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SECTION 14.0 - DENIAL AND APPEAL CLAIM PROCEDURES

The following Denial and Appeal Claim Procedures will be effective January 1, 2003.


A claim is a request for a benefit under this Welfare Plan made in accordance with this claim procedure. A request for a benefit under this Welfare Plan will be considered a claim only if it is submitted to the appropriate Claim Administrator identified below. In addition to the information provided on each benefit, information on submitting a claim is shown in Section 9.

  1. Claim Administrators:

    1. Inpatient Hospital: The Claim Administrator for inpatient hospital administration is Highmark Blue Cross Blue Shield. Claims for inpatient hospital administration must be pre-certified as shown under the Highmark Preferred Blue PPO Plan of Benefits and in the Highmark Preferred Blue Plan of Benefits Summary Plan Description. You or your authorized representative may contact the Fund Office if you require further information.
    2. Prescription Drug: The Claim Administrator for prescription drugs is Highmark Blue Cross Blue Shield. Claims for prescription drugs at participating pharmacies will be processed at the time your prescription is filled. You or your authorized representative may contact the Fund Office to obtain information regarding Highmark Blue Cross Blue Shield.
    3. Dental Benefits: The Claim Administrator for Dental Benefits is Delta Dental of Pennsylvania. You or your authorized representative may contact the Fund Office to obtain information regarding Delta Dental of Pennsylvania.
    4. Vision Benefits: The Claim Administrator for Vision Benefits is National Vision Administrators. You or your authorized representative may contact the Fund Office to obtain information regarding National Vision Administrators.
    5. Temporary disability benefits: The Claim Administrator for temporary disability benefits is the Plasterers Local 31 Insurance Fund. You or your authorized representative may contact the Fund Office if you require further information.
    6. Death Benefit and Accidental Death: The Claim Administrator for life insurance and accidental death and dismemberment benefits is the Plasterers Local 31 Insurance Fund.
  2. Initial Claim Determination:

    1. Definitions:
      1. Urgent claims are requests for eligibility status or for medical care or treatment of an emergency nature, which could seriously jeopardize the life or health of the claimant or would subject the claimant to severe pain.
      2. A pre-service claim is a request for eligibility status or for benefits for which a Plan requires pre-approval, such as pre-admission certification for a hospital admission or a predetermination of benefits for major dental care.
      3. A post-service claim is a request for a benefit following the claimant’s receipt of services
      4. A disability claim is a request for a disability benefit as described in.
      5. A life insurance claim is a request for life insurance or accidental death and dismemberment benefits under the Welfare Plan.
    2. Time Limits for Initial Claim Determinations:
      1. Urgent Care Claim: A decision and notification to you with respect to an urgent care claim will be made within seventy-two (72) hours or sooner if possible (whether adverse or not). If the claim is not complete, the Plan will so notify you of the additional information required within twenty-four hours. The claimant shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. Notification of any adverse benefit determination pursuant to this paragraph shall be made in accordance with the Claim Denial procedures (described in section 10.3). The plan administrator shall notify the claimant of the plan’s benefit determination as soon as possible, but in no case later than 48 hours after the earlier of
        1. The plan’s receipt of the specified information
        2. The end of the period afforded the claimant to provide the specified additional information
      2. Pre-Service Claim: A decision and notification to you on a pre-service claim will be made within fifteen (15) days from receipt of the claim. The Plan may take an additional fifteen (15) days, if it is determined an extension is necessary due to matters beyond the control of the Plan and you are advised of the need for the extension, prior to the expiration of the fifteen (15) day period, and the date by which the Plan expects to render a decision. The Plan will advise of a defective or incomplete filing of a pre-service claim within five (5) days of receipt. If the extension is due to failure to submit necessary information to decide the claim, you shall be afforded at least 45 days from receipt of the notice within which to provide the information.
      3. Post-Service Claim: A decision and notification to you on a post-service claim will be made within 30 days from receipt of the claim. This determination period may be extended one time for 15 days for reasons beyond the Plan’s control, in which case the Plan will notify you in writing within the first 30-day period of the circumstances requiring an extension and the expected date of a decision. If the extension is due to a faulty claim, the notice of extension will describe the needed information and provide you at least 45 days from receipt of the notice to provide the necessary information.
      4. Disability Claim: A decision and notification to you on a disability claim will be made within 45 days from receipt of the claim. This determination period may be extended two times for 30 days for reasons beyond the Plan’s control, in which case the Plan will notify you in writing within the first 45-day period of the circumstances requiring an extension and the expected date of a decision. If the extension is due to a faulty claim, the notice of extension will describe the needed information and provide you at least 45 days from receipt of the notice to provide the necessary information. The deadline for the claim determination will be suspended for 45 days or until the information is received.
      5. Life Insurance Claim: A decision and notification to you on a life insurance claim will be made within 90 days from receipt of the claim. One 90-day extension is permitted if required by special circumstances, in which case the Plan will notify you in writing within the first 90-day period of the circumstances requiring an extension and the expected date of a decision.
    3. Concurrent Care Decisions:
      1. If the Plan has approved an ongoing course of treatment to be provided over a period of time or a number of treatments, any reduction or termination by the Plan of such course of treatment before the end of the period or number of treatments previously agreed to will be considered a denial. The Plan will notify you of this action in advance of the application of the reduction or termination and advise of the appeal rights to permit a review prior to the date the benefit is reduced or terminated.
      2. A decision to extend the previously agreed to course of treatment for an urgent care claim will be acted upon as soon as possible. The Plan will notify you of the determination within twenty-four (24) hours of receipt, provided the claim is made at least twenty-four (24) hours prior to the expiration of the prescribed period of time or number of treatments.
  3. Claim Denial Procedures: If your claim is denied or partially denied, you will be notified in writing and provided an opportunity for a review.

    1. The written notice of denial will provide:
      1. The specific reason(s) for the denial;
      2. The specific Plan provision on which the determination is based;
      3. A description of additional information or information necessary for you to perfect the claim and an explanation of why this additional information is necessary;
      4. A statement that the specific rule, guideline, protocol or other criterion relied upon in making the determination, if applicable, will be provided at no cost upon request;
      5. A statement advising that an explanation of the scientific or clinical judgment relied upon and the names of the individuals from whom opinion(s) were secured, if a determination is based upon medical necessity or experimental treatment, or similar exclusion or limit, will be provided at no cost; and
      6. A description of the Plan’s review procedures and the time limits applicable to such procedures, including a statement regarding your right to bring a civil action under section 502(a) of ERISA.
      7. For urgent care claim denials, a description of the expedited review process applicable to urgent care claims.
  4. Claim Appeal Procedures:

    1. Filing an Appeal: If your claim has either been denied or partially denied and you are not satisfied with the decision, you may appeal the decision and request a review of the claim. The appeal:
      1. Must be in writing and can be made by you or your duly authorized representative;
      2. Should be mailed or delivered to the Fund address shown in the Summary Plan Description;
      3. Should state the reasons you believe the initial determination was incorrect;
      4. Should include any written comments, documents, records and other information relating to the claim for benefits; and
      5. Must be submitted within one hundred eighty (180) days of the date you receive the notice of denial or partial denial.

      You will be provided access to and copies of, at a reasonable charge, all documents, records, and other information relevant to your claim.


    2. Timeframe for Claim Appeal Determinations:
      1. A determination of an urgent care claim will be made within seventy-two (72) hours after receipt of your request for review.
      2. A determination of a pre-service claim will be made within thirty (30) days of receipt of your request for review.
      3. A determination of a post-service claim will be made during the course of the regular quarterly Trustees’ meeting following receipt of the request for review and you will be notified of the decision within five (5) days of the date of such meeting. (If the request for review is received within thirty (30) days of the next regular quarterly Trustees’ meeting, the decision on review will be made not later than the date of the second meeting following the Plan’s receipt of the request for review). If special circumstances require an extension of time, a decision will be rendered not later than the next following quarterly Trustees’ meeting. You will be advised of the special circumstances and the date the decision is expected to be made.
      4. A determination of a disability claim will be made within 45 days from receipt of your appeal. One 45-day extension is permitted if the Claims Administrator provides you with notice and an explanation of the circumstances resulting in the delay prior to the expiration of the initial 45-day period.
      5. A determination of a life insurance claim will made within 60 days from receipt of your appeal. One 60-day extension is permitted if the Claims Administrator provides you with notice and an explanation of the circumstances resulting in the delay prior to the expiration of the initial 60-day period.
  5. Claim Reviewers:

    1. Initial Claim Review will be conducted by the Fund Administrator or staff. If medical judgment is required, a qualified medical reviewer will be consulted.
    2. A review of the claim upon appeal will be conducted by the Board of Trustees. If medical judgment is required, a qualified medical reviewer will be consulted. The qualified medical reviewer will be not be connected in any way with the medical reviewer utilized in 10.5 (a).
  6. Adverse Appeal Determinations: If you receive an adverse appeal determination, you will be notified in writing and advised of the following:

    1. The specific reason for the adverse determination;
    2. Reference to the specific plan provisions on which the determination is based;
    3. That a copy of any internal rule guideline, protocol, or similar criteria which was relied upon is available without cost upon request;
    4. That a copy of the scientific or clinical judgment relating to a claim denial for medical necessity, experimental treatment or similar exclusion or limit is available without cost upon request;
    5. The identity of any medical or vocational experts whose advice was obtained on behalf of the Plan;
    6. That you are entitled to receive, upon request and without charge, reasonable access to and copies of all documents, records, and other information relevant to your claim for benefits;
    7. A description of the Plan’s review procedures and the time limits applicable to such procedures, including a statement regarding your right to bring a civil action under section 502(a) of ERISA.
THE DECISION OF THE TRUSTEES ON REVIEW WILL BE MADE IN GOOD FAITH AND WILL BE FINAL AND BINDING ON ALL ISSUES. CLAIMANT OR CLAIMANT’S DULY AUTHORIZED REPRESENTATIVE WILL BE REQUIRED TO EXHAUST THE ENTIRE CLAIM REVIEW PROCEDURE BEFORE INSTITUTING ANY OTHER FORM OF ACTION.