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Health Fund
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Pre-Service Health Care Claims

While most claims for benefits under the Fund are post-service claims subject to the rules described above, some claims require pre-approval and are considered pre-service claims. A claim is a pre-service claim only if failure to obtain approval before care is received results in a reduction or denial of benefits that would otherwise be covered. Claims requiring pre-approval include certain dental claims (these are submitted to Delta Dental), and certain prescription drugs (these are submitted to Express Scripts).

There are three types of pre-service health care claims: urgent care claims, non-urgent care claims and concurrent care claims. The rules described above apply to pre-service claims, except as described below:

  • If a health care claim is a pre-service claim but is not a claim for urgent health care, the Claims Administrator will notify the claimant of a denial within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receiving the claim, unless an extension of 15 days is necessary due to circumstances beyond the Fund's control. If the reason for the extension is because the Claims Administrator doesn't have enough information to decide the claim, the notice will describe the required information and the claimant will have 45 days from the date the notice is received to provide the necessary information.
  • If the health care claim is a pre-service claim for urgent health care, the Claims Administrator will notify the claimant of the determination as soon as possible, but not later than 72 hours after receipt of the claim. If the claimant fails to provide sufficient information for determination, the claimant will be notified of the missing information as soon as possible, but not later than 24 hours after receipt of the claim. The claimant will have a reasonable period of time (at least 48 hours) to provide the missing information. The claimant will then receive an eligibility determination or not later than 48 hours after the earlier of (1) the Fund's receipt of the missing information, or (2) the end of the period provided for the claimant to submit the missing information, provided the Claims Administrator is not required to provide a determination before the original 72-hour period expires. If the requested information is not provided within this time frame, your claim will be considered denied.
  • Special rules apply for concurrent care decisions. These are decisions involving an approved ongoing course of treatment, either for a specific period of time or for a specific number of treatments. A reduction or termination of the course of treatment before the approved time period or number of treatments will be considered a claim denial. If this occurs, the participant will be notified sufficiently in advance in order to appeal the decision before the benefit is reduced or terminated. For example, if BlueCross/BlueCard approves a three-week period of inpatient stay coverage and then determines mid-treatment that three weeks is inappropriate, the decision to shorten the three-week period is subject to the concurrent care rules.
  • On the other hand, claimants may request an extension of the course of treatment beyond the approved time period or number of treatments. For example, if BlueCross/BlueCard approves a three-week period of inpatient coverage and the claimant wants to extend the coverage beyond three weeks, this is also a concurrent care claim. If such a concurrent care claim involves urgent care, the Claims Administrator will provide notice of the determination within 24 hours of receiving the request, as long as the request is made at least 24 hours before the approved time period or number of treatments expires. If the request doesn't involve urgent care, the normal pre-service health care claim rules apply.
  • If a claimant fails to follow the Fund's claim procedures for filing a pre-service claim, the claimant will be notified of the failure and of the proper procedures to follow in filing a claim for benefits. The notice will be provided not later than 5 days (or 24 hours for an urgent care claim) after receipt of the claim. This provision applies only if the claim was received by a person customarily responsible for handling Fund benefit matters and includes the name of the claimant, a specific medical condition or symptom, and a specific treatment, service or product for which approval is requested.
  • If a pre-service claim for urgent health care is denied on appeal, the claimant will be notified of the eligibility determination as soon as possible, but not later than 72 hours after receipt of the request for review.
  • If a pre-service claim for health benefits that doesn't involve urgent health care is denied on appeal, the claimant will be notified of the determination within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days after receipt of the request for review.