(8) "Urgent Care
Claim", a claim for a medication, service, or product where a delay in
processing the claim:
(a) could seriously
jeopardize the life or health of the employee-beneficiary or
dependent-beneficiary, and/or could result in the employee-beneficiary's
failure to regain maximum function, or
(b) in the opinion of a physician with
knowledge of the employee-beneficiary's condition, would subject the
employee-beneficiary or dependent-beneficiary to severe pain that cannot be
adequately managed without the requested medication, service, or
product.
(c) Time limit for initial
filing of self-insured plan and administered claims.
(1) All post-service self-insured plan
administered claims must be submitted to the administrator within one year from
the date of service. No plan benefit will be paid for any claim not submitted
within this period.
(2) If a
self-insured plan claim is not approved, an employee-beneficiary or
dependent-beneficiary may appeal that denial by following the steps in this
Claim Filing and Appeal section. The Fund has delegated final claims and appeal
authority for self-insured plan administered benefits to the independent
self-insured plan administrator. This section discusses the claim appeal
process for the following types of claims: Pre-Authorization Claim Review
Services, Pre-Service Appeals Review Services, and Post-Service Appeals Review
Services.
(d) The claims
and appeals process
(1) Pre-authorization
review. The self-insured plan administrator will implement the cost containment
programs by comparing individual requests for certain medicines, services, or
products and/or other benefits against pre-defined lists or formularies before
those prescriptions, services, or products are approved. If the self-insured
plan administrator determines that the employee-beneficiary or
dependent-beneficiary's request for pre-authorization cannot be approved, that
determination will constitute an adverse benefit determination.
(2) Appeals of adverse benefit determinations
of pre-service and urgent care claims. If an adverse benefit determination is
rendered on the employee-beneficiary or dependent-beneficiary's self-insured
plan administered claim, the employee-beneficiary or dependent-beneficiary may
file an appeal of that determination. The individual's appeal of the adverse
benefit determination must be made in writing and submitted to the self-insured
plan administrator within one hundred eighty (180) days after the
employee-beneficiary or dependent-beneficiary receives notice of the adverse
benefit determination.
If the adverse benefit determination is rendered with respect
to an urgent care claim, the employee-beneficiary or dependent-beneficiary
and/or the employee-beneficiary or dependent-beneficiary's attending physician
may submit an appeal by contacting the self-insured plan administrator. The
employee-beneficiary or dependent-beneficiary's appeal should include the
following information:
(i) Name of the
person the appeal is being filed for;
(ii) The prescription drug program
identification number, service description and/or code, or product name and
number;
(iii) Date of
birth;
(iv) Written statement of
the issue(s) being appealed;
(v)
Prescription drug name(s), service(s), or product(s) being requested;
and
(vi) Written comments,
documents, records or other information relating to the claim.
The employee-beneficiary or dependent-beneficiary's appeal and
supporting documentation should be mailed, emailed, or faxed to the
self-insured plan administrator.
If a covered person or their covered dependent does not
understand English and has questions about a claim denial, the covered person
or covered dependent should contact the appropriate claims administrator to
find out if assistance is available.
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(3) The self-insured plan administered
program's review The self-insured plan administrator will provide the
first-level review of appeals of pre-service claims If the employee-beneficiary
or dependent-beneficiary appeals the self-insured plan administrator's
decision, the employee-beneficiary or dependent-beneficiary can request an
additional second-level medical necessity review That review will be conducted
by an Independent Review Organization ("IRO").
(4) Timing of review.
(i) Pre-Authorization Review. The
self-insured plan administrator will make a decision on a pre-authorization
request for a Fund benefit within fifteen (15) days after it receives the
request. If the request relates to an urgent care claim, the self-insured plan
administrator will make a decision on the claim within seventy-two (72)
hours.
(ii) Pre-Service Claim
Appeal. The self-insured plan administrator will make a decision on a
first-level appeal of an adverse benefit determination rendered on a
pre-service claim within fifteen (15) days after it receives the
employee-beneficiary or dependent-beneficiary's appeal. If the self-insured
plan administrator renders an adverse benefit determination on the first-level
appeal of the pre-service claim, the employee-beneficiary or
dependent-beneficiary may appeal that decision by providing the information
described above. A decision on the employee-beneficiary or
dependent-beneficiary's second-level appeal of the adverse benefit
determination will be made (by the IRO) within fifteen (15) days after the new
appeal is received. If the employee-beneficiary or dependent-beneficiary is
appealing an adverse benefit determination of an urgent care claim, a decision
on such appeal will be made not more than seventy-two (72) hours after the
request for appeal(s) is received (for both the first-and second-level appeals,
combined).
(iii) Post-Service Claim
Appeal. The self-insured plan administrator will make a decision on an appeal
of an adverse benefit determination rendered on a post-service claim within
sixty (60) days after it receives the appeal.
(5) Scope of review. During its
pre-authorization review, first-level review of the appeal of a pre-service
claim, or review of a post-service claim, the self-insured plan administrator
will:
(i) Take into account all comments,
documents, records and other information submitted by the employee-beneficiary
or dependent-beneficiary relating to the claim, without regard to whether such
information was submitted or considered in the initial benefit determination on
the claim;
(ii) Follow reasonable
procedures to verify that its benefit determination is made in accordance with
the applicable Fund documents;
(iii) Follow reasonable procedures to ensure
that the applicable Fund provisions are applied to the employee-beneficiary or
dependent-beneficiary in a manner consistent with how such provisions have been
applied to other similarly-situated individuals; and
(iv) Provide a review that does not afford
deference to the initial adverse benefit determination and is conducted by an
individual other than the individual who made the initial adverse benefit
determination (or a subordinate of such individual).
If an employee-beneficiary or dependent-beneficiary appeals the
self-insured plan administrator's denial of a pre-service claim, and requests
an additional second-level medical necessity review by an IRO, the IRO
shall:
a) Consult with appropriate
health care professionals who were not consulted in connection with the initial
adverse benefit determination (nor a subordinate of such individual);
b) Identify the health care professional, if
any, whose advice was obtained on behalf of the Fund in connection with the
adverse benefit determination; and
c) Provide for an expedited review process
for urgent care claims.
(6) Notice of adverse benefit determination.
Following the review of an employee-beneficiary or dependent-beneficiary's
claim, the self-insured plan administrator will notify the employee-beneficiary
or dependent-beneficiary of any adverse benefit determination in writing.
(Decisions on urgent care claims will be also communicated by telephone or
fax.) This notice will include:
(i) The
specific reason or reasons for the adverse benefit determination;
(ii) Reference to the pertinent Fund
provision on which the adverse benefit determination was based;
(iii) A statement that the
employee-beneficiary or dependent-beneficiary is entitled to receive, upon
written request, free of charge, reasonable access to, and copies of, all
documents, records and other information relevant to the claim;
(iv) If an internal rule, guideline, protocol
or other similar criterion was relied upon in making the adverse benefit
determination, either a copy of the specific rule, guideline, protocol or other
similar criterion; or a statement that such rule, guideline, protocol or other
similar criterion will be provided free of charge upon written request;
and
(v) If the adverse benefit
determination is based on a medical necessity, either the IRO's explanation of
the scientific or clinical judgment for the IRO's determination, applying the
terms of the Fund to the employee-beneficiary or dependent-beneficiary's
medical circumstances, or a statement that such explanation will be provided
free of charge upon written request.
(7) Authority as claims fiduciary. The
self-insured plan administrator has been designated by the Board as the claims
fiduciary with respect to all types of claim appeal review of the benefit
claims arising under the Fund it administers. The self-insured plan
administrator shall have, on behalf of the Fund, sole and complete
discretionary authority to determine these claims conclusively for all parties.
The self-insured plan administrator is not responsible for the conduct of any
second-level medical necessity review performed by an IRO.
(8) Voluntary external review. The Patient
Protection and Affordable Care Act ("ACA") imposes external review requirements
on group health plans, including outpatient prescription drug benefits. Under
the ACA, an employee-beneficiary or dependent-beneficiary who receives a final
internal adverse determination of a "Claim" for benefits under a self-insured
administered plan may be permitted to further appeal that denial using the
voluntary external review process. The external review process provides
employee-beneficiary or dependent-beneficiary's with another option for
protesting the denial of their claim.
(9) Standard/non-expedited Federal external
review process.
(i) Request for review. An
employee-beneficiary or dependent-beneficiary whose claim for self-insured
administered benefits is denied may request, in writing, an external review of
his or her claim within four (4) months after receiving notice of the final
internal adverse benefit determination. The employee-beneficiary or
dependent-beneficiary's request should include their name, contact information
including mailing address and daytime phone number, individual ID number, and a
copy of the coverage denial. The employee-beneficiary or
dependent-beneficiary's request for external review and supporting
documentation may be mailed, emailed, or faxed to the self-insured plan
administrator at their address, email, or fax.
(ii) Preliminary review. Within five (5) days
of receiving an employee-beneficiary or dependent-beneficiary's request for
external review, the self-insured plan administrator will conduct a
"preliminary review" to ensure that the request qualifies for external review.
In this preliminary review, the self-insured plan administrator will determine
whether:
a) The employee-beneficiary or
dependent-beneficiary is or was covered under the Fund at the time the benefit
at issue was requested, or in the case of a retrospective review, was covered
at the time the benefit was provided;
b) The adverse benefit determination or final
internal adverse benefit determination does not relate to the
employee-beneficiary or dependent-beneficiary's failure to meet the Fund's
requirements for eligibility (for example, worker classification or similar
determinations), as such determinations are not eligible for Federal external
review;
c) The employee-beneficiary
or dependent-beneficiary has exhausted the Fund's internal appeal process
(unless the employee-beneficiary or dependent-beneficiary's Claim is "deemed
exhausted" under the ACA); and
d)
The employee-beneficiary or dependent-beneficiary has provided all the
information and forms necessary to process the external review.
Within one (1) day after completing this preliminary review,
the self-insured plan administrator will notify the employee-beneficiary or
dependent-beneficiary, in writing, that:
(1) the employee-beneficiary or
dependent-beneficiary's request for external review is complete, and may
proceed;
(2) the request is not
complete, and additional information is needed (along with a list of the
information needed to complete the request); or
(3) the request for external review is
complete, but not eligible for review.
(iii) Referral to IRO. If the
employee-beneficiary or dependent-beneficiary's request for external review is
complete and the employee-beneficiary or dependent-beneficiary's claim is
eligible for external review, the self-insured plan administrator will assign
the request to one of the IROs with which the administrator has contracted. The
IRO will notify the employee-beneficiary or dependent-beneficiary of its
acceptance of the assignment. The employee-beneficiary or dependent-beneficiary
will then have ten (10) days to provide the IRO with any additional information
the employee-beneficiary or dependent-beneficiary wants the IRO to consider.
The IRO will conduct its external review without giving any consideration to
any earlier determinations made on behalf of the Fund.
The IRO may consider information beyond the records for the
employee-beneficiary or dependent-beneficiary's denied Claim, such as:
a) The employee-beneficiary or
dependent-beneficiary's medical records;
b) The attending health care professional's
recommendations;
c) Reports from
appropriate health care professionals and other documents submitted by the
Fund, the employee-beneficiary or dependent-beneficiary, or the
employee-beneficiary or dependent-beneficiary's treating physician;
d) The terms of the Fund to ensure that the
IRO's decision is not contrary to the terms of the plan (unless those terms are
inconsistent with applicable law);
e) Appropriate practice guidelines, which
must include applicable evidence based standards and may include any other
practice guidelines developed by the Federal government, national, or
professional medicine societies, boards, and associations;
f) Any applicable clinical review criteria
developed and used on behalf of the Fund (unless the criteria are inconsistent
with the terms of the Fund or applicable law); and
g) The opinion of the IRO's clinical
reviewer(s) after considering all information and documents applicable to the
employee-beneficiary or dependent-beneficiary's request for external review, to
the extent such information or documents are available and the IRO's clinical
reviewer(s) considers it appropriate.
(iv) Timing of IRO's determination. The IRO
will provide the employee-beneficiary or dependent-beneficiary and the
self-insured plan administrator (on behalf of the Fund) with written notice of
its final external review decision within forty-five (45) days after the IRO
receives the request for external review. The IRO's notice will contain:
a) 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, the health care provider,
the claim amount (if available), the diagnosis code and its meaning, the
treatment code and its meaning, and the reasons for the previous
denials);
b) The date the IRO
received the external review assignment from the self-insured plan
administrator, and the date of the IRO's decision;
c) References to the evidence or
documentation, including specific coverage provisions and evidence-based
standards, the IRO considered in making its determination;
d) A discussion of the principal reason(s)
for the IRO's decision, including the rationale for the decision, and any
evidence-based standards that were relied upon by the IRO in making its
decision;
e) A statement that the
determination is binding except to the extent that other remedies may be
available under State or Federal law to the either the Fund or to the
individual;
f) A statement that the
employee-beneficiary or dependent-beneficiary may still be eligible to seek
judicial review of any adverse external review determination; and
g) Current contact information, including
phone number, for any applicable office of health insurance consumer assistance
or ombudsmen available to assist the employee-beneficiary or
dependent-beneficiary.
(10) Reversal of the Fund's prior decision.
If the self-insured plan administrator, acting on the Fund's behalf, receives
notice from the IRO that it has reversed the prior determination of the
employee-beneficiary or dependent-beneficiary's claim, the self-insured plan
administrator will immediately provide coverage or payment for the
claim.
(11) Expedited Federal
external review process. An employee-beneficiary or dependent-beneficiary may
request an expedited external review:
(i) If
the employee-beneficiary or dependent-beneficiary receives an adverse benefit
determination related to a claim that involves a medical condition for which
the timeframe for completion of a an expedited internal appeal would seriously
jeopardize the life or health of the employee-beneficiary or
dependent-beneficiary, and/or could result in the employee-beneficiary or
dependent-beneficiary's failure to regain maximum function, and the
employee-beneficiary or dependent-beneficiary has filed a request for an
expedited internal appeal; or
(ii)
If the employee-beneficiary or dependent-beneficiary receives a final internal
adverse benefit determination related to a claim that involves:
(a) a medical condition for which the
timeframe for completion of a standard external review would seriously
jeopardize the life or health of the employee-beneficiary or
dependent-beneficiary, and/or could result in the employee-beneficiary or
dependent-beneficiary's failure to regain maximum function; or
(b) an admission, availability of care,
continued stay, or a prescription drug benefit for which the
employee-beneficiary or dependent-beneficiary has received emergency services,
but has not been discharged from a facility.
(12) Request for review. If the
employee-beneficiary or dependent-beneficiary's situation meets the definition
of urgent under the law, the external review of the claim will be conducted as
expeditiously as possible. In that case, the employee-beneficiary or
dependent-beneficiary or the employee-beneficiary or dependent-beneficiary's
physician may request an expedited external review by calling the customer care
toll-free at the number on their benefit ID card or contacting their benefits
office. The request should include the employee-beneficiary or
dependent-beneficiary's name, contact information including mailing address and
daytime phone number, employee-beneficiary or dependent-beneficiary's ID
number, and a description of the coverage denial.
Alternatively, a request for expedited external review may be
faxed; employee-beneficiary or dependent-beneficiary contact information and
coverage denial description, and supporting documentation may be faxed or
emailed to the attention the self-insured plan administrator's external review
appeals department. All requests for expedited review must be clearly
identified as "urgent" at submission.
(13) Preliminary review. Immediately on
receipt of an employee-beneficiary or dependent-beneficiary's request for
expedited external review, the self-insured plan administrator will determine
whether the request meets the reviewability requirements described above for
standard external review. Immediately upon completing this review, the
self-insured plan administrator will notify the employee-beneficiary or
dependent-beneficiary that:
(i) the
employee-beneficiary or dependent-beneficiary's request for external review is
complete, and may proceed;
(ii) the
request is not complete, and additional information is needed (along with a
list of the information needed to complete the request); or
(iii) the request for external review is
complete, but not eligible for review.
(14) Referral to IRO. Upon determining that
an employee-beneficiary or dependent-beneficiary's request is eligible for
expedited external review, the self-insured plan administrator will assign an
IRO to review the employee-beneficiary or dependent-beneficiary's claim. The
self-insured plan administrator will provide or transmit all necessary
documents and information considered in making the adverse benefit
determination or final adverse benefit determination to the assigned IRO
electronically, by telephone, by fax, or by any other available expeditious
method. The assigned IRO, to the extent the information or documents are
available and the IRO considers them appropriate, must consider the information
and documents described above. In reaching a decision on an expedited request
for external review, the IRO will review the employee-beneficiary or
dependent-beneficiary's claim de novo and will not be bound by the decisions or
conclusions reached on behalf of the Fund during the internal claims and
appeals process.
(15) Timing of the
IRO's determination. The IRO must provide the employee-beneficiary or
dependent-beneficiary and the self- insured plan administrator, on behalf of
the Fund, with notice of its determination as expeditiously as the
employee-beneficiary or dependent-beneficiary's medical condition or
circumstances require, but in no event more than seventy-two (72) hours after
the IRO receives the employee-beneficiary or dependent-beneficiary's request
for external review. If this notice is not provided in writing from the IRO and
is provided orally, within forty-eight (48) hours after providing the oral
notice, the IRO will provide the employee-beneficiary or dependent-beneficiary
and the self-insured plan administrator, on behalf of the Fund, with written
confirmation of its decision.
(16)
Authority for review. The self-insured plan administrator will be responsible
only for conducting the preliminary review of an employee-beneficiary or
dependent-beneficiary's request for external review, ensuring that the
individual is timely notified of the decision as to eligibility for external
review, and for assigning the request for external review to an IRO. The actual
external review of an employee-beneficiary or dependent-beneficiary's appeal
will be conducted by the assigned independent review organization (IRO). The
self-insured plan administrator is not responsible for the conduct of the
external review performed by an IRO.