Western Teamsters Welfare Trust

WESTERN TEAMSTERS WELFARE TRUST

NOTICE OF PLAN MODIFICATION

The following modifications are made to the Plan Booklets for Active Employees, Casual Employees and Retirees. The changes are being made to comply with Department of Labor regulations. The changes are made as of the effective dates listed below. Not all plans provide all the benefits covered in the benefit claim procedures.

Statement of Purpose
These procedures were effective for weekly disability benefits filed on or after January 1, 2002 and for all other types of claims for services or supplies provided on or after September 1, 2002. The Benefit Claim Procedures summarize the requirements for filing a claim for benefits with the Trust, the time frames for making an initial determination on properly submitted claims, the contents of a denial of benefits, the procedures for filing an appeal, the Trust's appeal procedures and the participant's rights if an appeal is denied. These Benefit Claim Procedures are intended to help assure the consistent processing of claims and claim appeals. The Board of Trustees shall interpret and administer these Benefit Claim Procedures in accordance with the requirements of applicable law.
Filing a Claim
1. General Requirements
  To constitute a claim, the participant or beneficiary must comply with the procedures set forth.
  To be considered a claim, the participants must request that the Trust provide benefits for a specific service or supply. Claims must be submitted within one year from the date expenses for the services or supplies for which benefits are sought were first incurred. (Note: HMO medical and dental arrangements may have different time limits.) Failure to submit a timely claim will result in a permanent denial of benefits. Subject to the special provisions dealing with urgent claims, claims must be submitted in writing by a participant and to the proper address.
  For any claim the Trust may require additional information to process claims or to meet plan requirements. This may include inquiries related to eligibility, the nature of services or supplies provided, coordination of benefits, other insurance, third party reimbursement requirements or other plan provisions. Failure to provide this required information may result in the denial of a participant's claim for benefits.
2. Requirements for Specific Claims
  The following requirements exist for filing specific types of claims:
  1. HMO Medical and Dental Options
    The requirements for filing a claim for participants participating in a health maintenance organization will be established by that entity. Any claims filing requirements will be stated in the Plan Document from that entity.
  2. Self-Funded Medical and Dental Plans
    In most situations, providers will submit bills to the appropriate Area Administrative Office for payment If the provider does not bill directly, participants should request an itemized statement of the services and charges including a diagnosis. You should submit the claim with the Trust's name, the participant's identification number and the name of the individual receiving the service. The claim form should be submitted to your Area Administrative office.
  3. Indemnity Plan Prescription Drug Claims (Medco Health)
    Present your Medco Health prescription drug Plan ID card at Medco Health network pharmacies and the participating pharmacy will collect your co-payment and bill the Trust for the remaining costs.
    To receive prescription drug plan benefits, you must use Medco Health network pharmacies. If a non-participating pharmacy is used, you will not receive benefits.
    If you use mail order to fill your claims, you must complete a Mail Order Pharmacy Order Form and submit it to:
    Medco Health Solutions, Inc.
    P.O. Box 3938
    Spokane, WA 99220-3938
  4. Mental Health and Chemical Dependency (MHN)
    No claim form is necessary to submit if you use an MHN network provider. If you use a non-MHN provider, you must submit a Non-Contracting Provider Claim Form which is available from MHN. This form is to be submitted to:
    MHN Claims Department
    PO BOX 14621
    Lexington, KT 40512-4621
  5. Vision (Vision Service Plan)
    No claim form is necessary if a Vision Service Plan provider is used. If a non-VSP provider is used, you should submit an itemized statement of charges along with your name and the participant's identification number to:
    Vision Service Plan
    P.O. Box 997105
    Sacramento, CA 95899-7105
  6. Life Insurance and AD&D (Prudential)
    In the event of an Employee or dependent's death, a certified copy of the Employee's death certificate along with a Prudential claim form must be submitted to your Area Administrative Office. The death certificate does not need to be certified if the insured has died within the previous six months in the United States or Canada; benefits are not assigned to a nursing home; the death does not involve a homicide, accident or an investigation; and the named beneficiary provides his or her Social Security Number and is not deceased, divorced from the deceased or a non-resident alien. Claims for dependent life insurance benefit should include the employee's Social Security Number.
  7. Weekly Time Loss
    You must submit a Statement of Disability Claim form that has been signed by you and completed by your employer and your physician. Your attending physician's Statement of Disability must accompany the Application. The Application must be submitted to your Area Administrative Office.
Procedures for Processing Claims
Claims for benefits other than those provided by an HMO medical or dental option or life and AD&D benefits which are properly filed will be processed in accordance with the guidelines set forth below. Claims filed with an HMO medical or dental option or for life and AD&D benefits will be processed by those entities in accordance with their procedures.
1. Post-Service Health and Weekly Disability Claims
  Any properly filed claim for benefits that does not involve urgent care or a pre-service health claim will be processed as a post-service health claim. If additional information is needed, a participant will be notified and given 45 days to provide the additional required information. The time period for making a benefit determination shall be tolled from the date the request for additional information is sent until the earlier of the date the requested information is received or 45 days have passed.
  A claim will be processed within 30 days of receipt. This may be extended by an additional 15 days if a notice is provided within the initial 30-day period.
2. Pre-Service Health Claims
  These procedures apply only to properly filed claims which must be preauthorized to receive full benefits from the Trust. Currently, only inpatient admissions meet this requirement.
  Claimants will be notified within five days if additional information is required to complete a pre-service claim or to allow processing. Claimants will be provided 45 days to submit any additional information. The time period for making a determination will be tolled from the date the information is requested until the earlier of the date information is received or 45 days have passed.
  A decision on a pre-service claim will be made within 15 days. If additional time is necessary, the claims administrative agent may extend this 15-day period by an additional 15 days by providing notice to the participant prior to the expiration of the initial 15-day period.
  If services which require preauthorization have been provided and the issue is what payment, if any, will be made, the Trust will process the claim as a post-service health claim.
3. Urgent Care Health Claims
  Urgent care claims are claims for services where the application of the normal time frames for appeals could seriously jeopardize the health of the claimant or expose him or her to severe pain. Urgent care claims may be filed, orally or in writing, by the participant or an eligible health care provider with knowledge of the participant's medical condition. Participants will be informed within 24 hours if additional information is needed to process the claim. Claimants will have at least 48 hours to submit the additional information. The claims administrative agent will develop procedures for identifying urgent care claims which may include seeking additional information from the participant or his or her providers about why the treatment involves urgent care.
  If services which constitute urgent care have been provided and the issue is what payment, if any, will be made, the Trust will process the claim as a post-service claim.
4. Life and AD&D Claim
  For any properly filed claim for Life and Accidental Death and Dismemberment benefits, Prudential shall notify participants of its claim determination within 45 days of its receipt of a claim. This time period can be extended by two 30-day periods if necessary due to reasons beyond the control of the Plan. If a claim is denied, the appeal shall provide the information listed below.
Notice of Administrative Denial
A denial of benefits will provide the following information:
1. The reason for the denial.
2. A reference to the plan provision relied on.
3. A description of any additional material needed to perfect the claim.
4. An indication if any internal guidelines or protocols have been relied on in denying the claim and statement that any such internal guidelines are available on request.
5. If the denial is based on medical necessity, the service or supply being experimental or investigational in nature or an equivalent exclusion, a statement that an explanation of the medical judgment will be provided upon request.
6. An explanation of the Trust's appeal procedures.
  The denial will be mailed to the participant at his or her last known address.
Appeal of Benefit Denial
Claimants will have 180 days from the date of denial to appeal an adverse benefit determination except denials of life insurance and AD&D claims which must be filed within 60 days. An appeal shall be submitted by the participant or an authorized representative in writing. It shall be submitted to the proper address for your Area Administrative Office. An appeal shall identify the benefit determination involved, set forth the reasons for the appeal and provide any information the participant believes is pertinent. Except for urgent care claims, appeals will be accepted from an authorized representative only if accompanied by a written statement signed by the claimant (or parent or legal guardian where appropriate) which identifies the representative and authorizes him or her to seek benefits for the claimant. An assignment of benefits is not sufficient to make a provider an authorized representative.
A failure to appeal a claim denial within 180 days of the denial (or 60 days for life and AD&D claims) will serve as a bar to any claim for benefits or for other relief from the Trust.
Appeal Procedures
The procedures specified below shall be the exclusive procedures available to a participant who is dissatisfied with an eligibility determination, benefit award or is otherwise adversely affected by an action of the Trust or its authorized claims payers. These procedures must be exhausted before a claimant may file suit under Section 502(a) of ERISA. A participant who is seeking benefits from an optional HMO provider with which the Trust contracts or life and AD&D benefits from Prudential shall utilize the appeal procedures established by that entity.
1. Information To Be Provided Upon Request
  The participant, and/or his or her authorized representative, may upon request and free of charge have reasonable access to all documents relevant to the claim for benefits. Relevant documents shall include information relied upon, submitted, considered or generated in making the benefit determination. It will also include internal guidelines, procedures or protocols concerning the denied treatment option without regard to whether such document or advice was relied on in making the benefit determination. Absent a specific determination by the Board of Trustees that disclosure is appropriate, relevant documents do not include any other individual's medical or claim records or information specific to the resolution of other individuals' claims.
  If a denial is based upon a medical determination, an explanation of that determination and its application to the claimant's medical circumstances is also available upon request.
2. Conduct of Hearings By the Appeals Committee
  Except for urgent care and pre-service health claims, an appeal will be presented to the Trust's Appeals Committee at its next quarterly meeting. If an appeal is received less than 30 days before the next quarterly meeting, consideration of the appeal may be postponed (if necessary) until the second quarterly meeting following receipt of the appeal.
  The Appeals Committee shall consist of at least one Employer and one Union Trustee. The Appeals Committee will review the administrative file which will consist of all documents relevant to the claim. It will also review all additional information submitted by or on the participant's behalf. The review will be de novo and without deference to the initial denial.
  If the denial is based on medical judgment, the Appeals Committee will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The Trust may have an individual with a different licensure review a matter if they are trained to deal with the condition involved. The health care professional consulted will not be the individual who made the initial benefit determination nor the subordinate of that individual. The Appeals Committee will identify by name any individuals consulted for medical or vocational advice.
3. Issuance of a Decision
  The Appeals Committee will provide the claimant written notification of its decision within five days. Where appropriate, the Board of Trustees may issue a more detailed explanation of the reasons for its decision within 30 days of the hearing. The decision will set out the specific reasons for an adverse decision, reference the plan procedure involved, inform the claimant that all information relevant to the individual's claim is available upon request and free of charge, notify the claimant of his or her rights under section 502(a) of ERISA, identify any internal rule or guideline relied on, and if a denial is based on a medical judgment, an explanation of the medical judgment applying it to the claimant's case or a statement that such information is available.
  If a decision cannot be reached at the initial meeting at which an appeal is heard, the Appeals Committee may defer a decision on an appeal until the next quarterly scheduled appeals meeting provided that written notice is provided to the claimant.
Modifications to the Appeal Procedures for Pre-Service, Urgent Care and Life and AD&D Claims
The following modifications will be made in the appeal procedures set forth in Section 6 for claims involving pre-service claims or urgent care claims:
1. Pre-Service Claims
  Pre-Service health claims will be conducted in accordance with the above procedures with the following modifications:
  1. A decision or an appeal of a denial of a pre-service health claim will be issued in 30 days of receipt of the appeal.
  2. Unless the appeal hearing coincides with a quarterly Appeals Committee meeting, the Appeals Committee meeting will be conducted by a telephone conference call.
2. Urgent Care Claims
  Appeals involving denial of urgent care will be subject to the rules set forth in Section 7 with the following modifications:
  1. An initial decision will be made within 72 hours if the initial claim was complete when submitted or an additional 48 hours after receiving additional information if it was necessary to process the claim.
  2. An appeal may be made orally or in writing.
  3. A health care professional with knowledge of the claimant's medical condition may act as an authorized representative of the claimant without a prior written authorization.
  4. Information will be provided to the claimant or authorized representative via telephone, facsimile or other expedited method.
  5. A decision will be issued within 72 hours of an appeal of an initial denial.
3. Life and AD&D
  1. The initial review of any appeal shall be conducted by the Prudential Appeals Review Unit.
  2. The initial review shall be completed within 45 days and can be extended to 90 days if special circumstances require such an extension.
  3. If the participant's claim remains denied, the participant may submit a second appeal within 180 days. A final decision on this review will be made by a member of the Prudential Senior Claims Management Unit who was not previously involved in the appeal within the same time frame identified above.
  4. (4) If the participant's claim remains denied and an appeal is made within 180 days, the third appeal will be reviewed by three members of the Senior Claims Management Team who have not been involved in any previous appeals.
Review of Denied Claims
The Trust provides for no voluntary alternative dispute resolution procedures. If a claimant remains dissatisfied with the Trust's determination after exhausting the claim appeal procedures, he or she has the right to pursue a civil action under 29 U.S.C. � 1132(a). The Plan provides that no legal or equitable action for benefits can be commenced more than one year after the issuance of the Appeals Committee's written decision.

Privacy Statement