Tri-State Preferred Plan SPD >> Claims and Appeals Procedures

• Overview
• Claims for Benefits
• Where to Send Claim Forms
• Approval and Denial of Claims
• Appealing Denied Claims
• Further Action

This section describes the procedures for filing claims for Plan benefits. It also describes the procedure for you to follow if your claim is denied in whole or in part and you wish to appeal that decision.

Claims for Benefits

A claim for benefits is a request for Plan benefits that is made in accordance with the Plan's claims procedures. Please note that the following are not considered claims for benefits:

• inquiries about the Plan's provisions or eligibility that are unrelated to any specific benefit claim,


• a request for prior approval of a benefit that does not require prior approval by the Plan, and


• presentation of a prescription to be filled at a pharmacy that is part of the Medco Health network of participating pharmacies. However, if you believe that your prescription has not been filled by a participating pharmacy in accordance with the terms of the Plan, in whole or in part, you may file a claim using the procedures described in the following section.

Filing Hospital and Medical Claims

Remember if you use network providers, you do not have to file claims. The providers will do it for you. If you use out-of-network providers, here are some steps to take to make sure your hospital or medical claim gets processed accurately and on time.

• File claims as soon as possible (and never later than 18 months after the date of service).

• Complete all information requested on the form.

• Submit all claims in English or with an English translation. Claims not in English will not be processed and will be returned to you.

• Attach original bills or receipts. Photocopies will not be accepted.

• If you have other coverage and Empire is the secondary payer, submit the original or a copy of the primary payer's Explanation of Benefits (EOB) with your itemized bill (see the "Coordination of Benefits" section).

• Keep a copy of your claim form and all attachments for your records.

Filing Dental Claims

When you see a participating dental provider, this provider will file all claims for you directly with Daniel H. Cook Associates, Inc., the administrator for the Plan's dental coverage. Daniel H. Cook Associates, Inc. will pay such providers directly as long as you authorize direct reimbursement.

You have to file a claim when you receive care from dentists or other providers or facilities not in the Plan's participating dental provider network. Here is what you need to know when you file a dental claim when you do not use a participating dental provider.

• Only an original, fully completed ADA claim form or approved treatment plan will be accepted for review.

• All necessary diagnostic information must accompany the claim.

• When you are the patient, your original signature or signature on file are acceptable on all claims for payment or assignment. If the patient is a child, an original signature or signature on file of the child’s parent or guardian are acceptable.

• All claims must be received by Daniel H. Cook Associates, Inc. within 180 days after services were rendered.

• You or your dentist must return the original approved treatment plan or prior authorization approval form with your claim. Routine eligible dental expenses totaling less than $300 on a claim do not require prior authorization.

• Approved treatment plans or prior authorization approval forms are valid only for one year from the date they are issued. In addition, they cannot be changed or used by any person other than the person to whom they are issued. The Plan reserves the right to withhold payment or request reimbursement from providers or participants for services that do not meet acceptable standards, as determined by its consultants or professional staff.

Filing Pharmacy Claims

If you use participating pharmacies or the mail order pharmacy, you do not have to file claims. The participating pharmacies or mail order pharmacy will do it for you. If you use an out-of-network pharmacy, then you must file a claim for benefits. Pharmacy claims should be filed as soon as possible, but never later than 12 months after the date the prescription was filled.

If you have other coverage and Medco is the secondary payer, submit the original or a copy of the primary payer's Explanation of Benefits (EOB) with your itemized bill (see the "Coordination of Benefits" section).

Filing EAP Claims

If you use network providers, you do not have to file claims. The providers will do it for you. If you do not use network providers, then no benefit is available.

If you have other coverage and MHN is the secondary payer, submit the original or a copy of the primary payer's Explanation of Benefits (EOB) with your itemized bill (see the "Coordination of Benefits" section).

Filing Vision Claims

If you use participating vision providers, you do not have to file claims. The providers will do it for you. If you do not use a participating vision provider, then you must file a vision claim with the Fund for reimbursement of eligible expenses. You can obtain a vision claim form from the Member Service Center. Vision claims should be filed as soon as possible, but never later than 12 months after the date of service.

Filing for a Pensioner's Death Benefit

To file a claim for a pensioner's death benefit, your beneficiary must complete a claim form and submit a certified copy of your Death Certificate. To get an application, contact the Member Service Center. A claim for a pensioner's death benefit should be filed as soon as possible after the pensioner's death.

Filing Life Insurance and AD&D Claims

To file a claim for a life insurance benefit, your beneficiary must complete a claim form and submit a certified copy of your Death Certificate. A claim for life insurance should be filed as soon as possible after the participant's death.

To file for an AD&D benefit, you must complete a claim form. In the event of your death, your beneficiary must submit a certified copy of the Death Certificate along with a completed claim form. A claim for an AD&D benefit must be filed within 90 days after the loss is incurred.

For both life insurance and AD&D claims you can get claim forms by contacting MetLife.

Where to Send Claims Forms

Approval and Denial of Claims

There are separate claims denial and approval processes for Health Services Claims (hospital/medical, pharmacy, EAP, dental and vision), Pensioner's Death Benefit Claims and Life/AD&D Claims. These processes are described separately below. Please review this information to ensure that you are fully aware of these processes and what you need to do in order to comply.

Health Service Claims (hospital/medical, pharmacy, EAP, dental and vision)

The time frames for deciding whether health service claims are accepted or denied depend on whether your claim is a pre-service, an urgent care, a concurrent care or a post-service claim.

• Pre-service claims. This is a claim for a benefit for which the Plan requires approval of the benefit (in whole or in part) before medical care is obtained. Prior approval of services is required for inpatient hospital benefits (see the "Pre-Certification" section), certain outpatient hospital benefits (see the "Pre-Certification" section), EAP benefits (see the "EAP" section) and for certain dental benefits (see the "Dental Benefits" section). For properly filed pre-service claims, you and/or your doctor or dentist will be notified of a decision within 15 days from receipt of the claim unless additional time is needed. The time for response may be extended up to 15 days if necessary due to matters beyond the control of the claims reviewer. You will be notified of the circumstances requiring the extension of time and the date by which a decision is expected to be rendered.

  If you improperly file a pre-service claim, you will be notified as soon as possible, but not later than 5 days after receipt of the claim, of the proper procedures to be followed in refiling the claim. You will only receive notice of an improperly filed pre-service claim if the claim includes:

  - your name
  - your current address
  - your specific medical condition or symptom, and
  - a specific treatment, service or product for which approval is requested.

  Unless the claim is refiled properly, it will not constitute a claim. If an extension is needed because additional information is needed from you, the extension notice will specify the information needed. In that case, you and/or your doctor will have 45 days from receipt of the notification to supply the additional information. If the information is not provided within that time, your claim will be denied.

  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 either for 45 days or until the date the claims reviewer receives your response to the request (whichever is earlier). The claims reviewer will then have 15 days to make a decision on a pre-service claim and notify you of the determination.

• Urgent care claims. This is a claim for medical care or treatment that, if the time periods for making pre-service claim determinations were applied, could jeopardize your life, health or ability to regain maximum function, or, in the opinion of a doctor, result in your having unmanageable, severe pain.
  
  Whether your treatment is considered urgent care is determined by an individual acting on behalf of the Fund applying the judgment of a prudent person who possesses an average knowledge of health and medicine. Any claim that a doctor with knowledge of your medical condition determines is an urgent care claim shall automatically be treated as such.
  
  If you (or your authorized representative*) file an urgent care claim, you will be notified of the benefit determination as soon as possible, taking into account medical emergencies, but no later than 72 hours after receipt of your claim.
  
  However, if you do not give enough information for the claims reviewer to determine whether, or to what extent, benefits are payable, you will receive a request for more information within 24 hours. You will then have up to 48 hours, taking into account the circumstances, to provide the specified information to the claims reviewer. You will then be notified of the benefit determination within 48 hours after:
  
  - the claims reviewer's receipt of the specified information, or if earlier,
  - the end of the period you were given to provide the requested information.
   
  
  If you do not follow the Plan's procedures for filing an urgent care claim, you will be notified within 24 hours of the failure and the proper procedures to follow. This notification may be oral, unless you request written notification. You will only receive notification of a procedural failure if your claim includes:

- your name
- your specific medical condition or symptom, and
- a specific service, treatment or product for which approval is requested.

* A health care professional with knowledge of your medical condition or someone to whom you have given authorization may act as an authorized representative in connection with urgent care.

• Concurrent claims. This is a claim that is reconsidered after an initial approval was made and results in a reduction, termination or extension of a benefit. An example of this type of claim would be an inpatient hospital stay originally certified for five days that is reviewed at three days to determine if additional days are appropriate. Here the decision to reduce, end or extend treatment is made while the treatment is taking place.
  
  Any request by a claimant to extend approved treatment will be acted upon by the claims reviewer within 24 hours of receipt of the claim, provided the claim is received at least 24 hours before the approved treatment expires.

• Post-service claims. This is a claim submitted for payment after health services and treatment have been obtained.
  
  Ordinarily, you will receive a decision on your post-service claim within 30 days from receipt of the claim. This period may be extended one time for up to 15 days if the extension is necessary due to extraordinary matters. If an extension is necessary, you will be notified, before the end of the initial 30-day period, of the circumstances requiring the extension of time and the date by which a determination will be made.
  
  If an extension is needed because additional information is needed from you, the extension notice will specify the information needed. In that case you will have 45 days from receipt of the notification to supply the additional information. If the information is not provided within that time, your claim will be denied. 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 either for 45 days or until the date the claims reviewer receives your response to the request (whichever is earlier). Within 15 days after the expiration of this time period, you will be notified of the decision.

Life and AD&D Claims

If you or your beneficiary file a claim for either Life or AD&D benefits, MetLife will make a decision on the claim and notify the Fund of the decision within 90 days. If MetLife requires an extension of time due to matters beyond its control, they are permitted an additional 90 days. MetLife will notify you, your authorized representative, your beneficiary or the executor of your estate, as applicable, before the expiration of the original 90-day period of the reason for the delay and when the decision will be made. A decision will be made within the 90-day extension period.

Pensioner's Death Benefit Claims

If your beneficiary files a claim for death benefits, the Fund will make a decision on the claim and notify your beneficiary within 90 days of receipt of the claim. If the Fund requires an extension of time due to matters beyond its control, the Fund is permitted an additional 90 days. The Fund will notify your beneficiary prior to the expiration of the original 90-day period of the reason for the delay and when the decision will be made. A decision will be made within the 90-day extension period.

Notice of Decision

You will be provided with written notice of a denial of a claim (whether denied in whole or in part) or if any adverse benefit determination is made (for example, the Plan pays less than one hundred percent of the claim). For urgent care and pre-service claims, you will receive notice of the determination even when the claim is approved. The timing for delivery of this notice depends on the type of claim as described above.

Appealing Denied Claims

An appeal is a request by you or your authorized representative to have an adverse benefit determination reviewed and reconsidered.

Filing an Appeal

You have 180 days to file an appeal following the notification of a denied claim.

Your appeal must include your identification number, dates of service in question and any relevant information in support of your appeal.

If you submit a written request, you will be provided access to or copies of all documents, records or other information relevant to your appeal (including, in the case of an appeal involving a disability determination, the identity of any medical or vocational experts whose advice the claims reviewer used in connection with the decision to deny your application).

A document, record or other information is relevant for review if it falls into any of the following categories:

• The claims reviewer relied on it in making a decision.

• It was submitted, considered or generated in the course of making a decision (regardless of whether it was relied on).

• It demonstrates compliance with the claims reviewer's administrative processes for ensuring consistent decision-making.

• It constitutes a statement of Plan policy regarding the denied treatment or service.

You (or your authorized representative) may submit issues, comments, documents and other information relating to the appeal (regardless of whether they were submitted with your original claim).

If you do not request a review of a denied claim within 180 days, you will waive your right to a review of the denial. However, the applicable reviewer may not enforce this waiver if you can prove that you have a good reason for missing this deadline, provided you ask the applicable reviewer in writing to review the denial and you do so within one year after the date shown on the notice of denial. You must file an appeal with the appropriate party and follow the process completely before you can bring an action in court. Failure to do so may prevent you from having any legal remedy.

Where to File an Appeal

* You may appear in person at the Appeals Committee meeting with the Fund, but you do not have to be there. If you do not attend, the Appeals Committee will decide your appeal based on all of the materials you have submitted.

** An appeal of an urgent care dental claim may be filed orally by calling 1-800-551-32BJ.

Time Frames for Decisions on Appeals

The time frame within which a decision on an appeal will be made depends on the type of claim for which you are filing an appeal.

Expedited Appeals for Urgent Care Claims

If your claim involves urgent care for medical, hospital, pharmacy, dental or EAP benefits, you can file an expedited appeal if your provider believes an immediate appeal is warranted because delay in treatment would pose an imminent or serious threat to your health or ability to regain maximum function, or would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. This appeal can be filed in writing or orally. You can discuss the reviewer's determination and exchange any necessary information over the phone, via fax or any other quick way of sharing. You will receive a response within 72 hours of your request.

Pre-Service or Concurrent Medical, Hospital, Pharmacy or EAP Claim Appeal

If you file an appeal of a pre-service (service not yet received) or concurrent (service currently being received) claim that does not involve urgent care, a decision will be made and you will be notified within 30 days of the receipt of your appeal. An appeal of a cessation or reduction of a previously approved benefit will be made as soon as possible, but in any event prior to the cessation or reduction of the benefit.

Post-Service Medical, Hospital, Pharmacy or EAP Claim Appeal

If you file an appeal of a post-service claim, a decision will be made and you will be notified within 60 days of the receipt of your appeal.

Voluntary Second Level Appeal of a Medical, Hospital, Pharmacy or EAP Claim

If you have been notified regarding the outcome of your appeal of a medical, hospital, pharmacy, dental or EAP claim, you have exhausted all required internal appeal options. If you disagree with the decision, you may file a voluntary appeal with the Appeals Committee. Voluntary appeals must be filed within 180 days following notification of the outcome of your mandatory appeal.

The voluntary level of appeal is available only after you (or your representative) have pursued the appropriate mandatory appeals process required by the Plan, as indicated previously. This second level of appeal is completely voluntary; it is not required by the Plan and is only available if you (or your representative) request it. The Plan will not assert a failure to exhaust administrative remedies where you or your authorized representative elect to pursue a claim in court rather than through the voluntary level of appeal. The Plan will not impose fees or costs on you (or your representative) because you or your authorized representative choose to invoke the voluntary appeals process. Your decision as to whether or not to submit a benefit dispute to the voluntary level of appeal will have no effect on your rights to any other benefits under the Plan. Upon your request, the Plan will provide you (or your representative) with sufficient information to make an informed judgment about whether to submit a claim through the voluntary appeal process, including your right to representation.

Your voluntary appeal must include your identification number, dates of service in question, and any additional information that supports your appeal. You (or your authorized representative) can write to the Appeals Committee at the following address:

If you or your authorized representative choose to pursue a claim in court after completing the voluntary appeal, the statute of limitations applicable to your claim in court will be tolled (suspended) during the period of the voluntary appeals process.

Vision, Pensioner Death Benefit, Life and AD&D Appeal

If you file an appeal of a vision, pensioner's death benefit, life or AD&D claim, a decision will be made at the next regularly scheduled meeting of the Appeals Committee following receipt of your appeal. However, if your request is received less than 30 days before the next regularly scheduled meeting, your appeal will 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. You will be advised in writing in advance if this extension will be necessary. Once a decision on review of your claim has been reached, you will be notified of the decision as soon as possible, but no later than 5 days after the decision has been reached. Please note that there are no Expedited Appeals for Post-service Claims.

Appeal Decision Notice

You will be notified in writing of the decision of your appeal. The timing for delivery of this notice depends on the type of claim that was appealed.

Further Action

All decisions on appeal will be final and binding on all parties, subject only to your right to bring a civil action under Section 502(a) of ERISA after you have exhausted the Plan's appeal procedures.

You may not start a lawsuit to obtain benefits until you have completed the mandatory appeals process and a final decision has been reached, or until the appropriate time frame described in this booklet has elapsed since you filed an appeal and you have not received a final decision or notice that an extension will be necessary to reach a final decision. In addition, no lawsuit may be started more than three years after the date on which the applicable appeal was denied.

If you have any questions about the appeals process, please contact the Compliance Office.