CHINESE (中文): 如果需要中文的帮助,请拨打这个号码 800-922-9902.
  • NAVAJO (Dine): Dinek’ehgo  shika  at’ohwol  ninisingo, kwiijigo  holne’ 800-922-9902.

Participants and beneficiaries may request documents and plan instruments regarding whether the plan is providing benefits in accordance with Mental Health Parity and Addiction Equity Act (MHPAEA) and copies must be furnished within 30 days of a request. This may include documentation that illustrates how the health plan has determined that any financial requirement, quantitative treatment limitation, or non-quantitative treatment limitation is in compliance with MHPAEA.

Request for Review of an Adverse Benefit Determination

Information on appeals for Indemnity Dental Plan benefits or Vision Care benefits is omitted from the discussion that follows. For Indemnity Dental or Vision claims, you must exhaust the appeals process with Delta Dental or VSP first. (See the materials from Delta Dental or VSP.) You may then file an appeal with the Trust Fund’s Board of Trustees. If your prescription drug claim is denied by WellDyne you should contact the Trust Fund Office.

If you disagree with the decision made on a claim, you may ask for a review (appeal the decision). Your request for review must be made in writing (or by telephone, for urgent care claims appeals).

Appeals of decisions on urgent care claims or concurrent care decisions should be submitted to Anthem Blue Cross or BEAT IT, as applicable. All other appeals of adverse determinations based on benefits or eligibility should be submitted to the Trust Fund Office. You must submit your appeal by the applicable deadline below:

  • within 180 days after you receive the notice of denial for a claim involving health care (or, in the case of a concurrent care decision, within a reasonable time, given the exigencies of your situation); or
  • within 60 days after you receive the notice of denial for other claims.

When appealing, you must state your reason for disputing the denial and furnish any pertinent material not already furnished. You have the right to submit comments, documents, records, and other information in support of your claim for benefits.

Failure to file an appeal that meets the criteria above will constitute a waiver of your right to a review of the denial of your claim.

Please note that a rescission of coverage, whether or not there is an adverse effect on any particular benefit at that time is considered an adverse benefit determination. A rescission of coverage is a cancellation or discontinuance of coverage that has a retroactive effect, except to the extent it is attributable to a failure to timely pay required premiums or contributions.

Review Process

The review process works as follows:

You have the right to review documents relevant to your claim. A document, record, or other information is relevant if it was relied upon in making the decision; it was submitted, considered, or generated in connection with the claim (regardless of whether it was relied upon); it demonstrates compliance with this Trust Fund’s administrative processes for ensuring consistent decision-making; or it constitutes a statement of this Trust Fund’s policy regarding the denied treatment or service. You will be provided reasonable access to such documents or copies of them free of charge upon written request. Such documents will be provided as soon as possible (and sufficiently in advance of the date on which the notice of adverse benefit determination on review is required to be provided) to give you a reasonable opportunity to respond prior to that date. Additionally, before the Plan issues an adverse benefit determination on review based on a new or additional rationale, you will be provided, automatically and free of charge, with any new or additional evidence considered, relied upon, or generated by the Plan (or at the direction of the Plan) in connection with the denied claim and, before the Plan issues an Adverse Benefit Determination on review based on a new or additional rationale, you will be provided, automatically and free of charge, with the rationale.  The rationale will be provided as soon as possible (and sufficiently in advance of the date on which the notice of adverse benefit determination on review is required to be provided) to give you a reasonable opportunity to respond prior to that date.

Upon written request, you will be provided with the identification of medical or vocational experts, if any, that gave advice on your claim, regardless of whether their advice was relied upon.

Your appeal will be decided by an individual or individuals who did not take part in the original claim denial and are not subordinates of the person who originally denied the claim. No deference will be given to the initial adverse benefit determination. The decision will be made on the basis of the record, including such additional documents and comments as may be submitted by you.

The Trust Fund Office will send pre-service claim appeals to an independent review organization before providing all relevant information to the subcommittee of the Board of Appeals that will make the decision.

If your claim involves a medical judgment, a health care professional with training and experience in the relevant field of medicine will be consulted (one who did not take part in the claim denial and who is not the subordinate of such a person).

Notice of Decision on Appeal

You will receive notice of the decision made on your appeal according to the following timetable:

  • Pre-service claims: You will be sent a notice of a decision on review within 30 days of receipt of the appeal by the Trust Fund Office.
  • Urgent care claims: You will be sent a notice of a decision on review within 72 hours of receipt of the appeal by Anthem Blue Cross or BEAT IT.
  • Concurrent care decisions: You will receive notice of a decision on review within a reasonable amount of time for the type of care.
  • Post-service claims: Ordinarily, decisions on appeals will be made at the next regularly scheduled meeting of the Board of Trustees after your request for review is received. However, if your request for review is received at the Trust Fund Office within 30 days of the next regularly scheduled meeting, your request for review may be considered at the second regularly scheduled meeting following receipt of your request. In special circumstances, a delay until the third regularly scheduled meeting following receipt of your request for review may be necessary. If such a delay is necessary, you will be advised in writing of the special circumstances and the date by which a decision will be made. You will be notified of the decision no later than 5 days after it is reached.
  • Disability claims (effective for claims filed on or after April 1, 2018): Ordinarily, decisions on appeals will be made at the next regularly scheduled meeting of the Board of Trustees after your request for review is received. However, if your request for review is received at the Trust Fund Office within 30 days of the next regularly scheduled meeting, your request for review may be considered at the second regularly scheduled meeting following receipt of your request. In special circumstances, a delay until the third regularly scheduled meeting following receipt of your request for review may be necessary. If such a delay is necessary, you will be advised in writing of the special circumstances and the date by which a decision will be made. You will be notified of the decision no later than 5 days after it is reached.
  • Death Benefit claims: Decisions will ordinarily be made within 60 days of receipt of the appeal by the Trust Fund Office. The period for making a decision may be extended by up to 60 days, provided the Trust Fund notifies you, prior to the expiration of the first 60 days, of the circumstances requiring the extension and the date as of which the Trust Fund expects to render a decision.

If Your Appeal is Denied

NOTE:  If your appeal of a decision on an urgent care claim is denied by Anthem Blue Cross or BEAT IT, you may voluntarily resubmit your appeal to the Trust Fund Office under the pre-service claim rules. It will then be reviewed by the appeals subcommittee of the Board of Trustees.

If your appeal is denied, you will receive written notice of that appeal determination including:

  • information that is sufficient to identify the claim involved (e.g. date of service, health care provider, claim amount if applicable);
  • the statement that, upon request and free of charge, the diagnosis code and/or treatment code, and their corresponding meanings, will be provided. However, a request for this information will not be treated as a request for an external review;
  • the specific reason(s) for the adverse appeal review decision, including the denial code and its corresponding meaning and a discussion of the decision, as well as any Plan standards used in denying the claim;
  • reference the specific Plan provision(s) on which the determination is based;
  • a statement that you are entitled to receive upon request, free access to and copies of documents relevant to your claim;
  • a statement that you have the right to bring civil action under ERISA Section 502(a) following the appeal;
  • an explanation of the Plan’s external review process, along with any time limits and information regarding how to initiate the next level of review;
  • if the denial was based on an internal rule, guideline, protocol or similar criterion, a statement will be provided that such rule, guideline, protocol or criteria that was relied upon will be provided free of charge to you, upon request;
  • if the denial was based on medical necessity, experimental treatment, or similar exclusion or limit, a statement will be provided that an explanation regarding the scientific or clinical judgment for the denial will be provided free of charge to you, upon request;
  • the statement that “You and your Plan may have other voluntary dispute resolution options such as mediation. One way to find out what may be available is to contact your local U. S. Department of Labor Office and your State insurance regulatory agency;” and
  • disclosure of the availability of, and contact information for, any applicable ombudsman established under the Public Health Services Act to assist individuals with internal claims and appeals and external review processes.
  • (Effective for claims filed on or after April 1, 2018) For disability appeals, the notice will also include a discussion of the decision, including the basis for disagreeing with or not following:
  1. The view of a treating physician or vocational professional who evaluated the claimant;
  2. The views of medical or vocational experts obtained by the plan, and
  3. Any disability determination by the Social Security Administration.

If you do not understand English and have questions about a claim denial, contact the Trust Fund Office to find out if assistance is available.

  • SPANISH (Español): Para obtener asistencia en Español, llame al 510-864-6444 or 800-922-9902.
  • TAGALOG (Tagalog): Kung kailangan niyo ang tulong sa Tagalog tumawag sa 510-864-6444 or 800-922-9902.
  • CHINESE (中文): 如果需要中文的帮助,请拨打这个号码510-864-6444 or 800-922-9902.
  • NAVAJO (Dine): Dinek’ehgo  shika  at’ohwol  ninisingo, kwiijigo  holne’ 510-864-6444 or 800-922-9902.

The denial of a claim to which the right to review has been waived, or the decision of the Board or its designated appeals committee with respect to a petition for review, is final and binding upon all parties, including the claimant or the petitioner, subject only to any civil action you may bring under ERISA or any External Review rights. Following issuance of the written decision of the Board on an appeal, there is no further right of appeal to the Board or right to arbitration.

If you are not satisfied with the decision made on your appeal, you may file a civil lawsuit in Federal court against the Trust Fund under ERISA. However, no legal action for benefits from this Trust Fund shall be brought unless and until you have

  • submitted a claim for benefits,
  • been notified that the claim is denied (or the claim is deemed denied),
  • filed a timely appeal for review, and
  • been notified in writing that the denial of the claim has been confirmed (or the claim is deemed denied on review).

(“Deemed denied” means that you filed a claim or an appeal and had not received any response by the expiration of the response time allowed for the type of claim.  For medical, prescription drug and disability (effective for claims filed on or after April 1, 2018) claims and appeals, the claim or appeal will not be deemed denied if the plan’s violation was de minimis and did not cause, and is not likely to cause, prejudice or harm to the claimant so long as the plan demonstrates that the violation was for good cause or due to matters beyond the control of the plan, and that the violation occurred in the context of an ongoing, good faith exchange of information with the claimant.  This exception is not available if the violation is part of a pattern or practice of violations.  The Plan must provide a written explanation of the violation within 10 days or receipt of a request.) 

External Review of Claims

This External Review process is intended to comply with the Affordable Care Act (ACA) external review requirements as set forth in Interim Final Regulations implementing the ACA and in Technical Release 2010-01.  For purposes of this section, references to “you” or “your” include you, your covered Dependent(s), and you and your covered Dependent(s)’ authorized representatives; and references to “Plan” include the Plan and its designee(s).

You may seek further, external review by an Independent Review Organization (“IRO”), if your appeal of a health care claim, whether urgent, concurrent, pre-service or post-service claim is denied and it fits within the following parameters:

  • The denial involves medical judgment, including but not limited to, those based on the Plan’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, or a determination that a treatment is experimental or investigational. The IRO will determine whether a denial involves a medical judgment; and/or
  • The denial is due to a Rescission of coverage (retroactive elimination of coverage), regardless of whether the Rescission has any effect on any particular benefit at that time.

External review is not available for any other types of denials, including if your claim was denied due to your failure to meet the requirements for eligibility under the terms of the Plan. In addition, this external review process does not pertain to claims for life/death benefits, AD&D or if your claim was denied due to your failure to meet the requirements for eligibility under the terms of the Plan.

Generally, you may only request external review after you have exhausted the internal claims and appeals process described above. This means that, in the normal course, you may only seek external review after a final determination has been made on appeal.

There are two types of External Claims outlined below: Standard (Non-Urgent) Claims and Expedited Urgent Claims.

External Review of Standard (Non-Urgent) Claims

Your request for external review of a standard (not urgent) claim must be made, in writing, within four (4) months of the date that you receive notice of an Initial Claim Benefit Determination or adverse Appeal Claim Benefit Determination. For convenience, these Determinations are referred to below as an “Adverse Determination,” unless it is necessary to address them separately.

Because the Plan’s internal review and appeals process, generally, must be exhausted before external review is available, in the normal course, external review of standard claims will only be available for Appeal Claim Benefit Determinations.

An external review request on a standard claim should be made to the Trust Fund Office.

Preliminary Review of Standard Claims

Within five (5) business days of the Plan’s receipt of your request for an external review of a standard claim, the Plan will complete a preliminary review of the request to determine whether:

  1. You are/were covered under the Plan at the time the health care item or service is/was requested or, in the case of a retrospective review, were covered under the Plan at the time the health care item or service was provided;
  2. The Adverse Determination does not relate to your failure to meet the requirements for eligibility under the terms of the Plan or to a denial that is based on a contractual or legal determination; or to a failure to pay premiums causing a retroactive cancellation of coverage;
  3. You have exhausted the Plan’s internal claims and appeals process (except, in limited, exceptional circumstances when under the regulations the claimant is not required to do so); and
  4. You have provided all of the information and forms required to process an external review.

Within one (1) business day of completing its preliminary review, the Plan will notify you in writing as to whether your request for external review meets the above requirements for external review. This notification will inform you:

  1. If your request is complete and eligible for external review; or
  2. If your request is complete but not eligible for external review, in which case the notice will include the reasons for its ineligibility, and contact information for the Employee Benefits Security Administration (toll-free number 866-444-EBSA (3272)).
  3. If your request is not complete (incomplete), the notice will describe the information or materials needed to complete the request, and allow you to perfect (complete) the request for external review within the four (4) month filing period, or within a 48-hour period following receipt of the notification, whichever is later.

Review of Standard Claims by an Independent Review Organization (IRO)

If the request is complete and eligible for an external review, the Plan or appropriate Plan designee will assign the request to an IRO. (Note that the IRO is not eligible for any financial incentive or payment based on the likelihood that the IRO would support the denial of benefits.  The Plan may rotate assignment among IROs with which it contracts.)  Once the claim is assigned to an IRO, the following procedure will apply:

  1. The assigned IRO will timely notify you in writing of the request’s eligibility and acceptance for external review, including directions about how you may submit additional information regarding your claim (generally, you are to submit such information within ten (10) business days).
  2. Within five (5) business days after the external review is assigned to the IRO, the Plan will provide the IRO with the documents and information the Plan considered in making its Adverse Determination.
  3. If you submit additional information related to your claim to the IRO, the assigned IRO must, within one (1) business day, forward that information to the Plan. Upon receipt of any such information, the Plan may reconsider its Adverse Determination that is the subject of the external review. Reconsideration by the Plan will not delay the external review. However, if upon reconsideration, the Plan reverses its Adverse Determination, the Plan will provide written notice of its decision to you and the IRO within one (1) business day after making that decision. Upon receipt of such notice, the IRO will terminate its external review.
  4. The IRO will review all of the information and documents timely received. In reaching a decision, the IRO will review the claim de novo (as if it is new) and will not be bound by any decisions or conclusions reached during the Plan’s internal claims and appeals process. However, the IRO will be bound to observe the terms of the Plan to ensure that the IRO decision is not contrary to the terms of the Plan, unless the terms are inconsistent with applicable law. The IRO also must observe the Plan’s requirements for benefits, including the Plan’s standards for clinical review criteria, medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit.In addition to the documents and information provided, the assigned IRO, to the extent the information or documents are available and appropriate, may consider additional information, including information from your medical records, recommendations or other information from your treating (attending) health care providers, other information from you or the Plan, reports from appropriate health care professionals, appropriate practice guidelines and applicable evidence-based standards, the Plan’s applicable clinical review criteria and/or the opinion of the IRO’s clinical reviewer(s).
  5. The assigned IRO will provide written notice of its final external review decision to you and the Plan or appropriate Plan designee within 45 days after the IRO receives the request for the external review.
    1.     If the IRO’s final external review reverses the Plan’s Adverse Determination, upon the Plan’s receipt of the notice of such reversal, the Plan will immediately provide coverage or payment for the reviewed claim. However, even after providing coverage or payment for the claim, the Plan may, in its sole discretion, seek judicial remedy to reverse or modify the IRO’s decision.
    2. If the final external review upholds the Plan’s Adverse Determination, the Plan will continue not to provide coverage or payment for the reviewed claim. If you are dissatisfied with the external review determination, you may seek judicial review as permitted under ERISA Section 502(a).
  6. The assigned IRO’s decision notice will contain:
    1. A general description of the reason for the request for external review, including information sufficient to identify the claim (including the date or dates of service, health care provider, claim amount (if applicable), diagnosis code and its corresponding meaning, and treatment code and its corresponding meaning, and reason for the previous denial);
    2. The date that the IRO received the request to conduct the external review and the date of the IRO decision;
    3. References to the evidence or documentation considered in reaching its decision, including the specific coverage provisions and evidence-based standards;
    4. A discussion of the principal reason(s) for the IRO’s decision, including the rationale for its decision and any evidence-based standards that were relied on in making the decision;
    5. A statement that the IRO’s determination is binding on the Plan (unless other remedies may be available to you or the Plan under applicable State or Federal law);
    6. A statement that judicial review may be available to you; and
    7. Current contact information, including phone number, for any applicable office of health insurance consumer assistance or ombudsman established under the Affordable Care Act to assist with external review processes.
    8. The IRO will also provide the Notice in Spanish, upon request.

External Review of Expedited Urgent Care Claims

You may request an expedited external review if:

  1. you receive an adverse Initial Claim Benefit Determination that involves a medical condition for which the timeframe for completion of an expedited internal appeal would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function, and you have filed a request for an expedited internal appeal; or
  2. you receive an adverse Appeal Claim Benefit Determination that involves a medical condition for which the timeframe for completion of a standard external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function; or, you receive an adverse Appeal Claim Benefit Determination that concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, but you have not yet been discharged from a facility.

Preliminary Review for an Expedited Claim

Immediately upon receipt of the request for expedited external review, the Plan or appropriate Plan designee will complete a preliminary review of the request to determine whether the requirements for preliminary review are met (as described under Standard claims above). The Plan or appropriate Plan designee will immediately notify you (e.g. telephonically) as to whether your request for review meets the preliminary review requirements, and if not, will provide or seek the information (also described under Standard Claims above).

Review of Expedited Claim by an Independent Review Organization (IRO)

Following the preliminary review that a request is eligible for expedited external review, the Plan or appropriate Plan designee will assign an IRO (following the process described under Standard Review above). The Plan or appropriate Plan designee will expeditiously (e.g. meaning via telephone, courier, overnight delivery, etc.) provide or transmit to the assigned IRO all necessary documents and information that it considered in making its Adverse Determination.

The assigned IRO, to the extent the information or documents are available and the IRO considers them appropriate, must consider the information or documents described in the procedures for standard review, (described above under Standard Claims). In reaching a decision, the assigned IRO must review the claim de novo (as if it is new) and is not bound by any decisions or conclusions reached during the Plan’s internal claims and appeals process. However, the IRO will be bound to observe the terms of the Plan to ensure that the IRO decision is not contrary to the terms of the Plan, unless the terms are inconsistent with applicable law.

The IRO also must observe the Plan’s requirements for benefits, including the Plan’s standards for clinical review criteria, medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit.

The IRO will provide notice of their final expedited external review decision, in accordance with the requirements, set forth above under Standard Claims, as expeditiously as your medical condition or circumstances require, but in no event more than seventy-two (72) hours after the IRO receives the request for an expedited external review.  If the notice of the IRO’s decision is not in writing, within forty-eight (48) hours after the date of providing that notice, the IRO must provide written confirmation of the decision to you and the Plan.

  1. If the IRO’s final external review reverses the Plan’s Adverse Determination, upon the Plan’s receipt of the notice of such reversal, the Plan will immediately provide coverage or payment for the reviewed claim.  However, even after providing coverage or payment for the claim, the Plan my, in its sole discretion, seek judicial remedy to reverse or modify the IRO’s decision.
  2. If the final external review upholds the Plan’s Adverse Determination, the Plan will continue not to provide coverage or payment for the reviewed claim.   If you are dissatisfied with the external review determination, you may seek judicial review as permitted under ERISA Section 502(a).

Limitation on When a Lawsuit may be Started

You or any other claimant may not start a lawsuit or other legal action to obtain Plan benefits, including proceedings before administrative agencies, until after all administrative procedures have been exhausted (including this Plan’s claim appeal review procedures described in this document) for every issue deemed relevant by the claimant, or until 90 days have elapsed since you filed a request for appeal review if you have not received a final decision or notice that an additional 60 days will be necessary to reach a final decision.

No lawsuit may be started more than three years after the end of the year in which services were provided.

Discretionary Authority for Plan Benefit Interpretation, Administration and Operation

The Board of Trustees of the Trust Fund is the named fiduciary with the authority to control and manage the operation and administration of the Trust Fund. The Board shall make such rules, interpretations, and computations and take such other actions to administer the Plans of Benefits offered by the Trust Fund as the Board, in its sole discretion, may deem appropriate. The rules, interpretation, computations, and actions of the Board shall be binding and conclusive on all persons. The Board of Trustees, and/or persons appointed by the Board of Trustees, shall have full discretionary authority to determine eligibility for benefits and to construe terms of the Plans of Benefits payable, and any rules adopted by the Board of Trustees.

The Trust Fund recognizes that new technologies may develop which are not specifically addressed. The Trust Fund reserves the right to determine whether or not a service or supply is covered, and if covered, to determine Allowed Charges. If a Participant selects a more expensive service or supply than is customarily provided, or specialized techniques rather than standard procedures, the Trust Fund reserves the right to consider alternate professionally acceptable services and supplies as the basis for benefit consideration.

The Board of Trustees may engage such Employees, accountants, actuaries, consultants, investment managers, attorneys and other professionals or other persons to render advice and/or perform services with regard to any of its responsibilities under the Trust Fund, as it shall determine to be necessary and appropriate.

Facility of Payment

If the Plan Administrator or its designee determines that you cannot submit a claim or prove that you or your covered Dependent paid any or all of the charges for health care services that are covered by this Trust Fund because you are incompetent, incapacitated or in a coma, this Trust Fund may, at its discretion, pay Plan benefits directly to the Health Care Provider(s) who provided the health care services or supplies, or to any other individual who is providing for your care and support.  Any such payment of Trust Fund benefits will completely discharge this Trust Fund’s obligations to the extent of that payment.  Neither this Trust Fund, the Plan Administrator, Trust Fund Office, nor any other designee of the Plan Administrator will be required to see to the application of the money so paid.