Claims

No benefits are payable unless you have received approval before receiving the following benefits:

1. Hospital Admissions: Anthem Blue Cross, the Fund’s Utilization Review Organization, must approve any Hospital admission (except Emergency admissions) before you go to the Hospital.
2. Treatment for Alcohol or Chemical Dependency: The Teamsters Assistance Plan of Northern California (TAP) must pre-authorize any Claim. TAP can be reached at (510) 562-3600. (See page 37 for more details.)
3. Home Care or Alternative Treatment of any kind.
4. Hospice Care
5. Organ Transplants
6. Orthodontic Services

For pre-authorization for Hospital admissions, home or alternative care, hospice care or organ transplants, you (or your Doctor) must call Anthem Blue Cross at (800) 274-7767.

For pre-authorization for orthodontic services, you must call UnitedHealthcare Dental Plan at (800) 999-3367 if you are covered by the UnitedHealthcare Dental Plan or Anthem Dental PPO Plan at (844) 729-1565 if you are covered by the Anthem Dental PPO Plan.

Anthem Blue Cross, TAP or the Fund Administrator will respond to Pre-Service Claims within the following timelines:
 

1. Urgent Care Claims: As soon as possible but not later than 72 hours after receiving your request for authorization. If you do not supply sufficient information to determine whether the benefits are covered, Blue Cross will notify you or your Doctor as soon as possible but not later than 24 hours after receipt of the Claim. Blue Cross will inform you or your Doctor of the additional information needed to complete review of the Claim. You (or your Doctor) must respond within 48 hours of receiving notification of the required information.
2. Non-Urgent Pre-Service Claims: Within fifteen (15) days except that in cases where more time is required, Blue Cross of California, TAP or the Fund Administrator will have fifteen (15) additional days to respond, in which case you will be notified why the Fund requires additional time and when the Fund will provide a response. If your Claim is not an Urgent Care Claim and the Fund needs more time to process your Claim because it needs more information from you or your Doctor, you and your Doctor have up to forty-five (45) days to provide the additional necessary information. If you do not provide the necessary information on time, your Claim will be denied. After the Fund receives the information needed from you or your Doctor, the Fund will respond to your Claim within fifteen (15) days.

If you submit a completed Post-Service Claim and the Fund requires no additional information to reach a decision, the Fund will decide your Claim and notify you of the decision within thirty (30) days of its receipt. If the Fund requires additional time to reach a decision, the Fund may extend the 30-day deadline by an additional fifteen (15) days. You will be notified before the end of the initial thirty (30) days as to why the Fund needs additional time and when you can expect to receive a decision on your Claim.

If you did not submit sufficient information for the Fund to decide your Claim, you will be informed of the required additional information and you will have forty-five (45) days from date you receive the Fund’s notice to supply the additional information. The time for the Fund to make a decision regarding your Claim is tolled from the time the Fund notifies you that it needs more information until the time you provide the information. If you do not provide the additional information within the forty-five (45) day period, the Fund will deny your Claim.

If you file a complete Disability Claim (e.g., for continuation of benefits on the basis that you have become permanently and Totally Disabled), the Fund will decide your Claim and notify you of its decision within forty-five (45) days of its receipt by the Fund. The Fund can extend that deadline twice by an additional thirty (30) days if more time is needed to decide your Claim. In such case, you will be notified before the end of the initial 45-day period (or before the end of the 30-day extension period if the Fund has already extended the deadline) of both the reason why the Fund requires additional time and when you can expect to receive a decision on your Claim.

If you did not submit sufficient information for the Fund to decide your Claim, you will be informed of the required additional information and provided forty-five (45) days from the date you receive the Fund’s notice to supply the addition information. The time for the Fund to make a decision regarding your Claim is tolled from the time the Fund notifies you that it needs more information until the time you provide the information. If you do not provide the additional information within forty-five (45) days, the Fund will deny your Claim.

Short-Term Disability Form

For Concurrent Care Claims involving the reduction or termination of the course of treatment before the end of the time or number of treatments initially approved, you will be notified of the reduction or termination in advance of the reduction or termination, and you will be allowed to appeal and obtain a determination on appeal before the benefit is reduced or terminated.

For a Concurrent Care Claim requesting that a course of treatment be extended beyond the period of time or number of treatments initially approved and the request involves urgent care, the request will be decided as soon as possible, and you will be notified of the decision not later than 24 hours after receipt of the request, but only if your request was made at least 24 hours before the expiration of the approved period of time or number of treatments. Otherwise, the decision will be made as soon as possible, but not later than 72 hours after your request is made. For a Concurrent Care Claim requesting that a course of treatment be extended beyond the period of time or number of treatments initially approved that does not involve urgent care, you will be notified as if the Claim was a Pre or Post-Service Claim, whichever applies.

Under the terms of the Plan, benefits are not payable for any loss caused by or resulting from any employment, occupation or work for wage or profit. If you incur such a loss, you should file a workers’ compensation claim with your Employer.

In the event a workers’ compensation claim is denied by your Employer, you may appeal the denial through your Employer’s workers’ compensation insurance carrier. The Appeals Board will then issue an application for adjudication.

In order for the claim to be considered for payment under the Plan, you must submit a copy of the denial letter and the application for adjudication to the Fund Administrator. A notice and request for allowance of lien will then be sent to you for your signature. The lien form establishes a lien over any payments, including workers’ compensation benefits, that you receive for the treatment of your injury, up to the amount of any charges which have been submitted to the Fund Administrator for medical services rendered as a result of the alleged workers’ compensation injury of illness. Upon receipt of the executed request for allowance of lien, payment will be made on the pending claims and the Fund Administrator will file the lien claim with the workers’ compensation Appeals Board.