• SPD Table of Contents
  1. Important Contact Information
  2. Introduction
  3. Table of Contents
  4. Plan A Schedule of Benefits
  5. Plan B Schedule of Benefits
  6. Plan C Schedule of Benefits
  7. Plan 11 Schedule of Benefits
  8. Plan 11-C Schedule of Benefits
  9. Eligibility for Active Participants
  10. Eligibility for Retiree Coverage
  11. Insurance Coverage
  12. Weekly Loss of Time Benefit
  13. Medical Benefits
  14. Prescription Drug Program
  15. Medicare Part D Prescription Drug Plan (PDP) for Retirees
  16. Members Assistance Program (MAP)
  17. Dental Benefit
  18. Vision Benefit
  19. Hearing Benefit
  20. Special Fund Program
  21. General Plan Exclusions and Limitations
  22. Other Limitations on Your Benefits
  23. Definitions
  24. Claim and Appeal Procedures
  25. General Plan Provisions
  26. Information About the Plan
  27. Board of Trustees

Claim and Appeal Procedures

CLAIM FILING PROCEDURES

In order for the Plan to pay benefits, a claim must be filed with the Fund Office or the claims office designated for receiving claims in accordance with the procedures described below. A claim can be filed by the provider, you, your eligible dependent or by someone authorized to act on behalf of you or your eligible dependent.

1. A claim is considered to have been filed on the date it is received at the correct office, even if the claim is incomplete. Claims are received during regular business hours, Monday through Friday.
2. A “claim” is a request for Plan benefits, normally because the claimant has incurred a healthcare expense. A request for confirmation of Plan coverage is not a claim if you have not yet incurred the expense unless the Plan conditions payment on the receipt of prior approval. A general inquiry about eligibility or coverage when no expense has been incurred is not a claim, nor is presenting a prescription to a pharmacy.
3. Most claims must be filed before the end of the calendar year following the year in which the claim was incurred. Life and AD&D insurance claims must be filed within 90 days of the loss.
4. You may designate another person as your authorized representative for purposes of filing a claim. Except in the case of an urgent care claim, such designations must be in writing.
   • Unless your authorization states otherwise, all notices regarding your claim will be sent to your authorized representative and not to you.
   • A routine assignment of benefits so that the Plan will pay the provider directly is not a designation of the provider as your authorized representative. You have no right to assign any interest in your benefits or any right to recover benefits to any person, including a provider, and a provider is not a beneficiary under the Plan. All claims, internal or external appeals and judicial appeals must be brought in the name of the participant or beneficiary who incurred the claim.

WHERE TO SEND CLAIMS

Claims Offices

Prescription Drug Claims Sav-Rx OON Claims

In most cases you will not need to file prescription drug claims, but if you 224 North Park Avenue have a special situation, send your claim to Sav-Rx. Fremont, NE 68025

Group / Plan No. IBEW701

CLAIM AND APPEAL PROCEDURES

WHERE TO SEND CLAIMS

Claims Offices

CLAIM PROCESSING TIME PERIODS

The amount of time the applicable Plan can take to process a claim depends on the type of claim. A claim can fall into one of the following categories:

1. A claim is “post-service” if you have already received the treatment or supply for which payment is now being requested. Most claims are post-service claims.
2. A “disability claim” is a claim for Weekly Loss of Time Benefits.
3. A “pre-service claim” is a request for pre-authorization of a type of treatment or supply that requires approval in advance of obtaining the care.
4. An “urgent care claim” is a pre-service claim where the application of the time periods for making nonurgent care determinations could seriously jeopardize your life, health, or ability to regain maximum function, or that could subject you to severe pain that cannot be adequately managed without the proposed treatment.
5. A “concurrent care claim” is also a type of pre-service claim. A claim is a concurrent care claim if a request is made to extend a course of treatment beyond the period of time or number of treatments previously approved.

If all the information needed to process your claim is provided to the claims office, your claim will be processed as soon as possible. However, the processing time needed will not exceed the time frames allowed by law, which are as follows:

• Post-service claims – 30 days.
• Disability claims – 45 days.
• Pre-service claims – 15 days.

6. 6. Urgent care claims – 72 hours.Full-time supervision by at least one physician;
7. 24-hour nursing service by registered nurses;
8. Surgery or formal arrangements for available surgical facilities; and

• Therapeutic
• Concurrent care claims – 24 hours if the concurrent care is urgent and if the request for the extension if made within 24 hours prior to the end of the already authorized treatment. If the concurrent care is not urgent, then the pre-service time limits apply.

When Additional Information Is Needed (Claimant Extension)

If additional information is needed from you, your doctor or the provider, the necessary information or material will be requested in writing. If the request goes to your provider, you will receive a copy of the request. The request for additional information will be sent within the normal time limits shown above, except that the additional information needed to decide an urgent care claim will be requested within 24 hours.

It is your responsibility to see that the missing information is provided to the claims office. The normal processing period will be extended by the time it takes you to provide the information, and the time period will start to run once the claims office has received a response to its request. If you do not provide the missing information within 45 days (48 hours for an urgent care claim), the claims office will make a decision on your claim without it, and your claim could be denied as a result.

Plan Extension

The time periods above may be extended if the claims office determines that an extension is necessary due to matters beyond its control (but not including situations where it needs to request additional information from you or the provider). You will be notified prior to the expiration of the normal approval/denial time period if an extension is needed. If an extension is needed, it will not last more than:

• Post-service claims – 15 days.
• Disability claims – 30 days (a second 30-day extension may be needed in special circumstances).
• Pre-service claims – 15 days.

Claim Denials

If all or a part of your claim is denied after the claims office has received all other necessary information from you, you will be sent a written notice giving you the reasons for the denial. The notice will include reference to the Plan provisions on which the denial was based and an explanation of the claim appeal procedure. If applicable, it will give a description of any additional material or information necessary for you to perfect the claim, and the reason such information is necessary. The notice will provide a description of the appeal procedures and the applicable time limits for following the procedures. It will also include a statement concerning your right to bring a civil action under section 502(a) of ERISA. In cases where the Plan relied upon an internal rule, guideline, protocol or similar criterion to make its decision, the notice will state that the specific internal rule, guideline, protocol or criterion will be provided to you free of charge upon request. If the decision was based on medical necessity or if the treatment was deemed experimental, the notification will include either an explanation of the scientific or clinical judgment for the determination or a statement that such explanation will be provided free of charge upon request. For urgent claims, a description of the Plan's expedited review process will be provided.

CLAIM APPEAL PROCEDURE

Internal Appeals

If your claim has been denied in whole or in part, you may request a full and fair review (also called an “appeal”) by filing a written notice of appeal with the Plan.

1. A notice of appeal must be received at the applicable claims office not more than 180 days after you receive the written notice of denial of the claim. Your appeal is considered to have been filed on the date the written notice of appeal is received at the claims office.
2. For post-service claims and disability claims, the Review Committee will be the Board of Trustees or a committee of the Board of Trustees. Mail your written request for review to the Board of Trustees, IBEW Local 701 Welfare Fund, Fund Office, 28600 Bella Vista Parkway, Suite 1110, Warrenville, IL 60555.
3. For all pre-service claims, the Review Committee will be the Plan’s utilization review organization (MedCare Management, Inc.). You may orally request a review of a denied urgent care claim by calling MedCare at 1-800-367-1934, or you may submit your request in writing to Med-Care Management, Inc. at P.O. Box 20564, West Palm Beach, FL 33416-0564. Med-Care may notify you of its decision by telephone or facsimile. If you are not satisfied with the appeal decision made by Med-Care, you can request that the Board of Trustees conduct a second review of the claim.
4. The Review Committee will not include the person, or a subordinate of the person, who made the original claim denial.
5. If you wish, another person may represent you in connection with an appeal. If another person claims to be representing you in your appeal, the Review Committee has the right to require that you give the Plan a signed statement, advising the Review Committee that you have authorized that person to act on your behalf regarding your appeal. Any representation by another person will be at your own expense. You (and your authorized representative, if any) may request to appear in person before the Review Committee. If the Trustees grant your request, you and your representative’s appearance must be at your own expense.
6. You or your authorized representative may review pertinent documents and may submit comments and relevant information in writing.
   • Upon written request, the claims office will provide reasonable access to, and copies of, all documents, records or other information relevant to your claim.
   • If the claims office obtained an opinion from a medical or vocational expert in connection with your claim, the claims office will, on written request, provide you with the name of that expert.
   • The claims office will not charge you for copies of documents you request in connection with an appeal.
7. In deciding your appeal, the Review Committee will consider all comments and documents that you submit, regardless of whether that information was available at the time of the original claim denial. The review will not defer to the initial denial, and will take into account all comments, documents, records and other information submitted by you, without regard to whether such information was previously submitted or relied upon in the initial determination.
8. If an appeal involves a medical judgment, such as whether treatment is medically necessary, the Review

Committee will consult with a medical professional who is qualified to offer an opinion on the issue. If a medical professional was consulted in connection with the original claim denial, the Review Committee will not consult with the same medical professional (or a subordinate of that person) for purposes of the appeal.

Notification Following Internal Appeal

• If your appeal is for an urgent care claim, you will be notified of the decision about your appeal as soon as possible, taking into account the circumstances, but not later than 72 hours after receipt of your request for review. In the case of non-urgent pre-service claims, you will be notified no later than 30 days after receipt of your request for review. • A review and determination for disability and post-service claims will be made no later than the date of the meeting of the Trustees that immediately follows the Plan’s receipt of a request for review. The Review Committee meets on a monthly basis. However, if the request is filed within 30 days preceding the date of such meeting, a determination may be made by no later than the date of the second meeting.
• If special circumstances (such as the need to hold a hearing) require a further extension of time, a determination will be made not later than the third meeting of the Trustees. Before the start of the extension, you will be notified in writing of the extension, and that notice will include a description of the special circumstances and the date as of which the determination will be made.
• You will be informed of the Trustees’ decision, normally within five calendar days of the review. The decision will be in writing unless the appeal was for an urgent care claim and you are advised by telephone or fax. When you receive the written decision, it will contain the reasons for the decision and specific references to the particular Plan provisions upon which the decision was based. It will also contain a statement explaining that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to you claim, and a statement of your right to bring an action under section 502(a) of ERISA. If applicable, you will also be informed of your right to receive free of charge upon request the specific internal rule, guideline, protocol or similar criterion relied on to make the decision. If the decision was based on a medical judgment, you will receive an explanation of that determination or a statement that such explanation will be provided free of charge upon request.

External Appeals

If you appeal to the Review Committee but the process still results in a denial of your claim, you may, in certain cases, request an additional review by an independent review organization (IRO). An independent external review is available for claims denied based on clinical or scientific judgments, such as decisions based on medical necessity. It does not apply to claim denials related to a person’s eligibility for coverage. You must apply for the external review within four months after the date of receipt of the written appeal decision you received from the Fund. To request an external review, call or write the Fund Office. Fund Office staff will provide you with the information you need to file your formal request for an external review and provide you with the information you need to complete the process. The appellant must pay a $25 administrative fee for each external review, which will be refunded if the appeal is granted.

You may apply for an expedited external review if the claim involves a medical condition for which the regular timeframe for completion of an appeal would seriously jeopardize the life or health of the claimant, or would jeopardize the claimant’s ability to regain maximum function, or if the final internal adverse benefit determination (denial) concerns an admission, availability of care, continued stay, or health care item or service for which the claimant received emergency services, but has not been discharged from a facility.

Your Right to a Timely Decision

If the Plan fails to make timely decisions or otherwise fail to comply with the applicable federal regulations, you may go to court to enforce your rights. A claimant may not file suit against the Plan until the claimant has exhausted all of the procedures described in these procedures. The time limit for filing suit is one year from the date a decision was required to be provided under these Claim and Appeal Procedures.

Claim and Appeal Procedures for Life/AD&D Claims

Life/AD&D insurance claims should be filed with the Fund Office who will forward them to Union Labor Life Insurance Company, the insurer of these benefits. Since the Fund is the holder of the insurance contract, notices from Union Labor Life may be issued to the Fund instead of you.

Union Labor Life will normally issue an approval or denial of a life/AD&D claim within 90 days of the date it receives the claim. An extension of 90 days will be allowed if special circumstances are involved. The Fund Office will notify you in writing of any extension the insurer requires to review your claim, and the notice will state the special circumstances involved and the date by which it expects to reach a decision.

If Union Labor Life denies your claim, the Fund Office will issue you a notice written in an understandable manner explaining the reasons for the denial. The notice will also include an explanation of the claim appeal procedures.

Review of claim denials and final decisions on appeal are Union Labor Life’s responsibility.

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