Claim Procedures

HOW TO FILE CLAIMS

Hospital and Doctor Bills
All hospitals and doctors must send their bills di-rectly 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 pro-viders.

You don’t have to submit a claim form unless the Fund Office requests one.
 
In those rare circumstances when your provider will not submit the claim directly to BCBSIL, you can submit a paper claim to the Fund Office, and the Fund Office will submit it to BCBSIL. The Fund only accepts paper claims that are on HCFA-1500 or CMS-1500 forms since those are the only forms accepted by BCBSIL. (Use of these forms is standard in the medical industry.)
 
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

Benefit Payments

1. BCBSIL pays the Plan’s share of your medical expenses directly to the provider. After BCBSIL has made the payment, the doctor or hospital will bill you for any remaining charges. It is your responsibility to pay the balance directly to the hospital or doctor—do not file a claim for the remaining amount with the Fund Office.
2. Vision benefits, and dental benefits under the Dental PPO Plan, will be made to you (the employee) unless you assign benefits.
    
   Assigning benefits means that you or your spouse sign a form that tells the Fund Office to make payments directly to the provider of the services and supplies instead of to you. You will be sent an Explanation of Benefits telling you what the Fund Office paid. You are responsible for paying any amounts not paid by the Fund Office.
    
   You do not have to file claims for prescription drug benefits or benefits received under the Dental HMO Plan.
3. The Plan will reimburse you the Plan’s share of out-of-network doctor expenses unless there is a valid written assignment of benefits.
4. If the Trustees decide that a person isn’t mentally, physically, or otherwise capable of handling his business affairs, the Plan may pay benefits to his guardian or to the individual who has assumed his care and principal support, if there is no guardian. If the person dies before all due amounts have been paid, the Trustees may make payment to his estate, to his surviving spouse, parent, child, or children, or to any individual the Trustees believe is entitled to the benefits.

Any payments made by the Plan in accordance with these rules will fully discharge the Plan’s liability to the extent of its payments.
 

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 or precertification of a type of treatment or supply that requires approval in advance of obtaining the care.
4. An “urgent care claim” is a preservice 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 pre-service 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 – 72 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 such a request is not made at least 24 hours prior to the expiration of the prescribed period of time or number of treatments, the request must be treated as a claim involving urgent care and decided in accordance with the urgent care claim timeframes, i.e., as soon as possible and not later than 72 hours after receipt.

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 a pre-service claim will be requested within five days (24 hours for an urgent care claim).
 
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 15 days, except that for disability claims the extension will not last beyond 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 regarding medical, prescription, dental or vision claims, 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.
 
A denial of a disability claim, including a retroactive termination of such benefit, will also include a discussion of the decision, including an explanation of the basis for disagreeing with or not following the views of your treating health care professionals and the vocational professionals who evaluated you, as presented by you to the Plan as part of your claim; the views of medical or vocational experts whose advice the Plan obtained, without regard to whether the advice was relied upon in making the benefit determination; and disability determination by the Social Security Administration.
 
The denial also will include:

• A statement 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 for benefits;
• The Plan’s contractual time limits for pursuing a lawsuit against the Plan and the calendar date upon which such time limit expires;
• A statement disclosing any internal rule, guidelines, protocol, or similar criterion relied on in making the adverse benefit determination (or a statement that no such information was relied upon); and
• If the decision involves scientific or clinical judgment, either an explanation of the scientific or clinical judgment applying the terms of the Plan to your medical circumstances, or a statement that such explanation will be provided to you at no charge upon request.

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.Med-Care Management, Inc. 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.
3. The Review Committee will not include the person, or a subordinate of the person, who made the original claim denial.
4. 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.
5. 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.
6. You may request a personal appearance before the Review Committee, with or without your properly designated representative, but at your own expense.
7. 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.
8. 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.
9. Prior to issuing a denial of an appeal with respect to a disability claim, the Plan will provide you, free of charge, with any new or additional evidence considered or generated by the Review Committee, and the rationale for the adverse decision. The Plan will provide you such information as soon as possible and sufficiently in advance of the required date for providing an adverse review decision in order to provide you with a reasonable opportunity to respond prior to that date.
10. If the Plan obtained the advice of a medical or vocational expert in connection with the benefit decision, the Plan will provide to you upon your request the names of each such expert, regardless of whether the advice was relied on by 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 post-service 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 five 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 you 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.
 
EXTERNAL REVIEW
If you appeal to the Review Committee but the process still results in a denial of your claim, you may, in certain cases, request an additional review by an independent review organization (IRO). An independent external review is available for claims denied based on clinical or scientific judgments, such as decisions based on medical necessity. It does not apply, for example, to claim denials related to a person’s eligibility for coverage. External review is also not available with respect to disability claims. You must apply for the external review within four months after the date of receipt of the written appeal decision you received from the Fund. To request an external review, call or write the Fund Office. Fund Office staff will provide you with the information you need to file your formal request for an external review and provide you with the information you need to complete the process. If allowed by law, you must pay a $25 administrative fee for each external review, which will be refunded if the adverse benefit determination is reversed upon external appeal.
 
You may apply for an expedited external review if the claim involves a medical condition for which the regular timeframe for completion of external review would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function, or if the final internal adverse benefit determination (denial) concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, but have not been discharged from a facility.
 
YOUR RIGHT TO A TIMELY DECISION
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 here.
 
LEGAL ACTIONS
You may not file legal action against the Plan or the Trustees to recover a loss until all of the proper claim procedures and claim review procedures have been followed.
 
Section 502(a) of ERISA gives participants and beneficiaries the right to bring a court action to re-view Trustees’ decisions. In order to be timely, a court action seeking to review a Trustee’s decision must be filed and served no later than one year after receipt of the Trustee’s decision to deny the claim or appeal.