Retiree Health Summary Plan Description
As of February 1, 2018
En Español (PDF)

1.3 Appeals

Any appeals related to insured benefits are handled directly by the respective insurance company. Please refer to the insurance vendor's Evidence of Coverage document for the claims and appeals procedures pertaining to each benefit plan.

The Administrative Office makes all initial determinations as to basic eligibility and enrollment issues under Article 3 (see page 13) and comparable eligibility and enrollment provisions of this document. Appeals of denial of eligibility and enrollment by the Administrative Office are handled by the Board of Trustees upon timely notification to the Administrative Office. Individuals will be notified in writing of all adverse determinations as to eligibility, enrollment and appeal decisions within the time required by federal law and regulations.

Citizens Rx is a claims fiduciary and handles prescription drug claims and appeals under its claims and appeal rules. Citizens Rx will decide appeals and obtain independent medical reviews requested by Participants. Citizens Rx will use an IMR company licensed in the State of California. Participants will be notified in writing of any adverse determinations within the time required by federal law and regulations.

Coast Benefits, Inc. is a claims fiduciary and handles all Health Reimbursement Arrangement and Medicare Supplement claims under its claims and appeal rules. In the unlikely event that a claim is denied based upon a lack of medical necessity and an appeal brought, Coast Benefits, Inc. will use an IMR company licensed in the State of California for any appeals related to medical necessity issues. Participants will be notified in writing of any adverse determinations within the time required by federal law and regulations.

For more information on appeals, see Article 10.3: Claims and Appeal Rules on page 51.