Claim Procedures

HOW AND WHERE TO SEND CLAIMS

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.

Other Claims

1. Submit itemized bills relating to the claim to the Fund Office at the address below AS SOON AS POSSIBLE:

   Local 734 Welfare Fund
   6643 North Northwest Highway
   Chicago, IL 60631-1360

2. Each claim submission should include:
   • Your full name
   • Your Social Security number
   • Name of patient
   • Patient’s date of birth and relationship to you
   • Date of service
   • Type of service or supply
   • Itemized charges for each service or supply
   • The sickness or injury

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:

1. A claim is “post-service” if you have already received the treatment or supply for which payment is now being requested. Most claims are post-service claims.
2. A “disability claim” is a claim for Weekly Disability Benefits.
3. A “pre-service claim” is a request for preauthorization precertification of a type of treatment or supply that requires approval in advance of obtaining the care.
4. An “urgent care claim” is a pre-service claim where the application of the time periods for making non-urgent care determinations could seriously jeopardize your life, health, or ability to regain maximum function, or that could subject you to severe pain that cannot be adequately managed without the proposed treatment.
5. A “concurrent care claim” is also a type of preservice claim. A claim is a concurrent care claim if a request is made to extend a course of treatment beyond the period of time or number of treatments previously approved.

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:

• Post-service claims-30 days.
• Disability claims-45 days.
• Pre-service claims-15 days.
• Urgent care claims-24 hours.
• Concurrent care claims-24 hours if the concurrent care is urgent and if the request for the extension is made within 24 hours prior to the end of the already authorized treatment. If the concurrent care is not urgent, then the pre-service time limits apply.

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:

• Pre-service claims-15 days.
• Post-service claims-15 days.
• Disability claims-30 days (a second 30-day extension may be needed in special circumstances).

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.

1. A notice of appeal must be received at the Plan office not more than 180 days after you receive the written notice of denial of the claim. Your appeal is considered to have been filed on the date the written notice of appeal is received at the Plan office.
2. The Review Committee will be the Board of Trustees or a committee appointed by the Board. Mail your written request for review to the Board of Trustees, Local 734 Welfare Fund, 6643 North Northwest Highway, Chicago, IL 60631-1360.
3. Med-Care will conduct reviews of pre-service claims. You may orally request a review of a denied urgent care claim by calling Med-Care at 1 (800) 367-1934, or you may submit your request in writing to Med-Care Management, Inc. at P.O. Box 20564, West Palm Beach, FL 33416-0564. Med-Care may notify you of its decision by telephone or facsimile. If you are not satisfied with the appeal decision made by Med-Care, you can request that the Board of Trustees conduct a second review of the claim.
4. The Review Committee will not include the person, or a subordinate of the person, who made the original claim denial.
5. If you wish, another person may represent you in connection with an appeal. If another person claims to be representing you in your appeal, the Review Committee has the right to require that you give the Plan a signed statement, advising the Review Committee that you have authorized that person to act on your behalf regarding your appeal. Any representation by another person will be at your own expense.
6. You or your authorized representative may review pertinent documents and may submit comments and relevant information in writing.
   • Upon written request, the Plan office will provide reasonable access to, and copies of, all documents, records or other information relevant to your claim.
   • If the Plan office obtained an opinion from a medical or vocational expert in connection with your claim, the Plan office will, on written request, provide you with the name of that expert.
   • The Plan office will not charge you for copies of documents you request in connection with an appeal.
7. You may request a personal appearance before the Review Committee, with or without your properly designated representative, but at your own expense.
8. In deciding your appeal, the Review Committee will consider all comments and documents that you submit, regardless of whether that information was available at the time of the original claim denial. The review will not defer to the initial denial, and will take into account all information submitted by you, including comments, documents and records, without regard to whether such information was previously submitted or relied upon in the initial determination.
9. If an appeal involves a medical judgment, such as whether treatment is medically necessary, the Review Committee will consult with a medical professional who is qualified to offer an opinion on the issue. If a medical professional was consulted in connection with the original claim denial, the Review Committee will not consult with the same medical professional (or a subordinate of that person) for purposes of the appeal.

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.