Hospital and Doctor Bills
All hospitals and doctors must send their bills directly to Blue Cross and Blue Shield of Illinois (BCBSIL) at the address shown on your BCBSIL I.D. card. Be sure to show your I.D. card to these providers.
You don’t have to submit a claim form.
If the claim does not contain enough information for your claim to be processed, the missing information will be requested from you or the medical provider. Be sure that you respond promptly if the Fund Office asks you for more information.
Local 734 Welfare Fund
6643 North Northwest Highway
Chicago, IL 60631-1360
TIME LIMIT FOR FILING CLAIMS
No payment will be made if the claim is not submitted within one year (12 months) after the claim is incurred.
CLAIM PROCESSING TIME LIMITS
When used in the following explanation, the term “Plan office” means the office or organization designated by the Trustees for handling claims.
The amount of time the Plan can take to process a claim depends on the type of claim. A claim can fall into one of the following categories:
If all the information needed to process your claim is provided to the Plan office, your claim will be processed as soon as possible. However, the processing time needed will not exceed the time frames allowed by law, which are as follows:
WHEN ADDITIONAL INFORMATION IS NEEDED (“CLAIMANT EXTENSION”) – If additional information is needed from you, your doctor or the provider, the necessary information or material will be requested in writing. The request for additional information will be sent within the normal time limits shown above, except that the additional information needed to decide an urgent care claim will be requested within 24 hours.
It is your responsibility to see that the missing information is provided to the Plan office. The normal processing period will be extended by the time it takes you to provide the information, and the time period will start to run once the Plan office has received a response to its request. If you do not provide the missing information within 45 days (48 hours for an urgent care claim), the Plan office will make a decision on your claim without it, and your claim could be denied as a result.
PLAN EXTENSION – The time periods above may be extended if the Plan office determines that an extension is necessary due to matters beyond its control (but not including situations where it needs to request additional information from you or the provider). You will be notified prior to the expiration of the normal approval/denial time period if an extension is needed. If an extension is needed, it will not last more than:
CLAIM DENIALS – If all or a part of your claim is denied after the Plan office has received a completed claim form and all other necessary information from you, you will be sent a written notice giving you the reasons for the denial. The notice will include reference to the Plan provisions on which the denial was based and an explanation of the claim appeal procedure. If applicable, it will give a description of any additional material or information necessary for you to perfect the claim, and the reason such information is necessary. The notice will provide a description of the appeal procedures and the applicable time limits for following the procedures. It will also include a statement concerning your right to bring a civil action under section 502(a) of ERISA. In cases where the Plan relied upon an internal rule, guideline, protocol or similar criterion to make its decision, the notice will state that the specific internal rule, guideline, protocol or criterion will be provided to you free of charge upon request. If the decision was based on medical necessity or if the treatment was deemed experimental, the notification will include either an explanation of the scientific or clinical judgment for the determination or a statement that such explanation will be provided free of charge upon request. For urgent claims, a description of the Plan’s expedited review process will be provided.
CLAIM APPEAL PROCEDURE
APPEALING THE DENIAL OF A CLAIM – If your claim has been denied in whole or in part, you may request a full and fair review (also called an “appeal”) by filing a written notice of appeal with the Plan.
NOTIFICATION FOLLOWING REVIEW – If your appeal is for an urgent care claim, you will be notified of the decision about your appeal as soon as possible, taking into account the circumstances, but not later than 72 hours after receipt of your request for review. In the case of non-urgent pre-service claims, you will be notified no later than 30 days after receipt of your request for review.
A review and determination for disability and postservice claims will be made no later than the date of the meeting of the Trustees that immediately follows the Plan’s receipt of a request for review. The Review Committee meets on a quarterly basis. However, if the request is filed within 30 days preceding the date of such meeting, a determination may be made by no later than the date of the second meeting.
If special circumstances (such as the need to hold a hearing) require a further extension of time, a determination will be made not later than the third meeting of the Trustees. Before the start of the extension, you will be notified in writing of the extension, and that notice will include a description of the special circumstances and the date as of which the determination will be made.
You will be informed of the Trustees’ decision, normally within 5 calendar days of the review. The decision will be in writing unless the appeal was for an urgent care claim and you are advised by telephone or fax. When you receive the written decision, it will contain the reasons for the decision and specific references to the particular Plan provisions upon which the decision was based. It will also contain a statement explaining that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim, and a statement of your right to bring an action under section 502(a) of ERISA. If applicable, you will also be informed of your right to receive free of charge upon request the specific internal rule, guideline, protocol or similar criterion relied on to make the decision. If the decision was based on a medical judgment, you will receive an explanation of that determination or a statement that such explanation will be provided free of charge upon request.
If the Plan fails to make timely decisions or otherwise fails to comply with the applicable federal regulations, you may go to court to enforce your rights. A claimant may not file suit against the Plan until the claimant has exhausted all of the procedures described in these procedures.