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Claims And Appeals Rules

The claims and appeals rules apply to the benefits administered by the Fund and benefits administered for the Fund by third-party administrators.

A claim is a request for plan benefit made in accordance with the Health Plan's procedures for filing such claims. Inquiries that are unrelated to a specific claim, such as inquiries regarding benefits available under the Fund, or the circumstances under which benefits might be paid, or qualification for benefits, will not be treated as claims (except for pre-service claims as described below). In addition, a request for prior approval of a benefit that does not require prior approval under the Fund is considered an inquiry, and not a claim for purposes of these procedures and the appeal procedures that follow.

In addition to special requirements as described below for pre-service claims and urgent care claims, a claim for health benefits under the Fund must include the following information, as applicable to health care related claims, in order to be considered for payment by the Health Plan.

  • Plan participant's name and address;
  • Plan participant's 12-character participant ID number (WRXA12345678);
  • Patient's name and address (if different from the participant's);
  • Patient's date of birth;
  • Provider's name and address;
  • Provider's federal tax identification number;
  • Itemized provider bill, preferably in a standardized CMS-1500 or UB-04 format (non-standard billing formats can delay claim processing);
  • Amount paid (if any);
  • CPT (Current Procedural Terminology) procedure code(s);
  • ICD-9 (International Classification of Diseases, Ninth Edition) diagnosis code(s);
  • Date(s) of service; and
  • Other information or proof reasonably required by the Fund.

The scope of an adverse benefit determination or claim will include rescissions (within the meaning of PPACA) of coverage whether or not there is an immediate adverse effect on any particular benefit. As a result, rescissions of coverage are subject to the Fund's claims and appeal rules. The Fund's procedures for all Fund claims are described below.

You will find contact information for all Claims Administrators in the Summary Of Benefits section starting on page 16.


Sub-Topics:

Filing Claims In General
Denial Notices
Appealing A Denied Claim
Decisions On Appeal
Notice Of Decision On Appeal
Pre-Service Health Care Claims
Disability Claims
Other Claims
Plan Interpretations