The determination of whether a claim falls under the procedures for health claims or under the procedures for disability and other non-health claims is based on the nature of the specific claim or benefit, not the characterization of the plan under which the claim is made or the benefit is offered.
This article provides a general overview of claims and appeals procedures that apply to most health and disability plans. Please consult your actual Certificate of Coverage for specific details on your plan provisions.
Filing a Claim
The claims filing procedures are set forth in the Certificates of Coverage for each benefit plan. In general, any participant or beneficiary under the Plan (or his or her authorized representative) may file a written claim for benefits using the proper form and procedure. A claimant can obtain the necessary claim forms from the Plan Administrator. When you submit a claim, the insurance company will be responsible for reviewing the claim and determining how to pay the claim on behalf of the Plan. As described in the Evidence of Coverage documents, there may be other reasons that a claim for benefits is not paid (or not paid in full). For example, claims must generally be submitted for payment within a certain period of time, and failure to submit within that time period may result in the claim being denied.
Disability and Non-Health Claims
If any portion of your disability-based claim is denied, you will receive a written notice of denial containing an explanation of the reasons for such denial. You may request a review of any denied claim. For a detailed description of the required procedures for filing claims and of the appeals procedures for any denied claims, please refer to the Certificates of Coverage for each of the separate Benefit Plans. If you cannot locate your plan Certificate, you may request a duplicate from the Plan Administrator.
Under Affordable Care Act (ACA) and Department of Labor (DOL) regulations, claimants are entitled to full and fair review of any claims made under the Plan. As required by law, the Plan recognizes four categories of health benefit claims as described below. Each of the different types of claims have different timing requirements.
Urgent Care Claims. Claims (other than post-service claims) for which the application of non-urgent care time frames could seriously jeopardize the life or health of the patient or the ability of the patient to regain maximum function or, in the judgment of a physician, would subject the patient to severe pain that could not be adequately managed otherwise. Individuals in urgent care situations and those receiving an ongoing course of treatment may proceed with expedited external review at the same time as the internal appeals process.
Pre-Service Claims. “Pre-service claims” are claims for approval of a benefit if the approval is required to be obtained before a patient receives health care (for example, claims involving Preauthorization or referral requirements).
Post-Service Claims. Claims involving the payment or reimbursement of costs for health care that has already been provided.
Concurrent Care Claims. “Concurrent care claims” are claims for which the Plan previously has approved a course of treatment over a period of time or for a specific number of treatments, and the Plan later reduces or terminates coverage for those treatments. A concurrent care claim may be treated as an “urgent care claim,” “pre-service claim,” or “post-service claim,” depending on when during the course of your care you file the claim. However, the Plan must give you sufficient advance notice of the initial claims determination so that you may appeal the claim before a concurrent care claims determination takes effect.
If the Plan does not fully agree with your claim, you will receive an “adverse benefit determination” — a denial, reduction, or termination of a benefit, or failure to provide or pay for (in whole or in part) a benefit. An adverse benefit determination includes a decision to deny benefits based on:
An individual being ineligible to participate in the Plan;
A service being characterized as experimental or investigational or not medically necessary or appropriate; and
A concurrent care decision
For a full description of the required procedures for filing claims and of the appeals procedures for any denied claims, please refer to the Certificates of Coverage for each of the separate Benefit Plans. Your Certificates of Coverage also provide a full description of the procedures for appealing an adverse benefit decision, for requesting internal review of an adverse benefit decision, as well as the procedures required to request an external review of any adverse benefit decision.
Acts of Third Parties
When you or your covered dependent are injured or become ill because of the actions or inactions of a third party, the Plan may cover your eligible health care expenses. However, to receive coverage, you must notify the Plan that your illness or injury was caused by a third party, and you must follow special Plan rules. This section describes the Plan’s procedures with respect to subrogation and right of recovery. Subrogation means that if an injury or illness is someone else’s fault, the Plan has the right to seek expenses it pays for that illness or injury directly from the at-fault party or any of the sources of payment listed later in this section. A right of recovery means the Plan has the right to recover such expenses indirectly out of any payment made to you by the at-fault party or any other party related to the illness or injury. By accepting Plan benefits to pay for treatments, devices, or other products or services related to such illness or injury, you agree that the Plan:
Has an equitable lien on any and all monies paid (or payable to) you or for your benefit by any responsible party or other recovery to the extent the Plan paid benefits for such sickness or injury;
May appoint you as constructive trustee for any and all monies paid (or payable to) you or for your benefit by any responsible party or other recovery to the extent the Plan paid benefits for such sickness or injury; and
May bring an action on its own behalf or on the covered person’s behalf against any responsible party or third party involved in the sickness or injury.
If you (or your attorney or other representative) receive any payment from the sources listed later in this section – through a judgment, settlement or otherwise – when an illness or injury is a result of a third party, you agree to place the funds in a separate, identifiable account and that the plan has an equitable lien on the funds, and/or you agree to serve as a constructive trustee over the funds to the extent that the Plan has paid expenses related to that illness or injury. This means that you will be deemed to be in control of the funds. You must pay the Plan back first, in full, out of such funds for any health care expenses the Plan has paid related to such illness or injury. You must pay the Plan back up to the full amount of the compensation you receive from the responsible party, regardless of whether your settlement or judgment says that the money you receive (all or part of it) is for health care expenses. Furthermore, you must pay the Plan back regardless of whether the third party admits liability and regardless of whether you have been made whole or fully compensated for your injury. If any money is left over, you may keep it. Additionally, the Plan is not required to participate in or contribute to any expenses or fees (including attorney’s fees and costs) you incur in obtaining the funds. The Plan’s sources of payment through subrogation or recovery include (but are not limited to) the following:
Money from a third party that you, your guardian or other representatives receive or are entitled to receive;
Any constructive or other trust that is imposed on the proceeds of any settlement, verdict or other amount that you, your guardian or other representatives receive;
Any equitable lien on the portion of the total recovery which is due the Plan for benefits it paid; and
Any liability or other insurance (for example, uninsured motorist, underinsured motorist, medical payments, workers’ compensation, no-fault, school, homeowners, or excess or umbrella coverage) that is paid or payable to you, your guardian or other representatives.
As a Plan participant, you are required to:
Cooperate with the Plan’s efforts to ensure a successful subrogation or recovery claim, including setting funds aside in a particular account. This also includes doing nothing to prejudice the Plan’s subrogation or recovery rights outlined in this Summary.
Notify the Plan within 30 days of the date any notice is given by any party, including an attorney, of your intent to pursue or investigate a claim to recover damages or obtain compensation due to sustained injuries or illness.
Provide all information requested by the Plan, the Claims Administrator or their representatives, or the Plan Administrator or its representatives.
The Plan may terminate your Plan participation and/or offset your future benefits in the event that you fail to provide the information, authorizations, or to otherwise cooperate in a manner that the Plan considers necessary to exercise its rights or privileges under the Plan. If the subrogation provisions in these "Acts of Third Party" provisions conflict with subrogation provisions in an insurance contract governing benefits at issue, the subrogation provisions in the insurance contract will govern. If the right of recovery provisions in these "Acts of Third Party" provisions conflict with right of recovery provisions in an insurance contract governing benefits at issue, the right of recovery provisions in the insurance contract will govern.
Recovery of Overpayment
Whenever payments have been made exceeding the amount necessary to satisfy the provisions of this Plan, the Plan has the right to recover these expenses from any individual (including you, or any other organization receiving excess payments). The Plan may also withhold payment, if necessary, on future benefits until the overpayment is recovered. In addition, whenever payments have been made based on fraudulent information provided by you, the Plan will exercise the right to withhold payment on future benefits until the overpayment is recovered.
Non-assignment of Benefits
Plan participants cannot assign, pledge, borrow against, or otherwise promise any benefit payable under the Plan before receipt of that benefit. However, benefits will be provided to a participant’s child if required by a Qualified Medical Child Support Order. In addition, subject to the written direction of a Plan participant, all or a portion of benefits provided by the Plan may, at the option of the Plan, and unless a participant requests otherwise in writing, be paid directly to the person rendering such service. Any payment made by the Plan in good faith pursuant to this provision shall fully discharge the Plan and Employer to the extent of such payment.
Misstatement of Fact
In the event of a misstatement of any fact affecting your coverage under this Plan, the true facts will be used to determine the coverage in force.
Pre-existing Conditions Limitations – Health Plan Coverage
Effective January 1, 2014, Health Care Reform prohibits Plans from applying a pre-existing condition limit on eligible employees and dependents. Pre-existing Conditions Limitations for individuals under age 19 have been prohibited since the first Plan Year beginning on or after September 23, 2010.
Pre-existing Conditions Limitations – Non-Health/Disability Plan Coverage
The prohibition on pre-existing conditions for health plan coverage does not apply to disability insurance coverage. Disability plans typically have a pre-existing condition exclusion that will exclude from coverage any disability that is caused or contributed to by a pre-existing condition. This includes both coverage provided at your initial effective date and any increases in coverage thereafter. Refer to your Certificate of Coverage for full details.