• Types of Medical Claims and Fund Office Procedures to Handle Your
  Claims
• Pre-Service Claims Under the Pre-Admission Review Process
• Urgent Care Claims
• Concurrent Claims
• Disability Claims
• Post-Service Claims
• If Your Claim Is Denied
• Appealing the Denial of Your Claim
• Limitation on Legal Actions

5.1 Types of Medical Claims and Fund Office Procedures to Handle Your Claims

When you send your completed claim for benefits to the Fund Office, the Fund Office determines whether you are eligible for benefits and the amount of benefits that are payable, if any. The way the Fund Office handles your claim depends on the type of claim you are making.

5.2 Pre-Service Claims Under the Pre-Admission Review Process

You are required to get Fund approval in advance of elective surgery or hospitalization under the Blue Cross Blue Shield MSA (see above). The Fund will make a decision on your pre-service claim and notify you of the decision within a reasonable period of time appropriate to the medical circumstances, but no later than 15 days after receiving your claim. If the Fund requires an extension of time due to matters beyond the control of the Fund, the Fund will notify you of the reason for the delay and when the decision will be made. This notification will occur before the expiration of the 15-day period. A decision will be made within 15 days of the time the Fund notifies you of the delay.

If the Fund needs additional information fromyou to make its decision, you will be notified as to what information must be submitted. You will have at least 45 days to submit the additional information. Once the Fund receives the information from you, you will be notified of the Fund’s decision on the claim within 15 days.

5.3 Urgent Care Claims

Urgent care claims are claims for medical care or treatment that:

1. Would seriously jeopardize your life or health if normal pre-service standards were applied, or
2. Would subject you to severe pain that cannot be adequately managed without the care or treatment for which approval is sought, in the opinion of a physician with knowledge of your condition.

If your claim involves urgent care, the Fund will make a decision on your claim and notify you of the decision as soon as possible, taking into account your medical needs, but not later than 72 hours after the Fund receives your claim.

If you do not provide sufficient information to determine whether or to what extent benefits are covered or payable for urgent care, the Fund Administrator or its designee will notify you as soon as possible, but not later than 24 hours after receipt of the claim, of the specific information necessary to complete the claim. You must provide the specified information within 48 hours. If you do not provide the information, your claim will be denied.

5.4 Concurrent Claims

Concurrent claims involve a reconsideration of services you are currently receiving. In some cases, the Fund may approve your claim for a certain number of visits or for a certain length of time. For example, the Fund may approve a hospital stay for five days for treatment of a medical condition.

The Fund may decide to reduce or terminate the number of visits or length of time that was previously approved. If such a decision is made, the Fund will inform you of the decision sufficiently in advance of the reduction or termination so that you can request and receive a review of the decision before it takes effect.

If you request an extension of the number of visits or length of time at least two hours before the expiration of the approved limit and your request involves urgent care, the Fund will make a decision on your request and notify you of the decision within 24 hours. All other requests for extensions will be handled as Pre-Service Claims.

5.5 Disability Claims

If your claim is one for Weekly Accident and Sickness Benefits due to disability, the Fund will make a decision on your claim and notify you of the decision within 45 days of receiving your claim. If the Fund requires an extension of time due to matters beyond the control of the Fund, the Fund will notify you of the reason for the delay and when the decision will be made. This notification will occur before the expiration of the 45-day period. A decision will be made within 30 days of the time the Fund notifies you of the delay.

If the Fund needs additional information from you to make its decision, you will be notified as to what information must be submitted. You will have at least 45 days to submit the additional information. Once the Fund receives the information from you, you will be notified of the Fund’s decision on the claim within 30 days.

5.6 Post-Service Claims

For claims you submit after you have received the services, the Fund will make a decision on your claim and notify you of the decision within 30 days of receiving your post-service claim. If the Fund requires an extension of time due to matters beyond the control of the Fund, the Fund will notify you of the reason for the delay and when the decision will be made. This notification will occur before the expiration of the 30-day period. A decision will be made within 15 days of the time the Fund notifies you of the delay.

If the Fund needs additional information from you to make its decision, you will be notified as to what information must be submitted. You will have at least 45 days to submit the additional information. Once the Fund receives the information from you, you will be notified of the Fund’s decision on the claim within 15 days.

5.7 If Your Claim Is Denied

If your claim is denied in whole or in part, you will receive notice of the denial of your claim within the appropriate time frame that provides the following information:

1. The specific reason or reasons your claim was denied,
2. A reference to the specific plan provisions on which the denial was based,
3. If an internal rule, protocol or guideline was relied on in making the denial, you will receive a copy of the rule or a statement that it is available upon request at no charge,
4. If the determination was based on medical necessity, experimental/investigational exclusion or similar exclusion, you will receive an explanation of the scientific or clinical judgment for the determination applying the terms to your claim or a statement that it is available upon request at no charge,
5. A description of any additional information you need to submit to support your claim,
6. An explanation of why the additional information is needed,
7. An explanation of the Fund’s claim appeal procedures and applicable time limits, and

A statement of your right to bring a civil action under ERISA following an adverse benefit determination.

If you do not receive the notice within such time period and there has been no settlement on your claim, you should write to the Fund Office for information.

5.8 Appealing the Denial of Your Claim

If your claim is denied, you are entitled to a full and fair review of your claim. You or your authorized representative must submit your written appeal within 180 days of the denial of your claim. If your claim involves urgent care, you may make your request for review orally.

In making your appeal, you or your authorized representative will be entitled to submit additional proof that you are entitled to benefits and examine any document related to your claim that is in the possession of the Fund Office. You will also be entitled to review all relevant information (free of charge) upon reasonable request to the Trustees. A document, record or other information is relevant if:

1. It was relied upon by the Plan in making the decision,
2. It was submitted, considered or generated in the course of making the decision, regardless of whether it was relied upon in making the decision, or
3. It demonstrates compliance with the claims processing requirements.

The decision on your appeal will be made as soon as possible and no later than within:

60 days of receiving your written appeal for post-service claims,
45 days of receiving your written appeal for Weekly Accident and Sickness Disability claims, 30 days of receiving your written appeal for pre-service claims, and 72 hours for urgent care claims.


If the Trustees receive your request for review of a post-service or Weekly Accident and Sickness Disability claim within 30 days of the next regularly scheduled board meeting, your request for review will be considered at the second regularly scheduled board meeting. In special circumstances, a delay until the third regularly scheduled meeting following receipt of your request for review may be necessary. You will be advised in writing in advance if this extension will be necessary. Once a decision on review of your claim is reached, you will be notified of the decision as soon as possible, but no later than five days after the decision has been reached.In special circumstances, up to an additional 45 days may be necessary to reach a final decision on a disability claim. You will be advised in writing within 45 days after receipt of your request for review if an additional period of time will be necessary to reach a final decision on your disability claim.

The written notice of the decision on review will include:

1. The specific reason or reasons your claim was denied,
2. A reference to the specific plan provisions on which the denial was based,
3. A statement that you are entitled to receive reasonable access to and copies of all documents relevant to your claim upon request and free of charge,
4. A statement of your right to bring a civil action under ERISA following an adverse benefit determination on review, and
5. A statement about alternative ways to appeal the decision and referral to the Department of Labor or your state’s regulatory agency.

The Trustees have discretionary authority to determine all benefit claim appeals and to interpret the Fund. The determination rendered by the Trustees will be binding on all parties. The Trustees’ decision in your appeal will be given judicial deference in any later court action to the extent that it does not constitute an abuse of discretion. You must follow the Fund’s appeal procedures before you are permitted to bring any court action against the Fund.

5.9 Limitation on Legal Actions

The Plan contains a two (2) year statute of limitations. Notwithstanding any other state or federal law, any and all legal actions against the Plan or its Trustees must be filed within two (2) years of 30 the action or inaction complained of. This includes but is not limited to actions to recover benefits that must be filed within two (2) years of the final decision on your claim. The situs of the Plan is in Cook County, Illinois. Legal actions must be brought in the appropriate state or federal court located in Cook County, Illinois.