ufcw apple
ufcw
ufcw
ufcw
ufcw ufcw
 
ufcw
ufcw ufcw  Summary of Benefits ufcw
ufcw ufcw  Election of Coverage and Eligibility Provisions ufcw
ufcw ufcw  Comprehensive Medical Benefits ufcw
ufcw ufcw  Income Protection Benefit ufcw
ufcw ufcw  Dental Benefit ufcw
ufcw ufcw  Dental Schedule of Benefits ufcw
ufcw ufcw  Prescription Drug Benefit ufcw
ufcw ufcw  Vision Benefit ufcw
ufcw ufcw  Life Insurance & AD&D Benefit ufcw
ufcw ufcw  General Exclusions and Limitations
ufcw
ufcw
ufcw
ufcw
ufcw ufcw  Summary of Benefits ufcw
ufcw ufcw  Election of Coverage and Eligibility Provisions ufcw
ufcw ufcw  Comprehensive Medical Benefits ufcw
ufcw ufcw  Prescription Drug Benefit ufcw
ufcw ufcw  General Exclusions and Limitations ufcw
ufcw
ufcw
ufcw
ufcw ufcw  How to File a Claim ufcw
ufcw ufcw  When to Call Us ufcw
ufcw ufcw  Request an ID Card ufcw
ufcw ufcw  Continuation of Coverage (COBRA) ufcw
ufcw ufcw  Claim Appeal Procedure ufcw
ufcw ufcw  Coordination of Benefits ufcw
ufcw ufcw  Privacy Practices ufcw
ufcw ufcw  Health Benefits Plan Claim Procedures ufcw
ufcw ufcw  Summary of the Cafeteria Plan ufcw
ufcw ufcw  Forms & Publications ufcw
ufcw
ufcw

Search this site

 

  Home > Health Plan > Health Benefits Plan Claim Procedures

HEALTH BENEFITS PLAN CLAIM PROCEDURES —
For Medical, Dental, Vision, Prescription Drug,
Income Protection, Life Insurance and
Accidental Death & Dismemberment Claims

Some plans do not include every benefit mentioned. Refer to your plan booklet to verify which benefits are included in your plan.

Click on any item to go directly to that section within this page
 

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.

Top of Page

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:

  • Health Claim—a new claim form is required at least once per year and when a claimant is advised that additional information is needed to process the claim.
  • Dental Claim—a UFCW claim form or standard American Dental Association claim form is required for each claim.
  • Vision Claim—a UFCW claim form or an optician’s form providing the same information is required for each claim. If routine vision care is provided by a BlueCross BlueShield Participating Provider Option (PPO) ophthalmologist, the claim may be submitted electronically through the BlueCross BlueShield system.
  • Special Laboratory Benefit Claim—Quest Diagnostics will file the claim directly for you using the electronic claim payor number (36659) and the ID number that appears on your UFCW Lab and Drug ID Card.
  • Income Protection Claim (weekly disability)—a UFCW claim form is required initially and periodically during the disability, in most cases every three weeks.
  • Life Insurance Claim—death claims are generally reported by telephone and then a UFCW claim form is sent out for completion.
  • Accidental Death and Dismemberment Claim—same as above for a Life Insurance claim.
  • Prescription Drug Benefit Direct Reimbursement Claim—no claim form is required when a valid prescription drug ID card is used at an NMHC/Rx participating pharmacy. If a prescription drug is obtained from any other pharmacy, a Direct Reimbursement Claim Form should be submitted.
A claimant may appoint an Authorized Representative to act on his or her behalf.

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
Unions and Employers
Midwest Health Benefits Fund
9801 West Higgins Road, Suite 500
Rosemont, IL 60018

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 9801 West Higgins Road, Suite 500, Rosemont, IL 60018.

Top of Page

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:

  • inpatient hospitalization
  • surgery (both inpatient and outpatient except for minor procedures in the doctor’s office)
  • advanced technology testing such as MRI, CT, PET, Doppler and stress tests
  • care in a skilled nursing facility
  • rehabilitation therapy
  • home health care, including oxygen therapy
  • hospice care
  • durable medical equipment, excluding minor devices such as canes and crutches

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 treatment 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.

Top of Page

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.

Top of Page

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:

  • the plan participant or spouse
  • the covered dependent (correspondence will be directed to the participant)
  • the provider of services if benefits are assigned to them by the patient (correspondence will be directed to the participant with copies to the provider)
  • an Authorized Representative.

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.

Top of Page

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 reasonably 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:

  • the specific reason for the denial, including a reference to the specific Plan provision on which the denial is based;
  • a statement that you are entitled, upon request and free of charge, to copies of all documents, records and other information relevant to your claim;
  • a statement of your right to file suit under ERISA if your appeal is denied;
  • any internal rule, guideline, protocol or other similar criterion that was used in denying your appeal, or a statement that this information is available upon request;
  • an explanation of any scientific or clinical judgement for the denial decision if it was based on a medical necessity, experimental treatment or other exclusion or limit, or a statement that this information will be provided on request.

Top of Page

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.

Top of Page

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.

Top of Page


(Updated 09/26/13)



 
     
[Home Page] [Health Plan] [Pension Plan] [Forms] [Links] [Newsletters] [About Us] [Who's Who] [Contact Us] [ERISA Rights]