Previous Policy

Denial

Processing of Claims. Claims that are properly filed will be processed in accordance with the following guidelines:

1. Post-Service Health Claims. A post-service claim is any properly filed claim for medical, dental, vision, or prescription drug benefits that is not a pre-service claim. A post-service claim will generally be processed within 30 days of receipt. This period may be extended for up to 15 days if the plan determines an extension of time for making the determination is necessary due to matters beyond the control of the plan and notifies the employee or beneficiary (hereafter “claimant”) within the initial 30-day period of the circumstances requiring the extension of time and the date by which the plan expects to render a decision.

   If an extension is necessary due to the claimant’s failure to submit the information necessary to process the claim, the notification of the extension will describe the necessary information, and the claimant will be provided at least 45 days from receipt of the notification to submit the additional information. The period for making a determination will be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information.

2. Pre-Service Claims. A pre-service claim is a properly filed claim which must be preauthorized to receive full benefits from the plan. Pre-service claims include, but are not limited to hospital admissions, surgeries, behavioral health services, certain prescription drugs, durable medical equipment, home health care, and hospice care. A pre-service claim will generally be processed within 15 days of receipt. This period may be extended for up to 15 days if the plan determines an extension of time for making the determination is necessary due to matters beyond the control of the plan and notifies the claimant within the initial 15-day period of the circumstances requiring the extension of time and the date by which the plan expects to render a decision.

   If an extension is necessary due to the claimant’s failure to submit the information necessary to process the claim, the notification of the extension will describe the necessary information, and the claimant will be provided at least 45 days from receipt of the notification to submit the additional information. The period for making a determination will be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information.

   If services that require precertification have been provided and the only issue is what payment, if any, will be made, the claim will be processed as a post-service claim.

3. Pre-Service Urgent Care Claims. Pre-service urgent care claims are claims with respect to which the normal time frames for review of a claim could seriously jeopardize the life or health of the claimant or expose the claimant to severe pain that could not adequately be managed without the care or treatment that is the subject of the claim.

   This plan does not require precertification of urgent care claims where the delay in treatment could: seriously jeopardize the life or health of the patient or the ability of the patient to regain maximum function; or subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

   If a claimant needs medical care for a condition which could seriously jeopardize his or her life or health, there is no need to contact the plan administrator for prior approval. The claimant should obtain such care without delay.

   Further, if the plan does not require the claimant to obtain approval of a medical service prior to getting treatment, then there is no pre-service claim. The claimant simply follows the plan’s procedures with respect to any notice which may be required after receipt of treatment, and files the claim as a post-service claim.

4. Concurrent Care Claims. Concurrent care claims are pre-service claims involving an ongoing course of treatment to be provided over a period of time or number of treatments, and either (a) the plan determines that the course of treatment should be reduced or terminated, or (b) the claimant requests extension of the course of treatment beyond that which the plan has approved.

   A claim to extend the course of treatment beyond the period of time or number of treatments previously approved will be treated as a new claim and processed within the timeframes appropriate to the type of claim. If the plan reduces or terminates a course of treatment before the end of the previously approved period or number of treatments, the plan will notify the claimant in advance of the reduction or termination to allow the claimant to appeal and obtain a determination or review before the benefit is reduced or terminated.

5. Time Loss Claims. Claimants will be notified of a determination on a claim for time loss benefits within 45 days after receipt of the claim by the plan. This period may be extended for up to 30 days (to a total of 75 days) if the plan determines that an extension of time for making the determination is necessary due to matters beyond the control of the plan and notifies the claimant prior to the expiration of the initial 45-day period of the circumstances requiring the extension of time and the date by which the plan expects to render a decision. If the plan determines that an additional extension of time for making the benefit determination is necessary due to matters beyond the control of the plan and notifies the claimant prior to the expiration of the first 30-day extension period of the circumstances requiring the extension of time and the date by which the plan expects to render a decision, then the period for making a benefit determination may be extended by the plan for an additional 30 days (to a total of 105 days).

   If an extension is necessary due to the claimant’s failure to submit information necessary to process the claim, the notification of the extension will describe the necessary information, and the claimant will be provided at least 45 days from receipt of the notification to submit the additional information. The period for making a determination will be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information.

Notification of Claim Denial. If a claim is denied or partly denied, the claimant will be notified in writing and given an opportunity for review. The written denial will give:

1. The specific reasons for the denial.
2. Specific reference to pertinent plan provisions on which the denial is based.
3. A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary.
4. If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, either the specific rule, guideline, protocol, or other similar criterion, or a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the determination and that a copy of the same will be provided free of charge to the claimant upon request.
5. If the denial is based on medical necessity or experimental treatment or a similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the claimant’s medical circumstances, or a statement that such an explanation will be provided free of charge upon request.
6. An explanation of the plan’s claim review procedure, including a statement of the claimant’s right to bring a civil action under ERISA § 502(a).

Appeal to Board of Trustees

• Notification of Appeal. Employees or beneficiaries (hereafter “claimant”) who apply for benefits and are ruled ineligible by the Trustees (or by the administrator acting for the Trustees), or who believe they did not receive the full amount of benefits to which they are entitled, or who are otherwise adversely affected by any action of the Trustees, have the right to appeal to and request review of the matter by the Board of Trustees, provided that they make such a request, in writing, within 180 days after the Trustee’s action or within 180 days after receipt of the notification or decision.

  A failure to file a request for appeal within 180 days will serve as a bar to any claim for benefits or for other relief from the plan.

  The appeal will be conducted by the Board of Trustees, or by the Appeals Committee of the Board of Trustees, which has been allocated the authority for making a final decision in connection with the appeal.

• Scheduling of Appeal. Except for appeals involving pre-service claims, the Trustees will review a properly filed appeal at the next regularly scheduled quarterly meeting of the Appeals Committee, unless the request for review is received by the Trustees within 30 days preceding the date of such meeting. In such case, the appeal will be reviewed no later than the date of the second quarterly meeting following the Trustee’s receipt of the notice of appeal, unless there are special circumstances requiring a further extension of time, in which case a benefit determination will be rendered not later than the third quarterly meeting of the Appeals Committee following the Trustee’s receipt of the notice of appeal. If such an extension of time for review is required because of special circumstances, such as a request for a hearing on the appeal, then prior to the commencement of the extension, the plan will notify the claimant in writing of the extension, describe the special circumstances and the date as of which the benefit determination will be made.

  The Trustees will review a properly filed appeal of a pre-service claim within 30 days after receipt of the appeal.

• Appeal Procedures. A claimant is generally entitled to present the claimant’s position and any evidence in support thereof, at an appeal hearing. Notwithstanding the foregoing, in order to expedite review, the appeal of a pre-service or post-service claim may be held telephonically by the Trustees, and unless the participation of the claimant or his representative is necessary to develop an adequate record, may be based upon the written record. Additionally, the Trustees may, at their sole discretion, refuse to allow for an in-person appeal hearing when the claimant’s request is unambiguously controlled by the plan language (i.e., requesting coverage for a procedure or service that is clearly excluded by the current plan language). The claimant may request postponement of the Trustees’ review if the claimant wishes to appear in person at a hearing.

  A claimant may be represented by an attorney or by any other representative of his choosing at his own expense.

  The claimant will be provided upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to his or her claim for benefits.

  The claimant must introduce sufficient credible evidence on appeal to establish, prima facie, entitlement to the relief from the decision or other action from which the appeal is taken. The claimant will have the burden of proving his right to relief from the decision or action appealed, by a preponderance of evidence. The Trustees will review all comments, documents, records and other information submitted by the claimant related to the claim, regardless of whether such information was submitted or considered in the initial benefit determination. The Trustees will not afford deference to the initial adverse benefit determination.

  When deciding an appeal of a claim that is based in whole or in part on a medical judgment, the Trustees will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. Any medical or vocational expert whose advice was obtained on behalf of the plan in connection with the adverse benefit determination will be identified to the claimant upon request. Any health care professional engaged for the purpose of a consultation on a claim will not be an individual who was consulted in connection with the initial adverse benefit determination that is the subject of the appeal, nor the subordinate of any such individual.

• Decision On Appeal. The Trustees will issue a written decision on review of a claim (other than a pre-service claim) as soon as possible, but not later than 5 business days following the conclusion of the Appeals Committee meeting. Where necessary, the Trustees may issue a more detailed explanation of the reasons for an adverse decision within 30 days of the conclusion of the Appeals Committee meeting. Notwithstanding the foregoing, a decision on review of a pre-service claim will be made within 30 days after receipt of the appeal. In the case of an adverse benefit determination, the written denial will indicate:

  1. The specific reasons for the adverse benefit determination and a specific reference to pertinent plan provisions on which the denial is based.
  2. A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of all documents, records, and other information relevant to the claimant’s claim for benefits.
  3. If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, either the specific rule, guideline, protocol, or other similar criterion, or a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the determination and that a copy of the same will be provided free of charge to the claimant upon request.
  4. A statement of the claimant’s right to bring a civil action under ERISA § 502(a).

Review of Trustees’ Decision

If a claimant remains dissatisfied after exhausting the appeal procedures, he or she may: request external review by an Independent Review Organization (IRO) (provided the claim is a medical claim involving medical judgment or rescission of health coverage); or bring a civil action under ERISA § 502(a).

External Review

An external review is only available if the claim on appeal involves medical judgment or the retroactive rescission of health coverage. There is no external review for dental or vision claims or for non-healthcare claims, such as time loss, accidental death and dismemberment, or life insurance.

A request for external review must be filed with Carpenters Trusts within four months from the claimant’s receipt of the Trustees’ decision on appeal. Requests for external review may be mailed to the following address:

Attn: Appeals
Northwest Carpenters Health and Security Plan
PO Box 1929
Seattle, WA 98111-1929

Failure to file a request for external review within the four-month period will end the claimant’s ability to seek external review.

Preliminary Review of External Review Request

Within five business days of receipt of a request for external review, the plan will complete a preliminary review of the request. Within one business day after completion of this review, the plan will notify the claimant of its decision. If the request is not eligible for external review, the plan will notify the claimant. If the request for external review is incomplete, the plan will identify what is needed and the claimant will have the longer of 48 hours or the remaining portion of the four-month external review request period to provide the information. If the external review request is complete and eligible for external review, the plan will refer the matter to an IRO.

Review by Independent Review Organization

If a properly filed request for external review is received, the plan will provide the IRO with the required documentation in the time required by applicable federal regulations. The IRO will provide a response to the claimant within 45 days after it has received the request to review.

If the IRO directs that benefits be paid, benefits will be provided under the plan in accordance with the decision. If the decision continues to be adverse, the claimant has the right to bring a civil action under ERISA § 502(a). A claimant must exhaust the plan’s Claim and Appeal Procedures prior to filing a civil action. Any civil action seeking to overturn a denial or other decision of the Trustees must be brought within 180 days of the Trustees’ issuance of a written decision on appeal. A failure to file a civil action within the 180 days will bar the right to further review of the appeal.

Judicial Review

If a claimant remains dissatisfied after issuance of the Trustees’ decision on appeal, or issuance of the IRO’s decision, the claimant may bring a civil action under ERISA § 502(a). The question on review of the Trustees’ determination will be whether the Trustees’ decision was an abuse of their discretion. Any action must be brought within 180 days after the Trustees’ decision was issued.

Sole and Exclusive Procedures

The plan’s appeal procedures are the sole and exclusive procedures available to a claimant who is dissatisfied with an eligibility determination or benefit award, or who is otherwise adversely affected by any action of the Trustees. The appeal procedures must be exhausted prior to fulfilling any legal action.