Northwest Carpenters Health and Security Plan

Claims and Appeals Rules 

Claim Denial

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

  1. Medical Claims. For information about medical claims appeals and other topics, please access the appropriate Regence Medcical Plan booklet below: If you are covered under Kaiser, review the Kaiser plan booklet for claims appeals information.
  2. 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 claiman'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).

Last Updated: 02/13/2024