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Teamsters Local 631
Security Fund
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Teamsters Local 631 Security Fund for Southern
Nevada
P.O. Box 26509
Las Vegas, Nevada 89126-0509
To
: All Plan Participants
From :
Board of Trustees
Date
: September 25, 2002
Revised
Claim Determination and Appeals Procedures
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Effective October 1,
2002, the Board of Trustees have revised the Retiree Rules.
Enclosed is your copy of the new rules.
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The Department of Labor
has issued new regulations shortening the time the Plan may take to make
claim determinations and extending the appeals period. Only written requests
for payment (or preauthorization when it is required) are "Claims" covered
by these procedures. These new regulations will become effective for claims
submitted on or after January 1, 2003.
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Under the new
regulations, the new time periods for the member claims and appeals are:
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If you submit a Claim
for urgent care, you will be notified within 72 hours whether benefits are
covered. If additional supporting documentation is needed in order to make
the determination, you will be notified within 24 hours of the initial
receipt of your claim.
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For non-urgent claims
requiring preauthorization, your Claim will, in most cases, be decided
within 15 days. If additional information is needed in order to make the
determination, you will be notified within 5 days of the initial receipt of
your Claims.
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If you make a Claim for
benefits after you receive the treatment, your Claim will, in most cases, be
decided within 30 days of receipt of your Claim.
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If your Claim is
denied, you will be provided with the specific reasons for the denial,
including any Plan provisions upon which the denial is based. Should you
choose to appeal the decision, you will have 180 days in which to submit
your appeal.
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Claims appeals will be
decided as soon as possible, but not later than:
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Claims made before
treatment – 30 days after receipt of appeal
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Claims made after
treatment- By the next regularly-scheduled meeting of the Board of
Trustees that is at least 30 days after your written appeal is received.
If the Board of
Trustees denies your appeal, you have the right to file suit in Federal
court against the Plan, but you must do so within 90 days after your appeal
is denied.
The above only summarizes the changes required by the Department of Labor
with respect to claims and appeals procedures.
For more details,
please refer to the attached Restated Claims and Appeal Procedures. These
restated procedures refer to medical, dental and prescription drug claims.
Should
you have any questions or need additional information regarding the changes
outlined above please call the Fund Administrative Office at
(702) 252-7001
You may also visit our website at
www.swadmin.com
Teamsters Local 631 website at
www.631trustfunds.com
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