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.
Any payments made by the Plan in accordance with these rules will fully discharge the Plan’s liability to the extent of its payments.
No payment will be made if the claim is not submitted within one year (12 months) after the claim is incurred.
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 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.
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).
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:
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 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.
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.
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.