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Medical Benefits
Depending on the Plan you are enrolled in (see below), it may offer you and your eligible dependents comprehensive medical benefits including coverage for many hospital and physician services, in network surgi-centers, chiropractic care, diagnostic x-ray, imaging and lab tests, durable medical equipment, emergency room physician services, skilled nursing, home health, hearing aids, infertility benefits, maternity benefits, mental health and substance abuse and organ transplants. When you use a PPO in-network provider, you will receive a higher level of benefits.
Non Medicare Plans:
- BCBS Plan #50441 - Hospital Only Coverage or
- BCBS Plan # 50445 - Comprehensive Major Medical Coverage
Medicare Eligible Plans:
- BCBS Plan # 50498 - Secondary “Hospital Only” Coverage or
- BCBS Plan # 50446 - Secondary Comprehensive Medical Benefits
Preferred Provider Organization
PPO vs. Non-PPO: Knowing the Difference Saves You Money
The Plan offers you access to a Preferred Provider Organization (PPO) through BlueCross BlueShield of Illinois (BCBS). When you or other eligible members of your family use a PPO provider physician and/or hospital, you save money both for your family and the Plan. BCBS has agreements with providers that participate in their network (PPO providers) to charge a negotiated dollar amount. Doing so saves you money in two ways: 1) The overall cost of the service is lower as a result of negotiated discounts and 2) the Plan typically pays a higher percentage of the covered expenses.
If your in-network PPO physician refers you to a hospital or facility, be sure to ask if it is “in-network.” As the chart below shows using healthcare providers in the PPO network, you can maximize your medical benefits and save money for yourself and the Fund.
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| Example of Network Savings: John Smith has a knee replacement surgery on January 5, 2011. |
| |
BCBS PPO In-Network Provider |
Non PPO Out-of-Network Provider |
| Cost of single knee replacement |
$70,000 |
$70,000 |
| Network Discount |
($30,000) |
n/a |
| Total charges for consideration |
$40,000 |
$54,000*** |
|
Participant Pays *
(Deductible, coinsurance)**
|
$2,300 |
$22,600*** |
| Plan Pays |
$37,700 |
$47,400 |
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* In this example, all covered in-network benefits for the remainder of the 2011 calendar year will be paid at 100% as John's deductible and his Annual Co-Insurance Maximum have been met.
** In-network and out-of-network deductible and coinsurance limits are separate.
*** The amounts charged for out-of-network medical expenses are subject to the Reasonable and Customary Allowances as adopted by the Fund. Amounts over the Reasonable and Customary Allowance ($16,000), plus deductible ($600) and Co-Insurance ($6,000) are the Covered Individual's responsibility.
Be Sure to “Make the Call” before all Hospital Admissions
If you are NOT YET Medicare-eligible, you or a family member must call BlueCross BlueShield's Medical Services Advisory (MSA) within one business day BEFORE you or a dependent are admitted to the hospital or within two business days AFTER emergency or maternity care admissions. If you do not, you will be required to pay a $500 penalty for each hospital admission in addition to any Deductibles and Coinsurance that may apply. Required notification applies to both In-Network PPO and Out-of-Network Non-PPO hospitals.
REMEMBER - MAKE THE CALL
CALL BlueCross MSA at 1-800-255-5192
Health Benefits for Non-Medicare Eligible Retirees
If you are not yet eligible for Medicare, depending on the plan you are enrolled in, you may have coverage under one of the following plans: (1) Hospital Only or (2) Comprehensive Major Medical.
Please note: Deductibles and Coinsurance Maximums for the Active Plan of Benefits do not carry over to the Retiree Plan of Benefits.
BCBS Plan #50441 - Hospital Only Coverage
This Plan is only available when the carpenter retired on or before June 1, 2006. The Plan pays hospital benefits for up to 180 days per covered Individual per calendar year. For a complete listing of covered expenses, please refer to the Summary Plan Description (SPD).
The Plan pays benefits through BCBS, the Fund’s preferred network provider (PPO).
|
|
BCBS In-Network
PPO Provider
|
Out-of-Network
Non-PPO Provider
|
|
Calendar Year Deductible*
|
$ 300 per Individual
|
$ 600 per Individual
|
|
Coinsurance
|
Plan pays 80%
Participant pays 20%
|
Plan pays 60%**
Participant pays 40%
|
|
Annual Coinsurance Maximum* (per calendar year)
|
$2,000 per Individual
|
$6,000 per Individual
|
|
Emergency Room (ER) Copayment
|
$250, waived if admitted to the hospital directly from ER
(Copayment does not apply to Annual Coinsurance Maximum)
|
|
Medical Services Advisory Non-Notification Penalty
|
$500 per admission
|
* There are separate Calendar Year Deductibles and Annual Coinsurance Maximums for in-network and out-of-network expenses.
** Out-of-network expenses are subject to Reasonable and Customary Allowances (R&C), as adopted by the Fund Office. Amounts over R&C are the Covered Individual’s responsibility.
Hearing Benefits
Retirees and their family members are eligible for a discount on hearing aids through EPIC Hearing Services (EPIC).
BCBS Plan # 50445 - Comprehensive Major Medical Coverage
The Plan’s Comprehensive Medical Benefits are provided through BlueCross BlueShield of Illinois (BCBS), the Fund’s preferred network provider (PPO).
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BCBS In-Network
PPO Provider
|
Out-of-Network
Non-PPO Provider
|
|
Calendar Year Deductible*
|
$300/Individual
|
$600/Individual
|
|
Coinsurance
|
Plan pays 80%
Participant pays 20%
|
Plan pays 60%**
Participant pays 40%
|
|
Annual Coinsurance Maximum* (per calendar year)
|
$2,000/Individual
|
$6,000/Individual
|
|
Emergency Room (ER) Copayment
|
$250, waived if admitted to the hospital directly from ER
(Copayment does not apply to Annual Coinsurance Maximum)
|
|
Medical Services Advisory Non-Notification Penalty
|
$500 per admission
|
* There are separate Calendar Year Deductibles and Annual Coinsurance Maximums for in-network and out-of-network expenses.
** Out-of-network expenses are subject to Reasonable and Customary Allowances (R&C), as adopted by the Fund Office. Amounts over R&C are the Covered Individual’s responsibility.
Plan benefits are subject to the following limitations and exceptions:
· Chiropractic Care: Calendar year maximum of $3,000 per Retired Carpenter, $1,000 per Spouse, $0 per Dependent Child
· Convalescent Facility: Up to 120 days per convalescent period
· Home Health Care: Up to 120 days per calendar year
· Hospice Care: Up to 180 days per lifetime
· Infertility Services (Hospital, Physician, Drugs, Treatments, etc.): Lifetime maximum of $10,000 per Family
· Preventive Care (Routine physicals/well child care): $300 per Individual per year, not subject to Calendar Year Deductibles or Coinsurance
· Preventive Colorectal Screening: Plan pays 100%, once every five years, for covered Retirees and Spouses over the age of 50, when performed by a BCBS In-Network PPO Provider. Screenings performed by out-of-network providers are subject to Calendar Year Deductibles and Coinsurance
· Hearing Benefits: The Plan pays a maximum of $1,500 per covered Individual for prescribed hearing aid instruments, or their repair, once every five consecutive years. Coverage is only for the device itself and is not subject to Calendar Year Deductibles. A hearing exam is not covered. Discounts on hearing aids are available through EPIC Hearing Services. If you do not go through EPIC, claims must be submitted through BCBS.
Health Benefits for Medicare Eligible Retirees
If you are eligible for Medicare, depending on the coverage your are enrolled in, you may be eligible for coverage under one of the following plans: (1) Secondary Hospital Only Coverage or (2) Comprehensive Secondary Medical Benefits Coverage.
Benefits are modified to take Medicare benefits into account – whether or not you are enrolled in Medicare. Therefore, when you become eligible for Medicare, you should enroll in Medicare Part A and Medicare Part B. However, if you want to participate in the Plan’s Prescription Drug Benefit, you should not enroll in Medicare Part D.
When you, your spouse, or your dependent becomes eligible for Medicare, a copy of the covered individual’s Medicare Card must be sent to the Fund Office.
BCBS Plan # 50498 - Secondary “Hospital Only” Coverage
This Plan is only available when the carpenter retired on or before June 1, 2006. The Plan pays covered expenses, secondary to Medicare. For a complete listing of covered expenses, please refer to the Summary Plan Description (SPD).
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Medicare Part A Supplement
(Hospital/Facility Fees per Benefit Period)
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*A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
|
|
|
Medicare Pays
|
Plan Covers
|
You Pay
|
- Hospital Confinement (Semi-private room and board, general nursing, and miscellaneous services and supplies:
|
|
|
|
|
o First 60 days
|
All but Part A Deductible
|
Part A Deductible
|
$0
|
|
o 61st through 90th day
|
All but Part A Copayment
|
Part A Copayment
|
$0
|
|
o 91st day and after
|
|
|
|
|
o While using 60 Lifetime Reserve Days
|
All but Part A Copayment
|
Part A Co-Payment
|
$0
|
|
o Once Lifetime Reserve days are used:
Additional 365 days
|
$0
|
100% of Medicare eligible expenses
|
|
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o Beyond the additional 365 days
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$0
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$0
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All costs
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Hearing Benefits
Retirees and their family members are eligible for a discount on hearing aids through EPIC Hearing Services (EPIC).
BCBS Plan # 50446 - Secondary Comprehensive Medical Benefits
The Plan pays covered expenses, secondary to Medicare. The Plan covers most, but not all, of the Medicare-eligible expenses that Medicare does not pay.
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Medicare Part A Supplement
(Hospital/Facility Fees per Benefit Period)
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|
*A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
|
|
|
Medicare Pays
|
Plan Covers
|
You Pay
|
- Hospital Confinement (Semi-private room and board, general nursing, and miscellaneous services and supplies:
|
|
|
|
|
o First 60 days
|
All but Part A Deductible
|
Part A Deductible
|
$0
|
|
o 61st through 90th day
|
All but Part A Copayment
|
Part A Copayment
|
$0
|
|
o 91st day and after
|
|
|
|
|
o while using 60 Lifetime Reserve Days
|
All but Part A Copayment
|
Part A Co-Payment
|
$0
|
|
o Once Lifetime Reserve days are used:
Additional 365 days
|
$0
|
100% of Medicare eligible expenses
|
$0
|
|
o Beyond the additional 365 days
|
$0
|
$0
|
All costs
|
- Skilled Nursing Facility Care* (You must meet Medicare’s requirements including having been in a hospital for at least three days and entered a medicate approved facility within 30 days after leaving the hospital.)
|
|
|
|
|
o First 20 days
|
All approved amounts
|
$0
|
$0
|
|
o 21st through 100th day
|
All but Part A Copayment
|
Part A Copayment
|
$0
|
|
o 101st day and after
|
$0
|
$0
|
All Costs
|
|
|
|
|
|
|
o First 3 pints
|
$0
|
Three Pints
|
$0
|
|
o Additional Amounts
|
100%
|
$0
|
$0
|
- Hospice Care (Available as long as your doctor certifies you are terminally ill and you elect to receive these services.)
|
All but very limited coinsurance for outpatient drugs and inpatient respite care
|
$0
|
Balance
|
|
Medicare Part B Supplement
(Professional Fees per Calendar Year)
|
|
*Once you have been billed $100 of Medicare-approved amounts for covered services (which are noted with a single asterisk), your Part B deductible will have been met for the calendar year.
|
- Medical Expenses – In or Out of the Hospital and Outpatient Treatment, such as physician services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic test, durable equipment.
|
|
|
|
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o First $100 of Medicare-approved amounts
|
$0
|
$0
|
$100 (Part B Deductible)
|
|
o Remainder of Medicare-approved amounts
|
80%
|
20%
|
$0
|
|
o Part B excess charges (above Medicare-approved amounts)
|
$0
|
$0
|
All Costs
|
|
|
|
|
|
|
o First three (3) pints
|
$0
|
All Costs
|
$0
|
|
o Next $100 of Medicare-approved amounts*
|
$0
|
$0
|
$100 (Part B Deductible)
|
|
o Remainder of Medicare approved amounts
|
80%
|
20%
|
$0
|
- Clinical Laboratory Services – Blood Tests for Diagnostic Services
|
100%
|
$0
|
$0
|
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Medicare (Parts A & B)
|
|
|
Medicare Pays
|
Plan Covers
|
You Pay
|
|
|
|
|
|
|
o Medically necessary skilled care services and medical supplies
|
100%
|
$0
|
$0
|
|
o Durable medical equipment
|
|
|
|
|
o Next $100 of Medicare approved amounts*
|
$0
|
$0
|
$100 (Part B Deductible)
|
|
o Remainder of Medicare-approved amounts
|
80%
|
20%
|
$0
|
- At-Home Recovery Services (Home care certified by your doctor, for personal care during recovery from and injury or sickness for which Medicare approved a home care treatment plan)
|
|
|
|
|
o Each Visit
|
$0
|
Actual charges to $40 a visit
|
Balance
|
|
o Number of visits covered (must be received within eights weeks of last Medicare-approved visit)
|
$0
|
Up to the number of Medicare-approved visits, not to exceed seven each week
|
Balance
|
|
o Calendar Year Maximum
|
$0
|
$1,600
|
Balance
|
- Foreign Travel (Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA.)
|
|
|
|
|
o First $250 each calendar year
|
$0
|
$0
|
$250
|
|
o Remainder of Charges
|
$0
|
80% to a lifetime benefit of $50,000
|
20% and amounts over the $50,000 lifetime maximum
|
* You must meet Medicare’s Requirements, including having been in a hospital for at least three days and enter a Medicare-approved facility within 30 days of leaving the hospital.
** Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a home treatment plan.
Hearing Benefits
The Plan pays a maximum of $1,500 per covered Individual for prescribed hearing aid instruments, or their repair, once every five consecutive years. Coverage is only for the device itself. A hearing exam is not covered. Discounts on hearing aids are available through EPIC Hearing Services. If you do not go through EPIC, claims must be submitted through BCBS.
Adverse Claim Determination Appeal Process
The Patient Protection and Affordable Care Act (“PPACA”) requires health plans to maintain an enhanced internal claims and appeals process and a new external review process for rescission of coverage and adverse benefit determinations (a claim that has been denied in whole, or in part). The information below will summarize the regulations and guidance on both the enhanced internal review process and the external review process.
For appeal purposes, claims are grouped into three different categories:
1. Pre-Service Claims – a pre-service claim in one in which a pre-authorization is required before a service can be performed. Adverse benefit determinations on pre-service claims are appealable; however this Plan does not require you to get prior authorization or approval before services are rendered and there are no preexisting condition exclusions under this Plan.
2. Post-Service Claims – a post-service claim is one in which a claim has been adjudicated (processed) after the service was rendered. Adverse benefit determinations on post-service claims are appealable. A post-service claim, also known as a claim for benefits, contains all of the following information:
a. patient’s name and date of birth
b. participant’s name and social security number or the identification number assigned by the Fund Office
c. date of service,
d. name of the health care provider and tax identification number
e. address of health care provider,
f. procedure code and its corresponding meaning;
g. place of service
h. the claim amount; and
i. denial code and it’s corresponding meaning.
3. Urgent Care Claims – an urgent care claim is one in which the patient’s health would be in serious jeopardy or delay would jeopardize the patient’s ability to regain maximum function or, in the opinion of patient’s physician, he/she may experience pain that cannot be adequately controlled while waiting for a decision on whether the procedure or service is approved for coverage. Adverse benefit determinations on urgent care claims are appealable; however this Plan does not require you to get prior authorization or approval before services are rendered and there are no preexisting condition exclusions.
Internal Review of Claims
An Explanation of Benefits (EOB) serves as the notice of an adverse benefit determination when payment of a claim for benefits has been denied, in whole or in part, for the reasons stated on the EOB. If you believe the determination was made in error, you have certain appeal rights. Only a Participant, patient or an Authorized Personal Representative may appeal an adverse benefit determination. The information below describes the Fund’s Internal Review process.
I. Determine if you have a claim for benefits.
A. A claim for benefits (also referred to as a “post-service claims) must contain all of the following information: patient’s name and date of birth, participant’s name and social security number or the identification number assigned by the Fund Office, date of service, name of the health care provider and tax identification number, address of health care provider, procedure code and its corresponding meaning; place of service, the claim amount; and a denial code and it’s corresponding meaning.
B. Because this Plan does not require a service or procedure to be pre-authorized and there are no preexisting condition exclusions, the only claims that generally can be appealed under this Plan are post-service claims that have been processed and denied in whole or in part.
C. Only a participant, patient or an Authorized Personal Representative has the right to appeal a claim for benefits that was denied in whole or in part.
D. To designate an Authorized Personal Representative, log on to the Fund’s website at www.cdccbenefits.org. On the left hand side of the screen under “Health Plan” select “Form” Scroll down and print an Authorized Personal Representative Designation form. By completing this form, you are requesting the Fund Office to provide and/or communicate with the person or entity (e.g., your doctor) you designate as your authorized personal representative.
E. A request by a provider or participant for information on whether a certain procedure, prescription, treatment plan or other similar request is covered by the Plan (often referred to as a “pre-determination of benefits request”) is not considered a claim for benefits; and therefore not appealable.
II. Determine if you are filing a timely appeal.
A. If a post service claim for benefits has been denied, in whole or in part, the Participant, Patient or Authorized Personal Representative have no more than 180 days after the receipt of an adverse benefit determination to file an appeal.
III. To Request an Appeal of an Adverse Benefit Determination
A. To file an appeal with the Board of Trustees, log on to the Fund’s website at www.crccbenefits.org. On the left hand side of the screen under “Health Plan” select “Forms.” Scroll down and print an Appeal Form. Complete the form in its entirety.
B. All appeals must be in writing, contain the signature of the participant, patient or authorized personal representative and addressed to the Board of Trustees.
C. Your written appeal should include evidence or specific facts and benefit plan provisions that support your claim for benefits. If you have additional information that pertains to your appeal, you may attach it to the Appeal Form.
D. Submit the completed Appeal Form and any additional information to substantiate your appeal to:
Scan & Email: Appeals@crccbenefits.org
Fax: Chicago Regional Council of Carpenters
Welfare Fund
Attn: Appeals Committee
Fax Number: 312-951-1515
(Note: Write the Participant’s name and
ID number on each page)
Mail: Chicago Regional Council of Carpenters
Welfare Fund
Attn: Appeals Committee
12 East Erie Street 7th floor
Chicago, IL 60611
IV. Upon Appeal, a Covered Individual has the Right:
A. To receive, upon written request, copies of all documents relevant to the claim;
B. To designate an authorized personal representative (who may be an attorney);
C. To request, free of charge, a copy of relevant information if the covered individual’s claim is denied based on internal rules, guidelines, protocol or other similar criteria;
D. To request, free of charge, a copy of an explanation of the scientific or clinical judgment that is the basis of the adverse claim determination, if the covered individual’s claims is denied based on medical necessity, experimental treatment or similar exclusion or limit
E. To be advised of the identity of any medical expert; and
F. The covered individual may:
1. Submit additional material, including comments, statements, or documents; and
2. Request, free of charge, all relevant information. A document, record or other information is considered relevant if it:
a. Was relied upon by the Plan in making the decision;
b. Was submitted, considered, or generated (regardless of whether is was relied upon; or
c. Demonstrates compliance with Claim processing requirement.
G. To receive copies or all new or additional information considered, relied upon or generated during the appeal as well as any new or additional rationale for the denial, if any; and
H. To challenge the denial of a claim by filing a lawsuit in court, seeking review of the Funds decision under section 502(a) of ERISA. Such lawsuit can be filed only after a covered individual has followed and exhausted the Fund’s internal Appeal procedures
V. Preliminary Review
A. The Plan will complete a preliminary review of the request within five (5) business days of the Plan’s receipt of your request for an appeal to determine whether:
i. You are/were covered under the Plan at the time the health care item or service is/was requested or, in the case of a retrospective review, were covered under the Plan at the time the health care item or service was provided;
ii. The Adverse Determination does not relate to your failure to meet the requirements for eligibility under the terms of the Plan; and
iii. You have provided all of the required information and forms to process your appeal.
VI. Review by the Appeals Committee of the Board of Trustees
A. Properly filed appeals are reviewed at the next regularly scheduled appeals meeting of the Trustees, who meet at least quarterly.
i. The Trustees will mail their decision to the covered individual within five (5) business days after making a determination.
B. If your appeal is denied, you have the right to initiate a lawsuit under ERISA section 502(a) or request an external review from an independent review organization.
i. Any lawsuit must be initiated within twelve months of the denial on review.
External Review of Claims
If your appeal of a claim is denied by the Appeal Committee of the Board of Trustee, you may request further review by an independent review organization (“IRO”) as described below. Generally, you may only request an external review after you have exhausted the internal review and appeals process described above.
NOTE that if your claim was denied due to your failure to meet the requirements for eligibility under the terms of the Plan, external review is not available.
I. External Review of Standard Claims
Your request for external review of a non-urgent claim must be made, in writing, within four (4) months of the date the Explanation of Benefits indicating an adverse benefit determination or the date of the letter advising of an adverse Appeal Claim Benefit Determination which ever is greater. For convenience, the determination(s) referred to below are “Adverse Determination(s),” unless it is necessary to address them separately.
The Plan’s internal review and appeals process generally must be exhausted before external review is available. External review of claims will only be available for adverse appeal benefit determinations. To request an external review, log on to the Fund’s website at www.cdccbenefits.org. On the left hand side of the screen under “Health Plan” select “Forms.” Scroll down and print an “External Review Form.” Follow the directions provided and submit to the Fund Office.
A. Preliminary Review
1. The Plan will complete a preliminary review of the request within five (5) business days of the Plan’s receipt of your external review request to determine whether:
(a) You are/were covered under the Plan at the time the health care item or service was requested or, in the case of a retrospective review, were covered under the Plan at the time the health care item or service was provided;
(b) The Adverse Determination does not relate to your failure to meet the requirements for eligibility under the terms of the Plan;
(c) You have exhausted the Plan’s internal claims and appeals process (except, in limited, exceptional circumstances); and
(d) You have provided all of the required information and forms to process an external review.
2. The Plan will notify you in writing within one (1) business day of completing its preliminary review if your request meets the requirements for external review. If applicable, this notification will inform you:
(a) If your request is complete but not eligible for external review, in which case the notice will include the reasons for its ineligibility, and contact information for the Employee Benefits Security Administration (toll-free number 866-444-EBSA (3272)).
(b) If your request is not complete, in which case the notice will describe the information or materials needed to make the request complete, and allow you to perfect the request for external review within the four (4) month filing period, or within a 48-hour period following receipt of the notification, whichever is later.
B. Review by Independent Review Organization
1. If the request is complete and eligible, the Plan will assign the request to an IRO. The IRO is not eligible for any financial incentive or payment based on the likelihood that the IRO would support the denial of benefits. The Plan may rotate assignment among IROs with which it contracts.
2. Once the claim is assigned to an IRO, the following procedure will apply:
(a) The assigned IRO will timely notify you in writing of the request’s eligibility and acceptance for external review, including directions about how you may submit additional information regarding your claim (generally, such information must be submitted within ten (10) business days).
(b) The Plan will provide, within five (5) business days after the assignment to the IRO, documents and information it considered in making its Adverse Determination.
(c) If you submit additional information related to your claim, the assigned IRO must within one (1) business day forward that information to the Plan. Upon receipt of any such information, the Plan may reconsider its Adverse Determination that is the subject of the external review. Reconsideration by the Plan will not delay the external review. However, if upon reconsideration, the Plan reverses its Adverse Determination, it will provide written notice of its decision to you and the IRO within one (1) business day after making that decision. Upon receipt of such notice, the IRO will terminate its external review.
(d) The IRO will review all timely received information and documents. In reaching a decision, the IRO will review the claim de novo (as if it is new) and will not be bound by any decisions or conclusions reached during the Plan’s internal claims and appeals process. However, the IRO will be bound to abide by the terms of the Plan to ensure that the IRO decision is not contrary to the terms of the Plan, unless the terms are inconsistent with applicable law. The IRO also must abide by the Plan’s requirements for benefits, including the Plan’s standards for clinical review criteria, medical necessity, appropriateness, health care setting, or level of care of a covered benefit. In addition to the documents and information provided, the assigned IRO, to the extent the information or documents are available and appropriate, may consider additional information, including information from your medical records, any recommendations or other information from your treating health care providers, any other information from you or the Plan, reports from appropriate health care professionals, appropriate practice guidelines, the Plan’s applicable clinical review criteria and/or the opinion of the IRO’s clinical reviewer(s).
(e) After the IRO receives the request for the external review, the assigned IRO will provide written notice of its final external review decision to you and the Plan within 45 days.
(f) The assigned IRO’s decision notice will contain:
(i) A general description of the reason for the request for external review, including information sufficient to identify the claim (including the date or dates of service, the health care provider, the claim amount (if applicable), the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning, and the reason for the previous denial);
(ii) The date that the IRO received the assignment to conduct the external review and the date of the IRO decision;
(iii) References to the evidence or documentation, including the specific coverage provisions and evidence-based standards, considered in reaching its decision;
(iv) A discussion of the principal reason(s) for its decision, including the rationale for the decision and any evidence-based standards that were relied upon in making its decision;
(v) A statement that the determination is binding except to the extent that other remedies may be available to you or the Plan under applicable State or Federal law;
(vi) A statement that judicial review may be available to you; and
(vii) Current contact information, including phone number, for the health insurance consumer assistance or ombudsman established under the Affordable Care Act to assist with external review processes.
II. Expedited External Review of Claims
You may request an expedited external review if:
1. You receive an Initial Adverse Benefit Determination that involves a medical condition for which the timeframe for completion of an internal appeal would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function, and you have filed a request for an urgent care internal appeal; or
2. You receive an adverse Appeal Claim Benefit Determination that involves a medical condition for which the timeframe for completion of a standard external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function; or, you receive an adverse Appeal Claim Benefit Determination that concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, but you have not yet been discharged from a facility.
A. Preliminary Review
Immediately upon receipt of the request for expedited external review, the Plan will complete a preliminary review of the request to determine whether the requirements for preliminary review set forth above, in section I.A.1, are met. The Plan will immediately notify you as to whether your request for review meets the preliminary review requirements, and if not, will provide or seek the information described above in section I.A.2.
B. Review by Independent Review Organization
(a) Upon a determination that a request is eligible for expedited external review following the preliminary review, the Plan will assign an IRO. The Plan will expeditiously provide or transmit to the assigned IRO all necessary documents and information that it considered in making its Adverse Determination.
(b) The assigned IRO, to the extent the information or documents are available and the IRO considers them appropriate, must consider the information or documents described in the procedures for standard review, at above section I.B. In reaching a decision, the assigned IRO must review the claim de novo (as if it is new) and is not bound by any decisions or conclusions reached during the Plan’s internal claims and appeals process. However, the IRO will be bound to abide by the terms of the Plan to ensure that the IRO decision is not contrary to the terms of the Plan, unless the terms are inconsistent with applicable law. The IRO also must abide by the Plan’s requirements for benefits, including the Plan’s standards for clinical review criteria, medical necessity, appropriateness, health care setting, or level of care of a covered benefit.
(c) The IRO will provide notice of the final external review decision, in accordance with the requirements set forth above in section I.B.f, as expeditiously as your medical condition or circumstances require, but in no event more than seventy-two (72) hours after the IRO receives the request for an expedited external review. If the notice is not in writing, within forty-eight (48) hours after the date of providing that notice, the IRO must provide written confirmation of the decision to you and the Plan.
III. After External Review
(A) If the final external review reverses the Plan’s Adverse Determination, upon the Plan’s receipt of notice of such reversal, the Plan will immediately provide coverage or payment for the reviewed claim.
(B) If the final external review upholds the Plan’s Adverse Determination, the Plan will continue not to provide coverage or payment for the reviewed claim. If you are dissatisfied with the external review determination, you may seek judicial review as permitted under ERISA Section 502(a).
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