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Home > Health Plan > Health Benefits Plan Claim Procedures
HEALTH BENEFITS PLAN CLAIM PROCEDURES — Some plans do not include every benefit mentioned. Refer to your plan booklet to verify which benefits are included in your plan.
These procedures provide covered persons and their representatives with information regarding filing a claim and appealing
a claim decision and are effective January 1, 2002 for Disability claims and December 1, 2002 for Health claims. For
information on benefits provided under the Health Benefits Plan, please refer to a plan booklet (Summary Plan Description)
or to the benefit description pages of this website.
Filing a Claim
Inquiries and requests for claim forms may be made by contacting the Benefits Fund
Office or by visiting the Forms page of this website.
Claim forms are required for each claimant for each type of coverage as follows:
At times, additional information may be required after a claim is filed, such as accidental injury details, information on
third-party liability, information on other group health coverage or any other information necessary to ensure that expenses
are covered under the Plan.
Claims should be filed within 90 days. No claim that is more than 2 years old will be considered for payment.
Claims for services provided by BlueCross BlueShield PPO providers should be submitted by the provider directly to
BlueCross BlueShield. Claims for Dental, Vision, Income Protection, Life Insurance, AD&D, and medical claims from
non-PPO or home health care providers should be sent to:
United Food and Commercial Workers
The Prescription Drug Benefit is administered for the Fund by NMHC/Rx at 888-354-0090. Claims are filed by the pharmacy
at the time a prescription is dispensed. Claims for reimbursement when the drug ID card is not used should be mailed to
1300 Higgins Road, Park Ridge, IL 60068.
Pre-Certification of Covered Expenses
Some treatments and supplies require pre-certification of expenses. To verify whether pre-certification is required,
contact Health Information Services at the Benefits Fund Office.
To protect patient privacy and rights, all requests for pre-certification must be submitted in writing by mail, fax or website.
The request must include the patient’s name and relationship to the participant, the participant’s name and UFCW ID # (or
social security number), the diagnosis, the proposed treatment, and the name and telephone number of the treating
physician. For foot surgery, the request should also include the amount of the surgeon’s fee.
Expenses that require pre-certification include any non-emergency treatment or supply, as follows:
When emergency care results in the patient being admitted to the hospital, the Benefits Fund Office must be contacted within
48 hours of the admission.
Pre-certification may be waived if another insurer or health plan is primarily responsible for the expense or treatment. If the
primary carrier, for whatever reason, decides not to cover the expense, the Fund’s pre-certification requirements apply.
Pre-certification may also be waived if, under the circumstances, obtaining prior approval is not possible. Pre-certification is
not required if the condition, left untreated, would seriously jeopardize the life or health of the patient or the ability to regain
maximum function or would subject the patient to severe pain that cannot be adequately managed without the care or t
reatment that is the subject of the claim.
Medical offices will often request pre-certification from the Benefits Fund Office for equipment, tests or procedures that are
not included on the list of expenses which require pre-certification. When such requests are received, the Benefits Fund
Office will make every effort to accommodate the request and review the proposed treatment for pre-certification. However, if
pre-certification is not required (i.e., the Fund will not deny benefits because pre-certification was not obtained) or the
request was not properly submitted, such requests are not considered claims and are not subject to the processing time and
appeal time guidelines set forth in these procedures.
Notification of Benefit Determination
Pre-Service Claim. If pre-certification has been appropriately requested, a determination will be made and the Fund
will issue a decision within 15 days, although every effort will be made to respond within a shorter period of time. If additional
information is required resulting in a delay in determining benefits, then the claimant will be notified that the response will be
delayed no more than an additional 15 days. The claimant will be notified if an extension is needed and will be advised of the
reason for the extension and the estimated date that a decision will be made. When additional information is requested, the
claimant has up to 45 days to provide the information to the Benefits Fund Office. When a request for additional information
is made, the measurement of the time elapsed while processing the claim is frozen.
The time limits noted above may be reduced if the treating physician advises the Fund that the need for medical treatment
constitutes an “urgent” claim under Federal Department of Labor guidelines and provides an explanation as to why the claim
should be considered an urgent claim.
Verbal requests for pre-certification of treatment expenses will be responded to, but such requests do not constitute a claim
and will not necessarily be responded to within the time limits noted above (unless the claim in an urgent claim).
Post-Service Claim. Post-service expenses will be adjudicated within 30 days after receipt of the claim at the Benefits
Fund Office. If additional time or information is required to determine benefits, the participant will be notified that the
determination of benefits will be delayed by no more than 15 days. If additional information is requested, the claimant has up
to 45 days to provide the information to the Benefits Fund Office. When a request for additional information is made, the
measurement of the time elapsed while processing the claim is frozen.
Concurrent Care Claim. If your ongoing course of treatment or number of treatments was approved and is later
reduced or terminated, you will be notified of the reduction or termination in enough time for you to appeal and receive a
decision on your appeal before your treatment is reduced or terminated. If you request to extend your treatment and your
request is an urgent claim, a decision on your request will be made as soon as possible, taking into account your medical
circumstances. You will be notified whether your request has been approved or not within 24 hours after the Fund receives
your request as long as you made your request at least 24 hours before your treatment is scheduled to end.
Income Protection Claim (Weekly Disability). A claim for Income Protection will be adjudicated within 45 days. This
time limit may be extended for up to two 30-day periods if the Fund Administrator determines that an extension is needed due
to matters beyond the Fund’s control. The claimant will be notified if an extension is needed and will be advised of the reason
for the extension and the estimated date that a decision will be made. If additional information is requested, the claimant has
45 days to provide the information to the Benefits Fund Office. When a request for additional information is made, the
measurement of the time elapsed while processing the claim is frozen.
If your claim is denied, you will be given a written explanation, as described on the
Claim Appeal Procedure page of this website.
Filing an Appeal of a Benefit Determination
You have the right to a full and fair review if your claim is denied in whole or in part by the Plan. The review will be conducted
by a fiduciary of the Fund who was not involved in the initial decision (and is not a subordinate of the person who made the
decision) and will not give deference to the initial decision. If the denial was based on a medical judgement, the fiduciary will
consult with a medical professional who has training and experience in the appropriate medical field and who was not involved
in the initial decision (and is not a subordinate of the person involved). The fiduciary will identify any medical or vocational
experts who were consulted regarding the appeal.
How to File an Appeal. A claimant or an Authorized Representative must
file an appeal in writing to the Fund Administrator within one year of the denial of the claim. To be considered an appeal, the
claimant must file a written request for a review of a specific claim and state the reason for disagreement with the benefit
determination. The Fund will review all information submitted with the appeal, whether or not it was considered in the initial
decision.
An appeal (as well as a claim) may be submitted by:
What is Not an Appeal. A communication will not be considered an appeal if any of the following apply (unless it is
an appeal of an urgent claim): (1) it is a telephone inquiry or other verbal request for review of a claim; (2) it involves a
dispute between a BlueCross PPO provider and BlueCross BlueShield regarding contractual allowances agreed to in the
contract between the parties; or (3) it is the submission of information originally requested by the Fund that was not previously
sent to the Fund.
Time Requirements for Appeal Response
Pre-Service Appeals. Pre-Service Appeals are defined as appeals concerning the denial, in whole or in part, of
expenses for services or supplies that have not yet been received by the claimant or billed to the Fund.
Within 15 days of receipt of the appeal, the Fund Administrative Manager will review all information submitted with the letter of
appeal, as well as any additional information that may be reasonably obtained. If the Fund Administrative Manager’s decision
is favorable to the claimant, a letter will be sent to the claimant advising of the decision. If the Fund Administrative Manager’s
decision is to continue to deny the expenses for the services or supplies, in whole or in part, the appeal will be referred to the
Appeal Committee of the Board of Trustees. The claimant will receive a written notice of the Appeal Committee’s decision
within 30 days of receipt of the pre-service appeal. The Appeal Committee’s decision will be the final administrative remedy.
For urgent claims, the review may be expedited. Under an expedited review, you may submit a request for review orally or in
writing and all necessary information will be transmitted by telephone, facsimile or another expeditious method. You will be
notified as soon as possible of the decision, but not later than 72 hours after your appeal is received.
Post-Service Claim Appeals. Post-Service Appeals are defined as appeals concerning expenses already processed
and denied in whole or in part by the Fund.
All Post-Service Appeals are reviewed by the Appeal Committee of the Board of Trustees at its quarterly meeting. Prior to the
quarterly meeting, the Fund Administrative Manager will issue an advisory notice to the claimant which will provide an analysis
of the additional information that has been submitted with the appeal. Following the receipt of the advisory notice, the claimant
may provide additional information or justification to the Fund in support of the claim. The Appeal Committee and the Fund
Administrative Manager will review the information that was submitted with the letter of appeal, as well as any additional
information that is provided by the claimant in response to the advisory notice and any other information that may be r
easonably obtained, and issue a written decision to the claimant within five days after the decision is made. The Appeal
Committee’s decision is the final administrative remedy.
Note that if, prior to the quarterly meeting, the Fund Administrative Manager determines that benefits should be paid on behalf
of the claimant based on the additional information submitted with the appeal, a favorable decision for the claimant will be
made. This favorable decision will be reported in writing to both the claimant and the Appeal Committee.
Income Protection Claim Appeals (Weekly Disability). All Income Protection Claim Appeals are reviewed by the
Appeal Committee of the Board of Trustees at its quarterly meeting. Prior to the quarterly meeting, the Fund Administrative
Manager will issue an advisory notice to the claimant which will provide an analysis of the additional information that has been
submitted with the appeal. Following the receipt of the advisory notice, the claimant may provide additional information or
justification to the Fund in support of the claim. The Appeal Committee and the Fund Administrative Manager will review the
information that was submitted with the letter of appeal as well as any additional information that is provided by the claimant in
response to the advisory notice and any other information that may be reasonably obtained, and issue a written decision to
the claimant within five days after the decision is made. The Appeals Committee’s decision is the final administrative remedy.
Note that if, prior to the quarterly meeting, the Fund Administrative Manager determines that benefits should be paid on behalf
of the claimant based on the additional information submitted with the appeal, a favorable decision for the claimant will be made.
This favorable decision will be reported in writing to both the claimant and the Appeal Committee.
Reviews will include examination of the claim material by qualified medical experts, when appropriate.
Notification of Appeal Response. You will be given written notification of the decision on your appeal. If your appeal
is denied, the notification will include the following information:
Right to File a Lawsuit
A claimant has the right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974
(ERISA) following the denial of a claim on appeal by the Appeal Committee.
Authorized Representative
A participant or legal guardian may authorize another individual or entity to act on his or her behalf to submit a claim and/or
an appeal. To establish that a person is an Authorized Representative, written notification must be sent to the Benefits Fund
Office on a form provided by the Fund and available on request. Once established, an Authorized Representative may only
be dismissed in writing by the participant.
An Authorized Representative does not need to be appointed to receive occasional verbal assistance from the Fund on
matters that are not considered a claim or an appeal. An example of this is the use of a translator or a non-claimant family
member to assist a participant in obtaining or understanding information. The Fund will not divulge personal employment or
health information when dealing with an informal representative.
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