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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
RESTATED CLAIMS AND APPEALS PROCEDURES
(Effective January 1, 2002)
I. Introduction
These claims and appeals procedures supersede and replace all previous
claims and appeals procedures adopted by the Trustees, whether such
procedures are contained in a Summary Plan Description, Rules and
Regulations, or separate documents.
These procedures are intended to comply with ERISA and the Internal Revenue
Code, and all applicable regulations. Any provision of these procedures that
is determined to conflict with such laws and regulations shall be deemed to
be displaced by such laws and regulations, which shall govern the claims and
appeals process.
These procedures shall be mailed to all Plan beneficiaries in conjunction
with, and at the same time, as Summary Plan Descriptions are mailed. Also,
any beneficiary may request a copy of these procedures from the Plan
Administrator for no charge, except that a reasonably copy charge may apply.
II. Claims and Appeals Procedures
These are the procedures for when a Claim is denied and you want to appeal
the denial to the Board of Trustees.
Important note regarding unofficial claims: Claims, inquiries, questions and
requests regarding eligibility, enrollment or available benefits made before
the expense is incurred are not "Claims" for purposes of this section, and
are not subject to the Plan's claims and appeals procedures, unless
preauthorization is required by the Plan. This is true even if these types
of unofficial claims are referred to as "Claims" by the Administrator,
Trustees or anyone acting on their behalf. Such unofficial claims and
questions will be responded to in a prompt manner, but carry no obligation
to apply these procedures and no right to appeal under these procedures.
1. Making a Claim - There are
no fees or charges to file a Claim or to appeal a benefit decision. These
procedures apply whenever a Claim for services that have already been
received by you is not granted in your favor. A "Claim" is a written request
by you, your authorized representative, or a health care provider, that the
Plan pay benefits. You may authorize another person to make a claim for you
only in writing, signed by you. However, in an emergency, your doctor may
make a claim on your behalf. An oral request is not a claim, but a facsimile
(fax) is acceptable. Once a Claim is made by you or your authorized
representative, the rights of any other person or entity to make a claim for
the same benefits are terminated.
2. Prior Approval for Treatment - These procedures also apply whenever you
are required to obtain Prior Approval before a course of treatment, which is
also considered a "Claim." You should review the Plan sections that discuss
your treatment carefully to determine whether Prior Approval (or
"preauthorization") is required and who to ask for approval.
3. Deciding a Claim - Whether a claim is granted in your favor will be
determined based on the Plan Documents. The Trustees have full discretion to
interpret and apply the Plan's provisions. However, the provisions of the
Plan will be interpreted consistently in similar circumstances and similar
past appeals, if any, will be reviewed when your appeal is decided.
4. When Will Your Claim Be Decided? The time periods in subsections (a)
through (d) apply to all health care Claims made on or after January 1,
2003. The time periods in subsection (e) apply to disability benefit Claims
made on or after January 1, 2002. For such Claims made before these dates,
and all other types of Claims, the time periods set forth in subsection (f)
apply.
a. Urgent Care - If you have
a claim for Urgent care and you provide sufficient information to
determine whether benefits are covered, your Claim will be decided as soon
as possible and not later than 72 hours after the Plan receives your
Claim. If you have a Claim for Urgent care and you do not provide
sufficient information to determine whether benefits are covered, you will
be told within 24 hours what additional information is needed to decide
your Claim. You will then have 48 hours to provide the additional
information.
The Plan will notify you of its decision as soon as possible and within 48
hours after (1) all necessary information is provided, or (2) the 48 hours
you have in which to provide the necessary information ends, whichever is
sooner.
b. Ongoing Treatment - If you are receiving ongoing treatment over a
period of time, and the Plan determines to reduce or discontinue that
treatment, you will receive notice early enough for you to appeal that
decision and receive a decision on your appeal before the ongoing
treatment is reduced or discontinued. If you are receiving ongoing Urgent
care treatment and make a Claim to continue such treatment, a decision
will be made within 24 hours after receipt of the claim.
c. Claims Made Before Treatment - If you make a Claim for benefits before
you receive the benefits, and neither (a) nor (b) above apply, your Claim
will be decided within a reasonable time no longer than 15 days after
receipt of your claim. However, an additional 15 days may be needed if
there are special circumstances beyond the Plan's control. If so, you will
be given notice of the special circumstances before the end of the first
15 days and told whether additional information is needed to decide your
claim. You will have at least 45 days to provide the additional
information. Keep in mind that only where preauthorization is required
will such a request prior to receiving benefits be an official "Claim."
When Preauthorization Is Required - The Plan will notify you if your
request for Prior Approval is not sufficient to be a "Claim" as soon as
possible, but in any event not later than 5 days (24 hours in a case of
Urgent care), and tell you how to submit a proper claim for Prior Approval
of treatment. However, you must at least provide your name, medical
condition and a description of the treatment requested before the Plan
will be able to help you complete your claim.
d. Claims Made After Treatment - If you make a Claim for benefits after
you receive the treatment, and neither (a) nor (b) above apply, your Claim
will be decided within a reasonable time no longer than 30 days after
receipt of your Claim. However, an additional 15 days may be needed if
there are special circumstances beyond the Plan's control. If so, you will
be given notice of the special circumstances before the end of the first
30 days and told whether additional information is needed to decide your
Claim. You will have at least 45 days to provide the additional
information.
e. Disability Benefit Claims - If you make a Claim for disability
benefits, your Claim will be decided within a reasonable time no longer
than 45 days after receipt of your Claim. However, an additional 30 days
may be needed if there are special circumstances beyond the Plan's
control. If so, you will be given notice of the special circumstances
before the end of the first 45 days and told the requirements for
receiving benefits, any unresolved issues, whether additional information
is needed, and when a decision is expected. You will have at least 45 days
to provide the additional information.
f. Other Claims - For all Claims, for which the time frames in (a) through
(e) above do not apply, a decision will be made within a reasonable time
no longer than 90 days after receipt of your Claim. However, an additional
90 days may be needed if there are special circumstances beyond the Plan's
control. If so, you will be given notice of the special circumstances
before the end of the first 90 days and stating when a decision is
expected.
g. The time in which to make any Claim decision is extended during any
time in which the Plan is waiting to receive requested additional
information.
5. Contents of Claim Denials -
If your Claim is denied, you will be provided in writing (via facsimile if
you wish):
a. The specific reasons for
the denial;
b. The Plan provisions on which the denial is based and any internal rules
or guidelines that are not in the Plan, with copies of them;
c. A list of any additional information needed to obtain approval of your
claim, and why such information is needed;
d. A reminder that these Claims and appeals procedures may be obtained
from the Administrator for no charge, except for reasonable copy charges,
and notice of your right to file a law suit if your appeal of the denial
is denied; and
e. If the denial is based on a Plan exclusion, information on how to
request an explanation of how the exclusion was applied and why.
6. Appealing a Decision - You
have the right to appeal any adverse Claim decision. Please keep in mind
that only where preauthorization is required by the Plan or you have already
received the service is there a "Claim" subject to these procedures.
a. For all Claims to which
4(f) above applies, a written appeal may be filed within 60 days of notice
of the Claim denial. You may submit any written records you wish to be
reviewed and you may obtain copies of any related Plan records.
Your appeal will be decided by the next regularly-scheduled meeting of the
Board of Trustees that is at least 30 days after your written appeal is
received. If special circumstances require additional time to process your
appeal, you will be notified of those circumstances and a decision will be
made no later than the third meeting following receipt of your written
appeal.
If your appeal is denied, you will receive written (or electronic as
permitted by law) notice, including the specific reasons, reference to the
specific plan provisions, and you may have access to all records that were
used in reaching the decision.
b. For Claims made to which 4(a) through (e) above apply, the following
appeals procedures apply.
i. You have 180 days to appeal a Claim denial. No deference will be given
to the initial Claim denial. Your appeal will be decided by an
individual(s) who did not take part in the Claim denial and who is not the
subordinate of such a person.
ii. If your Claim involves a medical judgment, a health care professional
trained in the relevant field will be consulted; one who did not take part
in the Claim denial and who is not the subordinate of such a person. You
may also request the names of medical professionals who gave advice on
your Claim denial.
iii. For Urgent care Claims, you may make a request for an expedited
appeal, orally or in writing, and all necessary information may be
exchanged by telephone, facsimile or other expeditious method.
iv. Appeals for Urgent care Claims will be decided as soon as possible,
but not later than 72 hours after receipt of the appeal.
v. Appeals of Claims made before treatment will be decided within a
reasonable period of time, but not later than 30 days.
vi. Appeals of Claims made after treatment and of Claims for disability
benefits will be decided by the next regularly-scheduled meeting of the
Board of Trustees that is at least 30 days after your written appeal is
received. If special circumstances require additional time to process your
appeal, you will be notified of those circumstances and a decision will be
made no later than the third meeting following your receipt of your
written appeal.
vii. If your appeal is denied, you will receive written (or electronic as
permitted by law) notice, including the specific reasons, reference to the
specific plan provisions, and you may have access to all records that were
used in the reaching the decision.
If any internal rule, guideline, protocol or other similar criterion was
used in the appeal denial, you will be told about it and may have a copy
of it. If the denial is based on medical necessity or experimental
treatment, or the like, you may have a copy of whatever scientific or
clinical explanation was used in the determination.
The appeal denial will also provide the following disclosure required by
ERISA: AYou and your plan may have other voluntary alternative dispute
resolution options, such as mediation. One way to find out what may be
available is to contact your local U.S. Department of Labor Office and
your State insurance regulatory agency.@
If you are not satisfied with the decision made on your appeal, you may
file a law suit in federal court against the Plan. However, you must
complete the appeal to the Trustees before you may file a law suit. You
will have (90) days after completing the appeals process and being denied
to file suit, after which your Claim will be waived.
III. Other Provisions
1. Exhaustion of Remedies - No legal or equitable action for benefits under
this Plan shall be brought unless and until the claimant, in accordance with
the foregoing claims and appeal procedures:
c. has submitted a written
Claim for benefits,
d. has been notified that the Claim is denied (or the Claim is deemed
denied),
e. has filed a written appeal for review and
f. has been notified in writing that the denial of the Claim has been
confirmed (or the claim is deemed denied on review).
2. Trustee Discretion - The
Trustees have the exclusive right, power and authority in their sole and
absolute discretion, to administer, apply and interpret this health and
welfare plan and all other documents that describe the Plan and Trust Fund.
The Trustees may decide all matters arising in connection with the operation
or administration of the Plan. Except as described in these procedures, all
determinations made by the Trustees with respect to any matter arising with
regard to Plan benefits will be final and binding on all concerned. Any
judicial review of any Trustee decision must be done in deference to the
Trustees decision.
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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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