CLAIMS AND APPEALS PROCEDURES
To obtain the various benefits made available through this Plan, you must identify yourself to the provider of service as a WTWT Retiree Plan participant or dependent and you must have current eligibility.

In some situations you will be provided with services or supplies without payment by you and without the need for a claim form. However, you may have to make a partial payment such as a deductible, copayment, or other charge.

In other situations, you must pay for services or supplies at the time they are received and then seek reimbursement from your Area Administrative Office by submitting a claim with a completed claim form. Charges must be itemized on the claim form or on an attached billing from the provider of services. When the claim is processed, any partial payments you owe, such as a deductible, copayment, or other charge, will be subtracted from the amount paid.

There is a section on the WTWT claim form that allows you to assign payment from the Plan directly to your doctor or hospital. If you sign the assignment requesting payment to the provider, payment of the claim will be made directly to the provider.

In all situations, you will be responsible to pay for services or supplies not covered by the Plan or for charges which exceed those allowable under the Plan.

Claim forms are always available from your Area Administrative Office and may also be available through your local union office.

Outline of Claim Requirements for the Various Benefits
The claim filing requirements that normally apply to the various benefits provided by the Trust are outlined below. If a claim involves an accident or a potential third-party liability or workers compensation claim, the Trust may require additional information from you in order to process your claim.

Non-Medicare Retiree Indemnity Medical Benefits

• Claim form may not be required if a preferred (PPO) provider is used
• WTWT claim form is required if a non-network provider is used

Medicare Retiree Indemnity Medical Benefits

• WTWT claim form is required
• Explanation of Benefits statement from Medicare is required

Optional HMO Medical Benefits

• Claim form is not required - see your HMO booklet

Prescription Drug Benefits

• Claim form is not required for mail order purchases
• WTWT claim form is required for non-network retail store purchases
• WTWT claim form is NOT required for network retail store purchases

Managed Mental Health and Chemical Dependency Benefits for Non-Medicare Retirees Only

• Claim form is not required if MHN network provider is used
• MHN claim form is required if a non-network provider is used

One Year Time Limit for Filing Claims
Where a claim is required, the claim, together with all itemized bills and other required papers necessary to prove the claim, must be submitted to your Area Administrative Office within one year (12 months) of the date the care or services are provided. Claims not filed within one year (12 months) are not payable under the terms of the Plan.

Denial of Claims
If your claim for benefits is wholly or partially denied, you will be sent a written Explanation of Benefits (EOB) form which notifies you of the denial and of the right to appeal the denial. If your benefits are payable through your Area Administrative Office, that Office will send the EOB. The EOB or accompanying correspondence will set forth specific reasons for the denial, specific references to the Plan provisions on which the denial is based, a description of any information or material necessary for you to perfect your claim, an explanation of why the material is necessary and an explanation of the Plan’s appeal procedures.

The Explanation of Benefits (EOB) will be provided within 90 days after your Area Administrative Office receives the claim, unless special circumstances require an extension of time for up to an additional 90 days for processing the claim. If an extension of time is required, you will be notified in writing before the end of the initial 90-day period. The notice of extension will indicate the special circumstances requiring the extension of time and the date by which your Area Administrative Office expects to render its decision. If written notice of denial of the claim is not furnished within the time specified above, including any extension, the claim will be deemed denied and you will be permitted to appeal the denial in accordance with the applicable appeals procedures which follow.

Right to Appeal
If your claim for benefits is wholly or partially denied (or is deemed denied), you or your duly authorized representative may submit a written request for a review of the claim by the WTWT Appeals Committee. The request for review must be submitted to your Area Administrative Office within 60 days after the date the claim is denied (or is deemed denied). If the request for review involves an issue as to the nature or extent of benefits which are to be provided by one of the other health care providers, the Area Administrative Office may refer your request to that organization for review according to that organization’s appeal procedures.

A request for review must be in writing and set forth all the grounds on which it is based, all facts in support of the request and any other matters which you deem pertinent. Your Area Administrative Office will provide you or your representative an opportunity to review pertinent documents if such review is necessary in preparing your request for review. Also, your Area Administrative Office may require you to submit additional facts, documents or other materials as it deems necessary or appropriate in evaluating your request.

Appeals Committee
All requests for review will be presented to the WTWT Appeals Committee, in written form only, at the next quarterly meeting of the Board of Trustees. In some cases this can be accomplished within 60 days of the submittal of the request for review, but, depending on the meeting schedule, an additional period of up to 60 days may be required. You will be informed of when your appeal is being referred to the Appeals Committee.

Notice of Decision
Following consideration by the Appeals Committee, your Area Administrative Office will give you written notice of the decision on your request for review.

If the denial of your claim for benefits is wholly or partially confirmed, the notice of decision will set forth the specific reasons for the decision and specific references to the Plan provisions on which the decision was based. If it is determined that your claim for benefits should not have been denied, in whole or in part, appropriate remedial action will be taken as soon as reasonably practical.

Optional Providers
Each optional HMO medical provider has internal procedures for claim appeals. Once you have exhausted these internal appeal procedures, you have the additional right to appeal to the WTWT Appeals Committee as outlined above.

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: (1) has submitted a written claim for benefits as required; (2) has been notified that the claim is denied (or is deemed denied); (3) has filed a written request for review; and (4) has been notified in writing of the decision of the Appeals Committee.