Active Health Summary Plan Description
As of September 1, 2017
En Español (PDF)

18.2 Claims and Appeal Rules

Remedies available under the Plan for the redress of claims, which are denied in whole or in part, including provisions required by Section 503 of Employee Retirement Income Security Act of 1974:

Introduction

Benefits provided to eligible Participants and Dependents by the following providers are subject to the claims and appeal rules established by these providers:

  1. Kaiser HMO Medical Plan (including the Kaiser vision benefit)
  2. UnitedHealthcare HMO Medical Plan
  3. The Anthem Blue Cross Premier PPO Plan
  4. Citizens Rx (Self-Funded Prescription Drug benefits)
  5. United Concordia PPO Plan
  6. CIGNA DHMO Dental Plan
  7. Delta Dental DHMO (PMI Dental Plan)
  8. United Concordia DHMO and PPO Dental Plans
  9. Anthem Blue Cross Life and Health Insurance Company (Life Insurance/AD&D benefit)
  10. Optum (Member Assistance Program)
  11. MedExpert (Advocacy and Assistance Program)
  12. Coast Benefits, Inc. (Medical Body Scan benefit, Specialized Footwear benefit and Health Reimbursement Arrangement benefit)

You should review each program's Evidence of Coverage document and contact the provider directly for its claims review or grievance procedure. The Administrative Office can provide you with information on where to write.

It is the intent and desire of the Trustees that these rules be consistent and comply with applicable regulations, including but not limited to 29 CFR 2560. et. seq. Please consult with each of the providers listed at their Evidence of Coverage on filing claims and appeals. These rules shall be construed in accord with that intent. Those regulations are incorporated here as though set forth in full. The regulations shall be construed in accord with Department of Labor guidance issued subsequent to issuance of the regulations.

B. Eligibility Determinations

The Administrative Office is responsible for determining eligibility. Each month the Administrative Office provides a listing of eligible participants to the benefit providers (Kaiser, UnitedHealthcare, Anthem Blue Cross, etc.).

There may be instances where a Participant has a claim denied because he or she has not met the plan rules to be eligible for benefits under the Plan. There are many reasons why this can happen.

For illustrative purposes only, several examples are cited below.

Example 1: A Participant may not work the required hours to be eligible for benefits as explained in Article 4: Eligibility and General Plan Provisions of this Summary Plan Description.

Example 2: A Participant has worked the required hours in covered employment but his or her employer has not remitted the required Contributions to the plan.

Example 3: A Participant does not work the required 100 hours per month to maintain eligibility and his or her Hours Bank Reserve has been depleted to zero, or there are not enough hours left in the Hours Bank Reserve to establish eligibility.

Example 4: A Participant is no longer working and the Participant has elected COBRA continuation coverage, but he or she has failed to make the required self-payment to be eligible for continuation coverage.

Most eligibility issues are resolved quickly with a call or a letter to the Administrative Office. The Administrative Office is there to assist you and provide you with exact information on the status of your eligibility and entitlement to benefits under the various plans.

C. Eligibility Appeals

If you have a claim denied because you do not meet the eligibility requirements of the Plan you have the right to appeal this denial. Your appeal must be in writing, and must be filed with the Administrative Office of the Trust Fund no later than 180 days after the denial of eligibility.

Regarding the timing of your appeal, please consider that the Trust Fund's benefit providers will generally not accept retroactive premiums or provide retroactive benefits beyond a typical 60- or 90-day time frame. As such, Participants and Dependents should, if possible, attempt to bring their appeal while considering those time frames.

When submitting an appeal, you must state in your appeal why you believe you meet the eligibility requirements (refer to Article 4: Eligibility and General Plan Provisions), and provide any factual information and evidence you believe is important in having your appeal reviewed.

The Trust Fund's Board of Trustees has established an Appeal Subcommittee for dealing with all eligibility appeals. The Appeal Subcommittee makes findings and recommendations to the full Board of Trustees which may be adopted by the Board of Trustees through the written unanimous consent provisions of the Trust Agreement.

D. Urgent and Pre-Service Claims

When an eligibility issue is intertwined with an urgent or pre-service claim, the Appeal Subcommittee will attempt to act through the written unanimous consent provisions of the Trust Agreement, subject to the 72-hour and 15-day requirements for urgent and pre-service claims, respectively.

E. Post Service Claims

When an eligibility issue affects a post-service claim, if the findings and recommendations of the Appeal Subcommittee are not adopted through the unanimous written consent procedure, the matter will be considered at the next regularly scheduled meeting of the Board of Trustees, subject to the 30-day requirement for post-service claims.

F. Exhaustion of the Appeal Process

Under a federal law known as ERISA, a Participant or Dependent whose claim for benefits has been denied may file suit against the Trust Fund seeking the denied benefit. However, prior to filing such a suit the appeal process under the Trust Fund described above must be pursued and exhausted. Thus, following any initial denial of benefits, if you disagree it is important you file a timely appeal. In all cases your appeal must be filed no later than 180 days after the initial denial of your claim was received by you. If you do not file an appeal within the required time frame you will have failed to exhaust your appeal rights. The organization responsible for hearing your appeal may extend the 180-day limit upon your showing good cause for the delay, but to protect your rights you should file any appeal promptly after your receipt of the initial denial.

Following the Trustees' decision, the Participant or Dependent shall have the right to bring a civil action under Section 502 of ERISA.

G. Some Questions Common to all Claims and Appeals Relating to Eligibility

Question: Who may file an appeal if my eligibility or the eligibility of my eligible dependents is denied?

Answer: You may file the appeal yourself or you may authorize a representative (i.e., doctor, spouse, etc.) to file an appeal on your behalf. Any representative acting on your behalf must have received written authorization from you to act on your behalf and that written authorization must be filed immediately with the Administrative Office as part of your appeal. If you are physically or mentally incapacitated the Trustees may waive this written authorization requirement. It is extremely important to understand that an assignment of benefits to the provider of services does not constitute an authorization for the provider to act as your representative.

Question: If my eligibility is denied will the Plan, upon request, supply me or my representative with all documents relevant to my eligibility claim?

Answer: Yes. You should be supplied copies of all documents and opinions relevant to your claim in accord with federal regulations.

H. Regulations

In conducting and considering all eligibility appeals, the Trustees intend to comply at all times with all applicable Department of Labor regulations, including 29 CFR Section 2560.530, as it may be amended from time to time. That regulation is incorporated herein by reference and is available to participants upon request.