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Notice Of Decision On Appeal

Any notice of an adverse determination will include the following:

  • The specific reason or reasons for the adverse determination;
  • Reference to the Fund's provisions on which the determination was based;
  • A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to and copies of all documents and other information relevant to the claimant's claim;
  • A statement describing the claimant's right to bring an action under ERISA Section 502(a);
  • If the determination is based on a medical necessity or experimental exclusion, a statement that an explanation of the scientific or clinical judgment applied to make the determination will be provided free of charge upon request; and
  • If an internal rule or guideline was applied in making the determination, a statement that the rule will be provided free of charge upon request
  • Information identifying the claim involved including the date of service, the health care provider, the claim amount, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning;
  • The reason(s) for the adverse benefit determination including the denial code and its corresponding meaning, as well as a description of the Plan's standard, if any, that was used to deny the claim at issue, and, in the case of final adverse benefit determinations, the description of the discussion of the decision;
  • A description of the available internal appeals and review processes, including information regarding how to initiate an appeal; and
  • The contact information and availability of any applicable offices of health insurance consumer assistance or ombudsman established under PPACA to assist you with the internal claims and appeals processes.

No lawsuit may be brought with respect to Fund benefits until the foregoing administrative procedures have been exhausted. Additionally, no lawsuit may be brought more than two years following the date the Claims Administrator notifies the claimant of a final adverse determination.

External Review Procedure

Effective for claims incurred on and after January 1, 2012, the Fund's claims and appeals procedures have been changed pursuant to PPACA. Most notably, the Fund implemented an external review appeal process. If, after exhausting the Fund's internal appeals procedure, you are not satisfied with the final determination, you may choose to participate in the external review program. This program only applies if the adverse benefit determination is based on:

  • Clinical reasons,
  • The exclusions for Experimental or Investigational Services or Unproven Services, or
  • As otherwise required by applicable law.

This external review program offers an independent review process to review the denial of a requested service or procedure or the denial of payment for a service or procedure. The process is available at no charge to you after exhausting the Fund's internal appeals process and receiving final adverse benefit determination from the Fund on your internal appeal (your "Internal Appeal Denial"). You may request an external review by an Independent Review Organization (IRO) within four (4) months of the notice of the Internal Appeal Denial.*

The Fund's internal appeal denial notice will inform you of your right to request an external review appeal, your external review rights and your right to file suit in federal court under the ERISA. See page 107 of the SPD for details regarding the Internal Appeals Process.

The external review will be performed by an independent Physician, or by a Physician who is qualified to decide whether the requested service or procedure is a covered health service under the Fund. The IRO has been contracted by the Fund and has no material affiliation with or interest in the Fund. The Fund will choose the IRO based on a rotating list of approved IROs. In certain cases, the independent review may be performed by a panel of Physicians, as deemed appropriate by the IRO. Within applicable timeframes of the Fund's receipt of a request for independent review, the request will be forwarded to the IRO, together with:

  • All relevant medical records;
  • All other documents relied upon by the Fund in making a decision on the case; and
  • All other information or evidence that you/or your Physician have already submitted to the Fund.

If there is any information or evidence you or your Physician wish to submit in support of the request that was not previously provided, you may include this information with the request for an independent review, and the Fund will include it with the documents forwarded to the IRO. A decision will be made within applicable timeframes. If the reviewer needs additional information to make a decision, this time period may be extended. The independent review process will be expedited if you meet the criteria for an Expedited External Review as defined by applicable law.

* If there is no corresponding date four (4) months after the date of your receipt of the internal appeal denial notice, you must then file the request for an external review by the first day of the fifth month following your receipt of such notice. For example, if the date of your receipt of the Fund's internal appeal benefit denial notice is October 30, because there is no February 30, the request must be filed by March 1. In addition, if the last filing date would fall on a weekend or federal holiday, the last filing date to request an external review is extended to the next day that is not a Saturday, Sunday or federal holiday.

Preliminary Review By The Plan

Within five (5) business days following the date of the Fund's receipt of your request for an external review, the Claims Administrator will complete a preliminary review to determine whether your request is complete and eligible for an external review. Specifically, that preliminary review will determine whether:

  • You were covered under the Fund at the time the health care item or service was requested or, in the case of a retrospective review, provided;
  • The final denial of your appeal relates to your failure to meet the Fund's eligibility requirements;
  • You exhausted the Fund's internal appeal process (or are not required to exhaust the process); and
  • You have provided all the information and forms required by the Fund to process an external review.

Within one (1) business day after the Claims Administrator completes its preliminary review, it will issue you a written notification of its determination. If your request is complete, but not eligible for external review, the notification will include the reasons for its ineligibility and contact information for the Employee Benefits Security Administration. If your request is not complete, the notification will describe the information or materials needed to make the request complete and you will be allowed to perfect your request for an external review within the original four-month filing period or, if later, the 48-hour period following your receipt of the notification.

Review By The IRO

If the Claims Administrator approves your request for an external review, the Fund will assign a qualified IRO to conduct the review. Within five (5) business days after making the assignment, the Fund will provide the assigned IRO with the documents and information that the Claims Administrator considered in making its final adverse benefit determination.

The Fund will also notify you of this assignment. Upon receiving such notice, you will have ten (10) business days to submit additional information to the IRO. If you submit additional information, within one (1) day after receiving such informacion, the IRO will send such information to the Fund so it may reconsider its determination. If the Fund decides to reverse its decision based on its review of this new information, it will provide a written notice of its decision to you and the IRO within one (1) business day after reaching that favorable decision; and the IRO will terminate the external review upon receipt of the Fund's notice. If, however, the Fund does not reverse its determination, the IRO will conduct a de novo review of all of the information and documents that it received from the Fund or you, and will not be bound by any decisions or conclusions reached by the Claims Administrator during the Fund's internal claim and appeal process. The IRO, at its discretion, may also consider the following in reaching its decision: your medical records; the attending health care professional's recommendation; reports from the appropriate health care professionals and other documents submitted by the Claims Administrator, you or your treating provider; the terms of the Fund, to ensure that the IRO's decision is not contrary to the terms of the Fund; appropriate practice guidelines; any applicable clinical review criteria developed and used by the Fund; and the opinion of the IRO's clinical reviewer(s).

The IRO will provide written notice to you and the Claims Administrator of the final external review decision within 45 days after the IRO receives the request for the external review. The IRO's notice will contain, to the extent required by law, the following information:

  • A general description of the reason for the Request for External Review including, if applicable, information sufficient to identify the claim, the amount of the claim, the diagnosis code and its corresponding meaning, the treatment code and its corresponding meaning and the reason for the previous denial;
  • The date the IRO received the assignment from the Fund to conduct the external review and the date of the IRO's decision;
  • References to the evidence or documentation considered in reaching its decision, including the specific coverage provisions and evidence-based standards;
  • A discussion of the principal reason or reasons for its decision, including the rationale for its decision and any evidence-based standards that were relied on in making its decision;
  • A statement that the determination is binding except to the extent that other remedies may be available under State or Federal law to either the Fund or you;
  • A statement that judicial review may be available to you; and
  • If applicable, the current contact information for any applicable office of Health Insurance Consumer Assistance or Ombudsman.
Overview Of The "New" Expedited External Review Procedures

Under the following circumstances, you may be eligible to file for an expedited external review:

  • If you receive an adverse benefit determination that involves a medical condition for which the timeframe for completion of an expedited internal appeal with the Claims Administrator would seriously jeopardize your life or health, or that would jeopardize your ability to regain maximum function, and you have filed a request for an expedited internal appeal; or

(ii) If you receive a final adverse benefit determination from the Claims Administrator and

  • You have a medical condition for which the timeframe for completion of a standard external appeal would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function; or
  • If the final adverse benefit determination concerns an admission, availability of care, continued stay, or a health care item or service for which you have received emergency services but have not been discharged from a facility.
Preliminary Review By The Fund

Immediately upon receipt of the request for an expedited external review, the Claims Administrator will conduct a preliminary review of your request and determine whether you are eligible for such a review. Immediately after completion of this preliminary review, the Claims Administrator will issue you a written notification of its determination. If your request is complete but is not found to be eligible for an expedited external review, the notice will include the reasons for ineligibility. If your request is incomplete, the notice will describe the information or materials needed to perfect the request.

Review By The IRO

Upon a determination that a request is eligible for an expedited external review, the Claims Administrator will assign an IRO to review it and will transmit all necessary documents and information to the IRO in accordance with the above-discussed "standard" external review rules. The IRO will provide a written notice of its final decision to you and the Claims Administrator as expeditiously as possible, but in no event later than 72 hours (24 hours for reviews involving urgent claims) after the IRO receives the request for the expedited external review. If notice is not in writing, within 48 hours of providing that notice, the IRO shall provide written notice to you and the Claims Administrator of its final decision.