Claims procedures for group health and disability plans covered by ERISA.

Download this Document (Word doc.) February, 2003

To All Employees and Dependents:

The Department of Labor has issued Final Regulations concerning claims procedures for group health and disability plans covered by ERISA. The Regulations are effective for this Plan for claims filed on or after January 1, 2003, and they require the Plan to establish and maintain reasonable procedures to govern the filing of claims, notice of benefit determinations, and appeal of adverse benefit determinations.

The Claims Procedure Regulations require the Plan to make several changes in its claims procedures, including making claims determinations within specific time frames, providing additional information to you concerning the reasons claims are denied and appeals rights, expanding the time limits for filing claim appeals, and shortening the time limits for the Trustees to hear a claim appeal. Following is a summary of the changes as they apply to your Plan.

Pre- and Post-Service Claims

Your Plan requires that you obtain preauthorization for certain services and supplies or Plan benefits will be denied. A list of these services and supplies is on page 1 of your Summary Plan Description. New services are added to the list from time to time.

If you have a question whether a service or supply requires preauthorization, please call the Fund Office. Also, precertification is required for any non-emergency hospital confinement, any non-emergency inpatient surgery, and certain outpatient surgeries in order to be eligible for the maximum level of benefits. See page 2 of your Summary Plan Description for details on how to obtain precertification. Also, you must contact the Fund Office for prior approval for all organ transplants.

Claims such as this are called "pre-service claims," which means any claim which requires approval of the benefit in advance of obtaining medical care. When you submit a pre-service claim (either by telephone or in writing), the Plan will notify you whether or not the claim is approved within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days of the Plan's receipt of the claim. If you fail to follow the Plan's procedures for filing a claim, (as detailed in the following section, "e;Filing a Benefit Claim"e;), you will be notified of the failure and the proper procedures as soon as possible, but no later than five days following the failure. We will notify you verbally, unless you request us to notify you in writing.

Any claim for benefits that is not a pre-service claim is considered a "e;post-service claim."e; Post-service claims include those for emergency hospital admissions. Please notify the Plan within 48 hours following such an emergency admission. You must submit all other post-service claims in writing within 90 days of the occurrence of the accident or sickness, or as soon thereafter as is reasonably possible. In no event can you submit a claim later than two years after the claim was required to be received by the Fund Office. In addition to the section of this Notice entitled "e;Filing a Benefit Claim,"e; see pages 89 and 90 of your Summary Plan Description for further details on how to apply for benefits. For post-service claims, the Plan will notify you of an adverse benefit determination within 30 days of the Plan's receipt of a claim.

For both pre- and post-service claims, if the Plan needs additional time to determine whether a claim is a covered expense for reasons beyond the Plan's control, the Plan may take one 15-day extension. The Plan will notify you prior to the expiration of the initial 15- or 30-day notification period, as applicable, of the circumstances requiring the extension and the date by which the Plan expects to make a decision. If an extension is needed due to your failure to submit necessary information, the Plan will tell you the information needed. The time period for making the determination is suspended from the date on which the notice of the necessary information is sent to you until the date you respond. You have 45 days from receipt of the notice to respond to the request for information. Once you respond, the Plan will decide the claim within the 15-day extension period. Your claim will be denied if you do not respond in a timely manner. The Plan may take only one extension for group health claims and may not further extend the time for making its decision unless you agree to a further extension.

Please note that there are special provisions in the Final Regulations for "e;urgent care claims"e; (referred to under the Plan as "e;emergencies"e;), but, by definition, these provisions do not apply to your Plan because the Plan does not require prior approval of emergency admissions.

Filing a Benefit Claim

Claims requiring precertification may be submitted initially by telephone. To avoid delays in the processing of your pre-service claim, provide as much of the information as possible [see (a) through (j) which follow]. For organ transplants that are insured by BCS Insurance Company, BCS will notify you directly of their decision. You must appeal directly to BCS according to their grievance procedures; the Fund Office will be glad to assist you. The decision by BCS will be final and binding.

Post-service claims must be submitted to the Fund Office,

P.O. Box 4002
Eau Claire, WI 54702.

Post-service claims must be submitted in writing. Post-service claims should be complete. They should contain, at a minimum:

Fund name (Wisconsin Carpenters' Health Fund)
Employee's name and Social Security number
Full name (including "e;Jr.,"e; if applicable) and date of birth of the eligible person who incurred the covered expense
Name and address of the service provider
Federal tax identification number of provider
Diagnosis of the condition
Procedure or nature of the treatment
Date of and place where the procedure or treatment has been provided
Amount billed and the amount of the covered expense not paid through coverage other than this Plan, as appropriate

- AND -

Evidence that substantiates the nature, amount, and timeliness of each covered expense that is in a reasonably understandable format and is in compliance with all applicable law.

Claims will not be deemed submitted for purposes of these procedures unless and until received at the correct address. A general request for an interpretation of Plan provisions will not be considered a claim for benefits. Pre-determined amounts that you must pay, such as a prescription drug co-payment or amount required because of use of a network or non-network provider, will not be considered a claim for benefits subject to these claims procedures. However, if you feel you have been charged an improper dollar or percentage co-payment (for example through the Preferred Provider Pharmacy Program), you may submit a formal appeal to the Fund Office in writing within 180 days to have your claim reviewed according to the appeal procedures stated in this Notice.

You or an authorized representative can pursue a claim. You may authorize a representative by submitting a written authorization to the Trustees.

Concurrent Care Claims

A concurrent care claim is when the Plan has approved an ongoing course of treatment to be provided over a period of time and the Plan is reducing or terminating the treatment before the scheduled end of the treatment. Although this situation almost never arises, we are required to tell you that this provision exists. If the Plan reduces or terminates treatment before the end of the course of the treatment, the Plan will notify you far enough in advance of the termination or reduction of treatment to allow you to appeal the adverse benefit determination before the termination or reduction takes effect.

Disability Claims

The Plan has a reasonable period of time, not in excess of 45 days, to provide notice of an adverse benefit determination for any claim for disability benefits under the Plan which is filed on or after January 1, 2002. The Plan may extend the decision-making period for up to an additional 30 days for reasons beyond the Plan's control. A second 30-day extension is allowable if the Plan still is unable to make the decision for reasons beyond its control. You will be provided, before the expiration of the applicable deadline, a notice that details the reasons for the delay.

You will be notified if additional information is needed, in which case you will have 45 days to provide the requested information. The Plan will issue its decision within 30 days of the date you timely submit your information (subject to the 30-day extension previously described). Your claim will be denied if you do not submit the requested information in a timely manner.

Content of Benefit Determination Notices

If your claim for benefits is denied in whole or in part, the Plan will provide you with written or electronic notice of adverse benefit determinations within the time frames previously stated. Notices will include the following information stated in an easily understandable manner:

The specific reasons for the adverse benefit determination.

References to specific Plan provision(s) on which the adverse benefit determination is based.
A description of any additional material or information necessary for you to perfect your claim and an explanation of why the material or information is necessary.
A description of the Plan's claims appeal procedures and time limits applicable to such appeal procedures, including a statement of your right to bring a civil action under Section 502(a) of ERISA following review of an adverse benefit determination.
If an internal rule, guideline, protocol, or similar criterion was relied upon in making the adverse benefit determination, a statement that it was relied upon and that a copy will be provided free of charge to you upon request.
If the adverse benefit determination was based on an exclusion for medical necessity or experimental treatment, an explanation of the scientific or clinical judgment of the Plan in applying the terms of the Plan to your medical circumstances will be provided free of charge to you upon request.
If a medical or vocational expert's advice was obtained, you may request the identity of the expert, regardless of whether the advice was relied on.

Rules Regarding Claims Appeal Procedures

If all or part of a claim is denied after the Plan has received all necessary claim information, you have the right to appeal the decision and request a review of the claim. The Plan will provide for a full and fair review of a claim and adverse benefit determination, pursuant to the following:

You will have 180 days from the date the adverse benefit determination was mailed to you to file your appeal in writing to the Fund Office.
You will be allowed the opportunity to submit written comments, documents, records, and other information relating to the claim for benefits.
You or your duly authorized representative will be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits.
Your review will take into account all comments, documents, records, and other information submitted by you relating to the claim, whether or not such information was submitted or considered in the initial benefit determination.
)The Plan will assign a decision maker on appealed claims that is an appropriate named fiduciary for the Plan and different than and not the subordinate of the person deciding the initial claim.
The Plan will consult with appropriate health care professionals in deciding appealed claims involving medical judgment, including determination of experimental or investigational treatments and medical necessity. Such health care professional will have appropriate training and experience in the field of medicine involved in the medical judgment. The health care professional consulted for the appeal of an adverse benefit determination will be someone who was not consulted in the initial adverse benefit determination nor the subordinate of such individual.
If a medical or vocational expert's advice was obtained, you may request the identity of the expert, regardless of whether the advice was relied on.

Your Plan has two levels of appeal. The first level of appeal is decided by the Eligibility and Appeals Committee of the Trustees. The second level is decided by the Executive Committee of the Trustees. These rules regarding claims appeal procedures apply to each level of appeal.

See pages 90 through 93 of your Summary Plan Description for further details of the Plan's claims appeal procedures.

Time Frames for Deciding Appeals

For appeals of pre-service claims, the Plan will notify you of the decision within 15 days of receiving the first appeal request and 15 days of receiving the second appeal request, if applicable.

For appeals of post-service claims, the Plan will notify you of their decision within 30 days of receiving the first appeal request and 30 days of receiving the second appeal request, if applicable.

Notification of Benefit Determination After Appeals Review

The Plan will provide you with written or electronic notice of an adverse benefit determination within five days of the decision being made. The notice will include the following information stated in an easily understandable manner:

The specific reasons for the adverse benefit determination.
References to specific Plan provision(s) on which the adverse benefit determination is based.
A statement that you will be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits.
A statement of your right to bring a civil action under Section 502(a) of ERISA after you have exhausted the Plan's claims appeal procedures.
If an internal rule, guideline, protocol, or similar criterion was relied upon in making the adverse benefit determination, a statement that it was relied upon and that a copy will be provided free of charge to you upon request.
If the adverse benefit determination was based on an exclusion for medical necessity or experimental treatment, an explanation of the scientific or clinical judgment of the Plan in applying the terms of the Plan to your medical circumstances will be provided free of charge to you upon request.

The Trustees will make every effort to interpret Plan provisions in a consistent and equitable manner. You will be given maximum opportunity to present your viewpoint on any denied claim. No lawsuit may be filed without first exhausting the previously stated appeal procedures. No legal action for any benefits under the Plan may begin later than two years after the time the claim was required to be filed as specified on page 89 of your Summary Plan Description. Benefits under this Plan will be paid only if the Board of Trustees (or its Administrative Manager) decides in its discretion that you are entitled to them. The Plan will be interpreted and applied in the sole discretion of the Board of Trustees (or its delegate, including but not limited to, its Administrative Manager). Such decision will be final and binding on all persons covered by the Plan who are claiming any benefits under the Plan.

Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions regarding any of this information, please feel free to contact the Fund Office.

Yours very truly,

THE BOARD OF TRUSTEES

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