Filing Claims and Appeals
 

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How to File Claims and Appeals

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Filing Claims Forms
Processing Claims and Appeals
Claims Appeals Procedures
Hearing Procedures
 

Filing Claims Forms

When you receive medical treatment at a PPO provider, you should present your medical benefits identification card at the time of treatment. Generally, if you use a PPO provider, the provider will submit a claim directly to the Plan Administrator.

Most health care providers will file claims for you. Be sure to show your ID card so your provider knows where to submit your claim. If your provider does not, follow the procedures listed in this section.

You should file your initial claim for Plan benefits within 90 days after the date you received services. If this is not possible, you must file your claim no later than one year from the date you received the services or your claim will be denied. If a claim is denied, in whole or in part, there is a process you can follow to have your claim reviewed by the Trustees.

If you need to submit a claim for a non-PPO provider medical, non-preferred pharmacy prescription drug, dental or vision expense, submit an itemized statement or bill that details charges to:
     Plan Administrator
     Carpenters' District Council of Kansas City and Vicinity Health Plan Office
     Penn Tower Building
     3100 Broadway, Suite 805
     Kansas City, MO  64111

Claim forms are available at the Fund Office.

When filing your claim:

• If your claim is for health care that is also covered by Medicare, attach a copy of the itemized bill relating to the health service provided and a copy of Medicare's explanation of benefits. Both the bill and Medicare's explanation of benefits should be submitted.
• If the claim is for an eligible Dependent, provide the name of the Dependent.
• If you or a Dependent has coverage under more than one plan, be sure to include the name of the other plan(s).

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Processing Claims and Appeals

This section describes how benefit claims are reviewed and processed. The Fund will:

• Take steps to assure that Plan benefit provisions are applied consistently with respect to similarly situated Plan participants; and
• Consult with a health care professional with appropriate training and experience when reviewing an adverse benefit determination that is based in whole or in part on a medical judgment (such as determination that a service is not Medically Necessary or is Experimental or Investigative).

Discretionary Authority of Plan Administrator

In carrying out their respective responsibilities under the Fund, the Plan Administrator, which is the Board of Trustees and the Claims Appeal Committee and other individuals to whom responsibility for the administration of the Fund has been delegated, have discretion and authority to interpret the terms of the summary Plan Description/Plan Document and Agreement and Declaration of Trust and to interpret any facts relevant to the determination and to determine eligibility and entitlement to Plan benefits. Any interpretation or determination made under that discretionary authority will be given full force and effect, unless it can be shown that the interpretation or determination was arbitrary and capricious.

Authorized Representative

An Authorized Representative is a person with authority to act on the claimant's behalf in accordance with the Fund's claims and appeals procedures. In the case of a claimant under the age of 18, the parent or stepparent of the claimant will automatically be deemed an Authorized Representative. Subject to the written statement requirement listed below, the following individuals may be recognized as the claimant's Authorized Representative.

• Health care provider;
• Legal Spouse;
• Dependent child age 18 or over;
• Parents or adult siblings;
• Grandparents;
• Court ordered representative, such as an individual with power of attorney for health care purposes or legal guardian or conservator; or
• Other adult.

An assignment of payment to a health care provider is not a designation of the provider as an Authorized Representative.

The Fund requires a written statement from the claimant that he or she has designated one of the above individuals as the Authorized Representative, along with the Authorized Representative's name, address and telephone number. If the claimant is unable to provide a written statement, the Fund requires written proof (e.g. power of attorney for health care purposes, court order of guardian/conservator) that the proposed Authorized Representative has been authorized to act on the claimant's behalf. A duly designated Authorized Representative will be able to make any decision or take any action or inaction that is available to the claimant regarding the claim.

Once the claimant names an Authorized Representative, the Fund will send all future claims and appeal related correspondence to the Authorized Representative and not the claimant. The Fund will honor the designated Authorized Representative for one year, or as mandated by a court order, before requiring a new authorization. The claimant may revoke a designated Authorized Representative by submitting a signed statement to the Fund stating the intent to revoke the designation. A duly Authorized Representative will be able to make any decision or take any action or inaction that is available to the claimant regarding the claim.

The Board of Trustees, or its designated representative, has the sole discretion to determine whether a claimant has properly designated an Authorized Representative. The Fund reserves the right to withhold information from a person who claims to be the Authorized Representative if there is suspicion about the qualifications of the individual claiming to be the Authorized Representative.

Definition of a Claim

• A claim is a request for a benefit from the Fund made by an individual (also referred to as "Claimant" or that individual's duly Authorized Representative in accordance with the Fund's claims procedures.
• There is no pre-certification or pre-approval required for any benefit payable under this Plan. Therefore, there are no pre-service, concurrent care or urgent care claims.
• All claims under this Fund are post-service claims. All payment of benefits is for expenses previously Incurred by the claimant. While there is no prior approval required for medical expenses or procedures, individuals or providers may telephone or write the Fund Office to ask if certain procedures or individuals are covered under the Plan. Such inquiries are not claims and answers are not binding on the Fund.

  Fund Office
  Carpenters' District Council of Kansas City and Vicinity Health Plan
    3100 Broadway, Suite 805
    Kansas City, MO  64111
    (816) 756-3313
    Toll-Free (866) 756-3313

• A post-service claim is a request for benefits under the Plan that is not a pre-service claim. Post-service claims are requests that involve only the payment or reimbursement of the cost of the care that has already been provided. A standard paper claim or electronic bill submitted for payment after services have been provided are examples of a post-service claim.
• A disability claim is a claim for Weekly Accident and Sickness or Accidental Death and Dismemberment Benefits. Any other type of claim is considered a non-disability claim.

Claim Elements

A claim must include the following elements to be processed by the Fund:

• Be written or electronically submitted in accordance with Electronic Data Interchange (EDI) standards under the Health Insurance Portability Act (HIPAA);
• Be received by the Fund Office or applicable Preferred Provider Organization (PPO) within one year of the date service was provided;
• Name a specific individual (claimant);
• Name a specific medical condition or symptom;
• Provide a description and date of a specific treatment, service or product for which payment is requested and an itemized list of charges;
• Identify the provider's name, address, phone number, professional degree or license and federal tax identification number (TIN);
• When another plan is primary payer, include a copy of the other plan's Explanation of Benefits (EOB) statement; and
• When accidental Injury is involved, details of the accident.

A request is not a claim if it is:

• Not made in accordance with the Fund's claims filing procedures described in this section;
• Made by someone other than the claimant or his/her Authorized Representative;
• Made by a person who will not identify himself (anonymous);
• A casual inquiry about benefits, such as verification of whether a service/item is a covered benefit or the estimated allowed cost for a service;
• For prior approval where prior approval is not required by the Fund;
• An eligibility inquiry that does not request benefits. However, if a benefit claim is denied on the grounds of lack of eligibility, it is treated as an adverse benefit determination and the claimant or their Authorized Representative will be notified of the decision and allowed to file an appeal; or
• The presentation of a prescription to a pharmacy that the pharmacy denies (where the pharmacy/pharmacy benefits manager has no discretion to make decisions on claims). After the denial by the pharmacy, a person may file a claim with the Fund.

Timing of Decisions for Non-Disability Claims

Non-disability claims are decided within 30 days of the Fund's receipt of the claim. The time for deciding the claim may be extended by the Fund for 15 days, upon notice to the claimant. The notice will be sent prior to the expiration of 30 days. The notice will state the circumstances that are beyond the control of the Fund and that require the extension and the date by which the Fund expects to render a decision. This is the "initial determination period."

If a claim cannot be processed due to insufficient information, the Fund will suspend the initial determination period and notify the claimant of the information required and the time period for providing the information to the Fund. The claimant will then have 45 days to provide the additional information. The suspension ends at the earlier of the Fund's receipt of the requested information or the end of the 45-day period. The initial determination period then begins to run again. If the information is not provided within the time period required by the Fund, the claim will be denied. The Fund will notify the claimant of the determination no later than the end of the initial determination period.

Timing of Decisions on Disability Claims

Disability claims will be decided within 45 days of the Fund's receipt of the claim. The time for deciding the claim may be extended by the Fund for two periods of 30 days each, upon notice to the claimant. The notice for the first extension will be sent prior to the expiration of the initial 45-day period. The notice for the second extension, if necessary, will be sent prior to the expiration of the first 30-day extension period. The notices will state the circumstances that are beyond the control of the Fund that require the extension and the date by which the Fund expects to render a decision. This is the "initial determination period".

If a claim cannot be processed due to insufficient information, the Fund will suspend the initial determination period and notify the claimant of the information required and the time period for providing the information to the Fund. The claimant will then have 45 days to provide the additional information. The suspension ends at the earlier of the Fund's receipt of the requested information or the end of the 45-day period. The initial determination period then begins to run again. If the information is not provided within the time period required by the Fund, the claim will be denied. The Fund will notify the claimant of the determination no longer than the end of the initial determination period.

For disability claims, the Fund reserves the right to have a Physician examine the claimant (at the Fund's expense) as often as is reasonable while a claim is pending.

Denial (Adverse Benefit Determination)

For the purpose of the claim and appeal processes, an adverse benefit determination is:

• A denial, reduction, termination or failure to provide or make payment, in whole or in part, for a benefit;
• A determination after service occurred of an individual's eligibility to participate in this Fund;
• A benefit denial resulting from failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental or Investigative or not Medically Necessary or appropriate; or
• Payment in accordance with the Plan, but less than the total amount of expenses submitted with regard to a claim; for example, application of deductible or co-payment requirements.

If the claim is wholly or partially denied, a notice of this initial denial (adverse benefit determination) will be provided to the claimant in writing or electronically, as applicable, within the timeframe required to make a decision on that claim. This notice of denial will:

• State the specific reason(s) for the denial;
• Reference the specific Plan provision(s) on which the denial is based;
• Describe any additional information needed to perfect the claim and an explanation of why such additional information is necessary;
• Provide an explanation of the Fund's appeal procedure along with time limits;
• Contain a statement that the claimant has the right to bring civil action under ERISA section 502(a) following an appeal;
• If the denial was based on an internal rule, guideline, protocol or similar criteria, a statement will be provided that the rule, guideline, protocol or criteria will be provided free of charge, upon request;
• If the denial was based on a medical judgment (Medical Necessity, Experimental or Investigative), a statement will be provided that an explanation regarding the scientific or clinical judgment for the denial will be provided free of charge, upon request; and
• Inform the claimant that if the claim is denied and the claimant disagrees with that decision, the claimant or the claimant's Authorized Representative may appeal, that is, request the Fund review its decision. The claimant will have 180 calendar days following receipt of an initial denial to request this review. The Fund will not accept appeals filed after this 180-day period.

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Claims Appeal Procedures

This Fund Maintains a one-level appeal process. Appeals must be submitted in writing to the Fund Office within 180 calendar days following a receipt of an initial adverse benefit determination. The claimant will be provided with:

• The opportunity, upon request and without charge, to receive reasonable access to and copies of all relevant documents, records and other information relevant to the claim for benefits;
• The opportunity to submit written comments, documents, records and other information relating to the claim for benefits;
• A full and fair review that takes into account all comments, documents, records and other information submitted, without regard to whether such information was submitted or considered in the initial benefit determination;
• A review that does not afford deference to the initial adverse benefit determination, treats similarly situated claimants consistently and that is conducted by an appropriate Named Fiduciary of the Fund, who is neither the individual who made the initial adverse benefit determination that is the subject of the appeal, nor the subordinate of that individual;

In deciding an appeal of any adverse benefit determination that is based, in whole or in part, on a medical judgment, including whether a particular treatment, drug or other item is Experimental, Investigative, Medically Necessary or appropriate, the appropriate Named Fiduciary will consult with a health care professional who:

• Has appropriate experience in the field of medicine involved in the medical judgment;
• Is neither an individual who was consulted in connection with the adverse benefit determination that is the subject of the appeal nor the subordinate of that individual; and
• Provide, upon request, the identification of medical or vocational experts whose advice was obtained on behalf of the Fund in connection with an adverse benefit determination, without regard to whether the advice was relied upon in making the adverse benefit determination.

The Board of Trustees is the Plan Administrator and the Named Fiduciary responsible for all benefit determinations on appeal. The Board of Trustees may delegate all fiduciary responsibility for claims determination on appeal to the Claims Appeal Committee. The Claims Appeal Committee will meet at least once each calendar quarter at regularly scheduled times.

The Claims Appeal Committee will make a benefit determination on appeal no later than the date of the quarterly Claims Appeal Committee meeting that immediately follows the Fund's receipt of a request for review, unless the request for review is filed within 30 days before the date of the meeting. In this case, a benefit determination will be made no later than the date of the second quarterly Claims Appeal Committee meeting following the Fund's receipt of the request for review. If special circumstances (such as the need to hold a hearing) require a further extension of time, a benefit determination will be rendered not later than the third quarterly Claims Appeal Committee meeting following the Fund's receipt of the request for review. If an extension is necessary, the Fund will notify the claimant in writing, describing the special circumstances and date the benefit determination will be made. A written notice of the appeal determination will be provided to the claimant within five days after the determination has been made. The notice will:

• State the specific reason(s) for the appeal review decision;
• Reference the specific Plan provision(s)
• Include a statement that the claimant is entitled to receive, upon request, free access to and copies of documents relevant to the claim.
• Include a statement that the claimant has the right to bring civil action under ERISA Section 502(a) following the appeal;
• If the denial was based on an internal rule, guideline, protocol or similar criteria, a statement will be provided that the rule, guideline, protocol or criteria will be provided free of charge, upon request, and
• If the denial was based on a medical judgment (Medical Necessity, Experimental or Investigative), a statement will be provided that an explanation regarding the scientific or clinical judgment for the denial, applying the terms of the Plan to the claim, will be provided free of charge, upon request.

This fund does not offer a voluntary appeal process.

Time Frames

All post-service claims must be submitted to the Fund within one year from the date of service. No benefits will be paid for any claim not submitted within this period. The Following chart summarizes the timeframes for the claim and appeal processes:

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Hearing Procedures

The following procedures are established for hearings by the Board of Trustees or the Claims Appeal Committee:

1. The claimant and/or duly Authorized Representative will, upon written request, have an opportunity to appear before the Board of Trustees or the Claims Appeal Committee and have the right and opportunity to examine witnesses and/or present documents and other evidence material to the claim.
2. The proceedings of the hearing will be preserved by tape recordings, stenographic or court reporter's records.
3. In conducting the hearing, the Board of Trustees or the Claims Appeal Committee will not be bound by the usual common law or statutory rules of evidence.
4. The claimant and/or duly Authorized Representative has the right, free of charge and on request, to review the tape recording of the hearing and obtain a reproduced copy and obtain a copy of all documents and records introduced or referred to.
5. There will be copies made of all documents and records introduced at the hearing, and the same will be attached to the record of the hearing and made a part of the records. As an alternative to attaching copies of the documents and records, reference may be made to them on the tape recording and the same may be retained in the claim file.
6. All information upon which the Board of Trustees or the claims Appeal Committee bases its decision will be disclosed to the claimant or the claimant's Authorized Representative at the hearing.
7. In the event that additional evidence is introduced by the Board of Trustees, which is not made available to the claimant before the hearing, the claimant will be granted a continuance of up to 30 days. For the purpose of this section, evidence discovered upon examination of the claimant's own witness will not be considered "new evidence".
8. The claimant will have the opportunity of presenting evidence. If the claimant offers new evidence, the hearing may be adjourned for a period of not more than 30 days so that the Board of Trustees or the Claims Appeal Committee may investigate the additional evidence and determine the accuracy of the claimant's new evidence.

The written decision of the Board of Trustees or the Claims Appeal Committee is final, binding and conclusive upon the claimant. All review procedures described above must be followed and exhausted before a claimant may initiate any legal action, including an action or proceeding before any court, administrative agency or arbitrator, unless the Fund fails to follow the claims and appeal procedures, as stated in this section.

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