CLAIMS AND APPEALS PROCEDURES
The following sections outline the steps you must take to file a claim and to appeal a denial of a claim (whether a complete or partial denial) for benefits under the Plans. Please note that claims procedures differ for hospital, major medical, prescription, mental health/chemical dependency and dental claims. If you have any questions about these procedures, you can contact the Participant Services Department in the Fund office.
A Claim for Benefits
A "claim for benefits" is a request for a plan benefit made in accordance with the Fund's procedures for filing benefit claims. Inquiries that are unrelated to a specific benefit claim, such as inquiries regarding benefits available under the plan, or the circumstances under which benefits might be paid, or eligibility for benefits, will not be treated as "claim for benefits" subject to these provisions (except for "pre-service claims"). In addition, a request for prior approval of a benefit that does not require prior approval under the plan is not considered a "claim for benefits" under the new procedures. Retail and mail order pharmacy transactions through the Medco network are point-of-service transactions and are not considered "claims for benefits" under these procedures.
In addition to special requirements as described below for "pre-service" and "urgent care" claims, a "claim for benefits" under the Plan must include all of the following information in order to be considered for payment by the Fund:
The following sections outline the steps you must take to file a claim and to appeal a denial of a claim (whether a complete or partial denial) for benefits under the Plans. Please note that claims procedures differ for hospital, major medical, prescription, mental health/chemical dependency and dental claims. If you have any questions about these procedures, you can contact the Participant Services Department in the Fund office.
A Claim for Benefits
A "claim for benefits" is a request for a plan benefit made in accordance with the Fund's procedures for filing benefit claims. Inquiries that are unrelated to a specific benefit claim, such as inquiries regarding benefits available under the plan, or the circumstances under which benefits might be paid, or eligibility for benefits, will not be treated as "claim for benefits" subject to these provisions (except for "pre-service claims"). In addition, a request for prior approval of a benefit that does not require prior approval under the plan is not considered a "claim for benefits" under the new procedures. Retail and mail order pharmacy transactions through the Medco network are point-of-service transactions and are not considered "claims for benefits" under these procedures.
In addition to special requirements as described below for "pre-service" and "urgent care" claims, a "claim for benefits" under the Plan must include all of the following information in order to be considered for payment by the Fund:
- Patient name and address
- A bill on the provider's letterhead
- CPT procedure codes
- ICD9 illness codes
- Date(s) of service
- Provider"s charge for service
- Other information or proof reasonably required by the Fund
