Loading...
HomeMy WebLinkAboutContracts & Agreements_211-2002Effective January 1, 2003 the Plan Document for CITY OF REDLANDS Group Dental Plan is amended to reflect the following changes: Delete the CLAIMS PROCEDURES section in its entirety and replace it with: It is the intent of the Plan Administrator that the following claims procedures comply with the United States Department of Labor ("DOL") regulation , 29 CFR § 2560.503-1, and the Employee Retirement Income Security Act of 1974, as amended ("ERISA"). Where any provision is in conflict with the DOL's claims procedure regulations, ERISA, or any or any other applicable law, such law shall control. SUBMITTING A CLAIM A claim is a request for benefit determination made, in accordance with the Plan's procedures, by a Claimant or his authorized representative. A claim must be received by the person or organizational unit customarily responsible for handling benefit matters on behalf of the Plan so that the claim review and benefit determination process can begin. A claim must name the Plan, a specific Claimant, a specific health condition or symptom or diagnostic code, and a specific treatment, service or supply (or procedure/ revenue codes) for which a benefit or benefit determination is requested, the date of service, the amount of charges, the address (location) where services are received, and provider name, address, phone number and tax identification number. For purposes of the Plan, the Plan Administrator, at its discretion, may contract with other entities to handle claims communications and benefit determinations for the Plan. Such other entities may include an insurance company, a '-third party claims payer, a managed care organization, or a pharmacy benefit manager. Contact information for such entities is provided below. There are two types of claims: (1) Pre -Service Claims, and (2) Post -Service Claims: 1). A Pre -Service Claim is a written or oral request for benefit determination where the terms of the Plan condition benefits, in whole or in part, on prior approval of the proposed care (e.g., a dental pre-treatment review requirement), Important: A benefit determination for a Pre -Service Claim shall only be for the purposes of assessing the Medical Necessity and appropriateness of care and delivery setting. A benefit determination for a Pre -Service Claim is not a guarantee of benefits from the Plan. Plan benefit payments are subject to review upon submission of a claim to the Plan after dental services have been received, and are subject to all related Plan provisions, including exclusions and limitations. Further, where the Plan does not require prior approval, a request for advance information on the Plan's possible coverage of an item • service, or advance approval of a covered item or service, does not constitute a Pre - Service Claim. Citv of Redlands 2). A Post -Service Claim is a written request for benefit determination after a service has been rendered and expense has been incurred. A Post -Service Claim must be submitted to the claims office within Twelve (12) months from the date the expense was incurred. PROCEDURES FOR SUBMITTING A CLAIM A Pre -Service Claim should be submitted to: Affordable Benefit Administrators, Inc. P. 0. Box 10787 Burbank, CA. 91510 (818) 842-0147 or (800) 350-0148 A Post -Service Claim should be submitted to: A P. 0. Box 10787 Burbank, CA. 91510 (818) 842-0147 or (800) 350-0148 Note: In accordance with federal law, the Centers for Medicare and Medicaid Services (CMS) have three (3) years to submit claims when Medicare has paid as the primary plan and the Plan should have been primary. ASSIGNMENTS TO PROVIDERS All Eligible Expenses reimbursable under the Plan will be paid to the covered Employee except that: (1) assignments of benefits to Hospitals, Physicians or other providers of service will be honored, (2) the Plan may pay benefits directly to providers of service unless the Covered Person requests otherwise, in writing, within the time limits for filing proof of loss, and (3) the Plan may make benefit payments for a child covered by a Qualified Medical Child Support Order (a QMCSO) directly to the custodial parent or legal guardian of such child. Notwithstanding any assignment or non -assignment of benefits to the contrary, upon payment of the benefits due under the Plan, the Plan is deemed to have fulfilled its obligations with respect to such benefits, whether or not payment is made in accordance with any assignment or request. No covered Employee or Dependent may, at any time, either while covered under the Plan or following termination of coverage, assign his rights to sue to recover benefits under the Plan, or enforce rights due under the Plan or any other causes of action which he may have against the Plan or its fiduciaries. Note: Benefit payments on behalf of a Covered Person who is also covered by a state's Medicaid program will be subject to the state's right to reimbursement for benefits it has paid on behalf of the Covered Person, as created by an assignment of rights made by the Covered Person or his beneficiary as may be required by the state Medicaid plan. Furthermore. the Plan will honor any subrogation rights the state may have gained from Medicaid -eligible beneficiary due to the state's having paid Medicaid benefits that were payable under the Plan. CLAIMS TIME LIMITS AND ALLOWANCES For group health plans subject to the Employee Retirement Income Security Act (ERISA), the chart below sets forth the time limits and allowance that apply to the Plan ar�d a Claimant with respect to claims filings, administration and benefit determinations. If there is anv variance betw,een the following information and the intended requirements of the law, the law will prevail. Citv of Redlands In the case of a Plan established and maintained pursuant to a collective bargaining agreement, such Plan will be deemed to comply with ERISA's claims requirements if the bargaining agreement sets forth or incorporates by reference: (1) provisions concerning the filing of claims and the initial disposition of claims, and (2) a grievance and arbitration procedure to which adverse benefit determinations are subject. If the bargaining agreement includes only grievance and arbitration procedure, then the provisions included herein concerning the filing and initial disposition of claims will apply but the appeal procedures will be superseded by the terms of the bargaining agreement. Important: The stated claims procedures herein address the periods within which claims determinations must be decided, not paid. Benefit payments must be made within reasonable periods of time following Plan approval as governed by ERISA. Urgent Claim - defined below Claimant Makes Initial Incomplete Claim Request Plan Receives Completin Information Claimant Makes Initial Complete Claim Request Plan Responds to Appeal 0#000 �*• �,# �,k __ Within not more than 24 hours (and as soon as possible taking into account the medical exigencies), Plan notifies Claimant of material needed to complete the claim request. Notification may be oral unless Claimant requests a written notice. Claimant will have a reasonable period of time, but not less than 48 hours, to provide the required information to complete the claim. Plan notifies Claimant, in writing or electronically, of its benefit determination as soon as possible and not later than 48 hours after the earlier of: (1) receipt of the completing information, or (2) the period of time Claimant was allowed to provide the completing information. Oral notice can be given in addition to written or electronic notice. Written or electronic notice of a benefit denial or reduction (an "adverse benefit determination '') must be provided to the Claimant not later than 3 days after oral notification. Within not more than 72 hours (and as soon as possible taking into account the medical exigencies), Plan responds with written or electronic benefit determination. Oral notice can be given in addition to written or electronic notice. Written or electronic notice of a benefit denial or reduction (an "adverse benefit determination") must be provided to the Claimant not later than 3 days after an oral notification. See "Appeal Procedures" subsection. An appeal for an urgent claim may be made orally or in writing. Within not more than 72 hours (and as soon as possible taking into account the medical exigencies), after receipt of Claimant's appeal. Citv of Redlands An "urgent claim" is an oral or written request for benefit determination where the decision would result in either of the following if decided within the time frames for non -urgent claims: (1) serious jeopardy to the Claimant's life or health, or the ability to regain maximum function, or (2) in the judgment of a Physician knowledgeable about the Claimant's condition, severe pain that could not be adequately managed without the care or treatment being claimed. All necessary information, including the Plan's handling of an appeal, shall be transmitted between the Plan and the Claimant by telephone, facsimile or other available and similar expeditious methods. Whether a claim is urgent will generally be decided by an individual acting on behalf of the Plan and applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine. However, if a Physician familiar with the Claimant's condition decides that the claim involves urgent care, the Plan must defer to the Physician's judgment. NOTE: THE BENEFIT DETERMINATION TIME FRAMES STATES ABOVE SHALL BEGIN AT THE TIME A CLAIM IS FILED IN ACCORDANCE WITH THE PROCEDURES OF THE PLAN, WITHOUT REGARD TO WHETHER ALL THE INFORMATION NECESSARY TO MAKE A BENEFIT DETERMINATION ACCOMPANIES THE FILING. "PRE -SERVICE" CLAIM ACTIVITY I TIME LIMIT OR ALLOWANCE Concurrent Care Claim - defined below I Plan Makes an Adverse Claim Decision Plan notifies Claimant of intent to reduce or deny benefits before any reduction or termination of benefits is made and provides enough time to allow the Claimant to appeal and obtain a determination on review before the benefit is reduced or terminated. Any decision with the potential of causing disruption to ongoing care which is Medically Necessary, is subject to the urgent claim rules. Claimant Requests Extension for Plan notifies Claimant of its benefit determination Urgent Care within not more than 24 hours after receipt of the request (and as soon as possible taking into account the medical exigencies), provided such request is made at least 24 hours prior to the expiration of the previously -approved period of time or treatment. Otherwise, the Plan's notification must be made in accordance with the time allowances for appeal of an urgent, pre -service or post -service claim, as appropriate. A "concurrent care claim" is a Claimant's request to extend a previously -approved ongoing course of treatment (e.g., kidney dialysis) beyond the approved period of time or number of treatments. An adverse claim decision for concurrent care does not include a benefit reduction or denial due to Plan amendment or termination. City of Redlands Non -Urgent Claim - defined below Claimant Makes Initial Incomplete Within 5 days of receipt of the incomplete claim Claim Request request, Plan notifies Claimant, orally or in writing, of material needed to complete the claim request. Claimant may request a written notification. Claimant has at least 45 days from receipt of such notice to provide required information. Plan Receives Completing Information Within 15 days, Plan responds with written or electronic benefit determination. 15 additional days may be allowed with full notice to Claimant - see definition of "full notice" below. Claimant Makes Initial Complete Claim 1 Within 15 days, Plan responds with written or Request electronic benefit determination. 15 additional days I may be allowed with full notice to Claimant. Claimant Appeals I See "Appeal Procedures" subsection. Plan Responds to Appeal Within 30 days after receipt of appeal (or where Plan provides for 2 levels of appeal, within 15 days for each appeal). "Full notice" means that notice is provided to the Claimant describing the circumstances requiring the extension of time and the date by which the Plan expects to render a decision. Such extension must be necessary due to matters beyond the control of the Plan and notification to Claimant must occur prior to the expiration of the initial 15-day period. In the case of any extension as outlined above, the notice of extension which is provided to the Employee or Claimant shall specifically explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim, and the additional information needed to respond to those issues. Where the Contract Administrator requires additional information of the Employee or Claimant, the Contract Administrator must afford the Employee or Claimant at least 45 days to provide the specific information. In such case, the benefit determination period will be tolled (suspended) from the date on which notification of the extension is sent to the Employee or Claimant until the date on which the response to the request for additional information is made. Claimant Makes Initial Incomplete Claim Request Plan Receives Completing Information Claimant Makes Initial Complete Claim Request Within 30 days (and sooner if reasonably possible), Plan advises Claimant of material needed to complete the claim request. The Plan may extend this period for up to 15 days with full notice to the Claimant - see definition of "full notice" below. Claimant has at 'least 45 days to provide required information, Within 30 days, Plan approves or denies claim. 15 additional days may be allowed with full notice to Claimant - see definition of "full notice" below. Within 30 days of'receiving the claim, Plan approves or denies claim. 15 additional days may be allowed with full notice to Claimant - see definition of "full notice" below. Cite of Redlands Claimant Appeals i Plan Responds to Appeal Within 60 days after receipt of appeal (or within 30 days for each appeal if Plan provides for two appeal levels). "Full notice" means that notice is provided to the Claimant describing the circumstances requiring the extension of time and the date by which the Plan expects to render a decision. Such extension must be necessary due to matters beyond the control of the Plan and notification to Claimant must occur prior to the expiration of the initial 30-day or 60-day period. In the case of any extension as outlined above, the notice of extension which is provided to the Employee or Claimant shall specifically explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim, and the additional information needed to respond to those issues. Where the Contract Administrator requires additional information of the Employee or Claimant, the Contract Administr-ator must afford the Employee or Claimant at least 45 days to provide the specific information. In such case, the benefit determination period will be tolled (suspended) from the date on which notification of the extension is sent to the Employee or Claimant until the date on which the response to the request for additional information is made. ADMINISTRATIVE PROCESSES AND SAFEGUARDS The Plan • that claims determinations be made in accordance with governing documents of the Plan and that they • applied • with respect to similarly situated Claimants. The claims procedures will not be administered in a way that unduly inhibits or hampers the initiation or processing of claims or claims appeals. AUTHORIZED REPRESENTATIVE MAY ACT FOR CLAIMANT Any of the above actions which can be done by the Claimant can also be done by an authorized representative acting on the Claimants behalf. The Claimant may be required to provide reasonable proof of such authorization. For an urgent claim, a health care professional, with knowledge of a Claimant's medical condition, will be permitted to act as the authorized representative of the claimant. "Health care professional" means a physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law. BENEFIT DETERMINATIONS Upon the Contract Administrator's receipt of a written claim for benefits and pursuant to the procedures described herein, the Contract Administrator will review the claim submission, proof of claim, and all associated and / or applicable information provided by the Claimant and gathered independently by the Contract Administrator in light of the Plan Document through which benefits of the Plan are paid - Further, the Contract Administrator will assure that all benefit determinations are applied consistently to similarlv-situated Plan participants by maintaining appropriate claim and benefit records which shall be reviewed periodically and on a case -by -case basis to determine past practices in similar claim situations. Documentation of such reviews shall be made available to the Employee or Claimant upon request. Should the Contract Administrator at any time during its revieur period determine that additional information is required from th� Employee or Claimant, the Contract Administrator will request such necessary information from the Employee. The Contract Administrator will make every effort to make its benefit determination in as reasonable a time frame as possible. CAL For benefit determination, the period of time within which such determination is required begins at the time a claim is filed in accordance with the Plan's reasonable procedures, without SHIM80= regard to whether all the information necessary to make a benefit determination accompanies the filing. In the event that an extended period of time is permitted due to a Claimant's failure to submit necessary information, the period for making the determination will be tolled (suspended) 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. WRITTEN OR ELECTRONIC NOTICES The Plan shall provide a Claimant with written or electronic notification of any benefit reduction or denial. Written or electronic notice of an approved benefit must be provided only for Pre -Service benefit determinations. "Notice" or "notification" means the delivery or furnishing of information in a manner that satisfies the standards of 29 CFR 2520.104b-l(b) as appropriate with respect to material required to be furnished or made available to an individual. Anv electronic notification shall comply with the standards of 20 CFR 2520.104b-(c)(1)(i), (ii), (iii), and (iv) and 2520.104b- l(c)(2)(i) and (ii). CLAIMS DENIALS If a claim is wholly or partially denied (see NOTE), the Claimant will be given written or electronic notification of such denial within the time frames required by law (see Claims Time Limits and Allowances). The notice will include the following and will be provided in a manner intended to be understood by the Claimant: the specific reason(s) for the decision to reduce or deny benefits; specific reference to the Plan provision(s) on which the denial is based as well as identification of and access to any guidelines, rules, and protocols which were relied upon in making the decision. Where a Plan utilizes a specific internal rule or protocol, the notice may wither set forth the protocol or included a statement that a copy of such protocol will be furnished to the Claimant or his authorized representative free of charge and upon request. A notification of denial or benefit reduction based on Medical Necessity or experimental treatment or other similar exclusion or limit must explain the scientific or clinical judgment of the Plan in applying the terms of the Plan to the Claimant's medical circumstances, or must included a statement that such explanation will be provided to the Claimant free of charge upon request; a statement that the Claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records or other information relevant to the Claimant's claim for benefits; the identity of any medical or vocational experts consulted in connection with the claim, even if the Plan did not rely upon their advice, or a statement that the identity of the expert(s) will be provided upon request; a description of any additional information needed to change the decision and an explanation of why it is needed; a description of the Plan's procedures and time limits for appealed claims, including a statement of the Claimant's right to bring civil action under section 502(a) of ERISA. A denial of an urgent claim must describe the expedited appeal process for urgent health claims. An urgent claim denial may be made orally to the Claimant if a written or electronic notification is furnished to the Claimant within 3 days after the oral notification. NOTE: A claim denial, or an "adverse benefit determination", means any of the following: a denial, reduction (which includes anv instance where the Plan pays less than the total amount City of Redlands of expenses submitted with regard to a claim), termination of a benefit, or a failure to provide or make payment (in whole or in part) for a benefit, including any such denial, reduction, termination or failure to provide or make payment that is based on a determination of a participant's or beneficiary's eligibility to participate n a plan, and including denial, reduction, or termination of a benefit, or failure to provide or make payment, in whole or in part for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not Medically Necessary or appropriate. Denial of a claim for failure to obtain a prior approval under circumstances that would make obtaining such prior approval impossible or where application of the prior approval process could seriously jeopardize the life or health of the patient (e.g., the patient is unconscious and is in need of immediate care at the time medical treatment is required) is prohibited. APPEAL PROCEDURES FILING AN APPEAL AND APPEAL REVIEW Within 180 days of receiving notice of a claim reduction or denial, a Claimant may appeal his claim, in writing, to a new decision -maker (an appropriate Named Fiduciary of the Plan who is neither the individual who made the initial adverse benefit determination nor a subordinate of the initial decision -maker) and he may submit new information (comments, documents, records, etc.) in support of his appeal. In response to his appeal, the Claimant is entitled to a full and fair review of the claim and a new decision and not simply a review whether the initial decision was reasonable. A "full and fair review" takes into account all comments, documents, records and other information submitted by the Claimant relating to the claim, without regard to whether the information was submitted or considered in the initial determination. At such time as the Claimant appeals a denied claim, he will be provided, upon request and free of charge, with access to and copies of all documents, records and other information relevant to his claim for benefits, without regard to whether the Plan relied on the material. The Plan will also disclose the names of any medical or health professionals consulted as part of the claim process, whether or not such information was submitted or considered in the initial benefit determination. For appeal of a denial based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug or other item is experimental, investigational, or not Medically Necessary or appropriate, the new decision - maker shall consult with an independent health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. Such professional must be independent of any health care professional involved in the initial decision to reduce or deny benefits. "Health care professional" means a physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law. DECISIOA 011 APPEAL A decision with regard to the claim appeal will be made within the allowed time frame (see Claims Time Limits and Allowances). If special circumstances which are out of the Plan's control, require an extension of time, written notice of the extension will be furnished to the Claimant prior to the termination of the initially -allowed time. The extension notice will explain the special circumstances requiring an extension and the date the Plan expects to render the final decision. No extension is permitted for urgent claims. The decision on appeal will be in writing or be electronic notification. With respect to an urgent care claim, the decision may be provided by phone, facsimile or other available and similarly Citv of Redlands expeditious method. If the decision is to continue to reduce or deny benefits, the notification will be provided in a manner calculated to be understood by the Claimant and will include: the specific reason(s) for the decision; reference to the pertinent Plan provision on which the decision is based; 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 claim "Relevant" information includes a document, record or other information which: (1) was relied upon in making the benefit determination, (2) was submitted, considered or generated in the course of making the benefit determination, whether or not it was relied upon, (3) demonstrates compliance with the administrative processes and safeguards required in making the benefit determination, or (4) constitutes a statement of policy or guidance with respect to the Plan concerning the denied benefit for the Claimant's diagnosis, whether or not it was relied upon. The Plan will also disclose any documents that were created or received by the Plan during the appeal process; identification of an medical or vocational experts whose advice was obtained in connection with the initial claim denial, whether or not the advice was relied upon in making the initial decision; identification of and access to any guidelines, rules, protocols which were relied upon in making the decision. Where a Plan utilizes a specific internal rule or protocol, the notice may either set forth the protocol or include a statement that a copy of such protocol will be furnished to the Claimant or his authorized representative free of charge and upon request. A notification of denial or benefit reduction based on Medical Necessity or experimental treatment or other similar exclusion or limit must explain the scientific or clinical judgment of the Plan in applying the terms of the Plan to the Claimant's medical circumstances, or must include a statement that such explanation will be provided to the Claimant free of charge upon request; a statement describing any voluntary appeal procedures offered bv the Plan, the Claimant's right to obtain the information about such procedure, and a statement of the Claimant's right to bring an action under ERISA section 502(a). In accordance with Federal law, the Plan cannot require mote than two (2) levels of mandatory appeal. If more than one (1) level of mandatory appeal is required, both must be completed within the time frame applicable to one(l) level. VOLUNTARY ADDITIONAL LEVELS OF APPEAL Subject to the Plan Administrator's established procedures, up to two (2) voluntary additional levels of appeal (including arbitration or any other form of dispute resolution) are permitted, but only after exhaustion of the Plan's mandatory appeal procedure. A Claimant cannot be required to pursue any voluntary level of appeal and a voluntary level of appeal cannot stop the Claimant from filing suit. The Plan waives any right to assert that a Claimant has failed to exhaust administrative remedies because the Claimant did not elect to pursue a voluntary level of appeal. Any statute of limitations or other defense based on timeliness is tolled (suspended) while a voluntary appeal is in process or pending. A Claimant may contact the Plan Administrator to determine if a voluntary appeal level is part of the Plan's written procedures and, upon request, the Claimant will be provided with: (1) sufficient information relating to the voluntary level of appeal to enable him to make an informed judgment about whether to submit a benefit dispute to the voluntary level of appeal, Citv of Redlands including a statement that his decision as to whether or not to use a voluntary level of appeal will have no effect on his rights to any other benefits under the Plan, (2) information about the applicable rules, (3) notice of his right to representation, (4) the process for selecting the decision -maker, and (5) the circumstances, if any, that may affect the impartiality of the decision -maker, such as any financial or personal interests in the result or any past or present relationship with any party to the review process. No fees or costs may be imposed on the Claimant as part of the voluntary level of appeal. NOTE: Arbitration is permitted as a level of appeal, but only if the Claimant is provided with full disclosure regarding the process, arbitrator, relationships, right to representation, and only if Claimant agrees to such arbitration after completing the internal appeal process. Mandatory arbitration is permitted only as a mandatory appeal level. However, a Claimant is not precluded from challenging the decision under Section 502(c) of ERISA (Employee Retirement Income Security Act) or other applicable law. WHEN THE NAMED FIDUCIARY IS A COMMITTEE OR BOARD OF TRUSTEES If the Plan's Named Fiduciary is a committee or board of trustees that holds regularly - scheduled meetings at least quarterly, the Named Fiduciary shall made a benefit determination not later than the meeting date that immediately follows the Plan's receipt of an appeal, unless the appeal is filed within thirty (30) days preceding the date of such meeting. In that case, a benefit determination may be made not later than the date of the second meeting following the Plan's receipt of the appeal. If special circumstances (such as the need to hold a hearing as is permitted by the Plan) require a further extension of time for processing, a, benefit determination shall be rendered not later than the third meeting following the Plan's receipt of the appeal. If such an extension of time for review is required because of special circumstances, the Employee will be provided with written notice of the extension describing the special circumstances and the date on which the benefit determination will be made. Such notice will be provided prior to the commencement of the extension. When benefit determination is made, notice of the decision will be provided to the Employee not later than five (5) days thereafter. December 17, 2002 Signature of Authorized Representative Date Karl N. Haws, Mayor Lorri;d Poyzer, 5 0_ lerk I Citv of Redlands