Appeals

If any part of your Claim is denied, you may appeal the decision to the Board of Trustees. This section describes the Claims process and applicable time limits within which you must file an appeal.

How To Appeal A Denial Of Your Claim

If you disagree with the decision on your initial Claim, you (or your authorized representative) may file a written appeal to the Board of Trustees within one hundred eighty (180) days after your receipt of the notice of adverse decision. You may, however, appeal an adverse decision regarding Urgent Care Claims by calling the Anthem at (800) 274-7767 or by presenting a written appeal. You should include the reasons you believe the Claim was improperly denied and all additional facts and documents you consider relevant in support of your appeal. If you don’t appeal on time, you may lose your right to file suit in a state or federal court because you have not exhausted your internal administrative appeal rights (which is generally a requirement before you can sue in state or federal court).

The members of the Fund’s Board of Trustees will decide your appeal. They will not defer to the initial adverse benefit determination and will consider all comments, documents and records or other information you submit, even if they were not submitted or considered during the initial Claim decision. Their decision on your appeal will be made on the basis of the record, including any additional documents and comments you submit.

If your Claim was denied on the basis of a medical judgment (such as the absence of Medical Necessity or the use of an Experimental or investigational treatment), the Board will consult a health care professional with training and experience applicable to the relevant field of medicine. Upon request, you can obtain the name of any professional consultant and the advice (if any) that was provided concerning your Claim (even if the Board did not rely on this advice in making its decision). Before the Plan sends an Adverse Decision on Appeal, you will be given, free of charge and sufficiently in advance of the date the Adverse Decision on Appeal is required to be provided, information regarding any new or additional evidence or rationale used to decide your Claim. You must respond to this information within forty-five (45) days.

You will receive notice of the decision on your appeal within seventy-two (72) hours for Urgent Care Claims and with thirty (30) days for other Pre-Service Claims. Appeals of Post-Service Claims and Disability Claims will be made at the next regularly scheduled meeting of the Board of Trustees following receipt of the appeal. If, however, your request for review is received within thirty (30) days of the next regularly scheduled Board meeting, your appeal will be decided at the second regularly scheduled Board meeting following receipt of your appeal. In special circumstances, review of your appeal may be delayed until the third regularly scheduled Board meeting following receipt of your appeal. You will be notified in writing if an extension is necessary. You will be notified of the decision on your appeal as soon as possible but no later than five (5) days after the Board of Trustees reaches a decision on your appeal.

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