9. Claims and Appeals Procedure

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1 9. Claims and Appeals Procedure Complaints, Expedited Appeals and Grievances Under Empire s Hospital Benefits or Retiree Health Benefits Plan Complaints If Empire denies a claim, wholly or partly, you have the right to appeal the decision under the Employee Retirement Income Security Act of 1974 ( ERISA ). Under the Affordable Care Act, you may be eligible for new internal and external review procedures for urgent care claims and other medical claims, as well as entitlement to additional information, which will be made available to you when they become effective in the future. If you have a complaint about any of the healthcare services offered by Empire, plan procedures or customer service, call Empire s Member Services at Member Services may ask you to put your complaint in writing if it is too complex to handle over the telephone. Empire BlueCross BlueShield P.O. Box 1407 Church Street Station New York, NY Attention: Member Services If your complaint concerns behavioral healthcare call or write to: Empire Behavioral Health Services 370 Bassett Road Building 3, 2 nd floor North Haven, CT Empire will resolve complaints within the following timeframes: Standard complaints: Within 30 days of receiving all necessary information. Expedited complaints: Within 72 hours of receiving all necessary information. If you are not satisfied with Empire s decision on your complaint, you may file a grievance under the procedures described below. Empire has a Quality Assurance Program designed to ensure that Empire s providers meet high standards for care. If you have a complaint about a provider s procedures or treatment decisions, you may submit a complaint to the address above. Empire will refer complaints about the clinical quality of the care received to the appropriate clinical staff member to investigate. If you are not able to submit a complaint, grievance or appeal on your own, you may appoint a representative to act on your behalf by calling Member Services for a form. Appeals of Medical Necessity Adverse Determinations You or your covered family members may appeal any adverse determination (i.e., denied authorization for a service) made by Empire s Medical Management Program that care is

2 not medically necessary or is excluded from coverage because it is considered experimental or investigational. Standard Level 1 Appeal A standard Level 1 Appeal is your first request for a review of the initial reduction or denial of services. You have 180 calendar days from the date on the notification letter to file a standard Level 1 Appeal. An appeal submitted beyond the 180- calendar-day limit will not be accepted for review. If the services have already been provided, Empire will acknowledge receipt of your appeal in writing within 15 calendar days from the date of receipt. Qualified clinical professionals who did not participate in the original decision will review your appeal. Empire will make a decision on a standard Level 1 Appeal within the following time frames: Precertification or Concurrent Empire will complete a review of a precertification or concurrent appeal within 15 calendar days of the receipt of the appeal. Retrospective Empire will complete a review of a retrospective appeal within 30 calendar days of receipt of the appeal. Empire will provide written notice of determination to you or your representative within two business days of reaching a decision. If you are dissatisfied with the outcome of your Level 1 Appeal, you have the right to file a Level 2 Appeal and/or the right to file an External Appeal through the New York State Department of Insurance. If the Medical Management Program does not make a decision within the appropriate timeframes above, Empire will approve the service. Expedited Level 1 Appeal You can file an expedited Level 1 Appeal and receive a quicker response if: You want to continue healthcare services, procedures or treatments that have already started; You need additional care during the ongoing course of treatment; or Your provider believes an immediate appeal is warranted because delay in treatment would pose an imminent or serious threat to your health or ability to regain maximum function, or would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject to the claim. Expedited Appeals may be filed by telephone and in writing. Please note that appeals of claims decisions made after the service has been provided cannot be expedited. When you file an expedited appeal, Empire will respond as quickly as possible given the medical circumstances of the case, subject to the following maximum time frames: You or your provider will have reasonable access to Empire s clinical reviewer within one business day of Empire s receipt of the request.

3 Empire will make a decision within two business days of receipt of all necessary information, but in any event within 72 hours of receipt of the appeal; and Empire will notify you immediately of the decision by telephone, and within 48 hours in writing. If you are dissatisfied with the outcome of your expedited Level 1 Appeal, you may request an external review by a New York State Department of Insurance appeals agent. For more details, see the explanation of External Appeals below. If the Medical Management Program does not make a decision within two business days of receiving all necessary information to review your appeal, Empire will approve the service. Level 2 Appeal If you are dissatisfied with the outcome of your standard or expedited Level 1 Appeal, you may file a Level 2 Appeal with Empire within 60 days from the date on the notice of the letter denying your Level 1 Appeal. If the appeal is not submitted within that time frame, Empire will not review it and Empire s decision on the Level 1 Appeal will stand. Appeals may be filed by telephone or in writing. Empire will make a decisions within the following time frames for Level 2 Appeals: Precertification or Concurrent Empire will complete a review of a precertification or concurrent appeal within 15 calendar days of the receipt of the appeal. Retrospective Empire will complete a review of a retrospective appeal within 30 calendar days of receipt of the appeal. External Appeals New York State Mandated Appeals You also may request an external review by a New York State Department of Insurance appeals agent. You have 45 days to file an application for an external appeal from the receipt of the adverse determination from your Level 1 Appeal. You can file an external appeal if benefits were denied: For lack of medical necessity; or Because the service was determined to be an experimental and/or investigational procedure. External appeals may be a substitute for a Level 1 Appeal with Empire if you and Empire jointly agree to waive Empire s internal appeal process and proceed directly to the external appeal process. You will receive an external appeal application when you receive the adverse determination by Empire regarding your Level 1 Appeal. The application will provide clear instructions for completion. Empire does not charge a fee for the filing of an external appeal. Send your external appeal application to the New York State Department of Insurance, as stated on the form. Do not send the application to Empire. You and your doctor must release all pertinent medical information about your medical condition and request for services. For more information or an appeal application, contact one of the following:

4 The New York State Department of Insurance at or Empire Member Services at An expedited external appeal may be requested if your doctor can attest that a delay in providing the recommended treatment would pose an imminent or serious threat to your health. In this case, the following time frames apply: The agent will make a decision with three calendar days. Every reasonable effort will be made by the agent to notify you and Empire within two business days by telephone or fax, with a written notice sent immediately. A New York State Department of Insurance appeal agent will review your request and decide if the denied service is medically necessary and should be covered by Empire. The agent s decision is final and binding on both you and Empire. Submit your appeal within 45 calendar days: From the date you received the adverse determination from the Level 1 Appeal, or From the date that you and Empire agree to waive Empire s internal appeals process. If you have any questions regarding external appeals, please call Empire s Medical Management Program at , which number only responds to inquiries about external appeals. File external appeal application promptly! You will lose your right to external appeal if you do not file an application for an external appeal within 45 days from your receipt of the final adverse determination of the Level 1 Appeal with Empire. In fact, the 45-day time limit to file your external appeal begins upon receipt of the Level 1 Appeal. So by choosing a Level 2 Appeal with Empire, the time may expire for you to request an external appeal from the New York State Department of Insurance. Grievances of Administrative Adverse Determinations (Not Related to Medical Necessity) You or your covered family members may appeal any adverse determination (i.e., denied authorization for a service) made by Empire for care not related to medical necessity (a grievance ). Examples of grievances include denials of a request for a referral to an outof-network provider, benefit denials based on specific limitations in the Empire contract (e.g., no pre-certification was obtained), and complaint decisions where the member disagrees with Empire s findings. Level 1 Grievance A Level 1 Grievance is your first request for a review of Empire s administrative decision. You have 180 calendar days from the date on the notification letter to file a grievance. A

5 grievance submitted beyond the 180-calendar-day limit will not be accepted for review. If the services have already been provided, Empire will acknowledge your grievance in writing within 15 calendar days from the date of receipt. The written acknowledgement will include the name, address and phone number of the department that will respond to the grievance and a description of any additional information needed to complete the review. A qualified representative who did not participate in the original decision will review your grievance. Empire will make a decision on a Level 1 Grievance within the following time frames: Pre-service grievance for services that have not been rendered Empire will complete a review of a pre-service grievance within 15 calendar days of the receipt of the grievance. Post-service grievance for services that already have been provided Empire will complete a review of a post-service grievance within 30 calendar days of receipt of the grievance. Empire will provide written notice of determination to you or your representative. Empire s notice of its Level 1 Grievance decision (whether standard or urgent) will include: the reason for Empire s decision, or a written statement that insufficient information was presented or available to reach a determination; the clinical rationale, if appropriate; and instructions on how to file a Level 2 Grievance if you are not satisfied with the decision. If you are dissatisfied with the outcome of your Level 1 Grievance, you have the right to file a Level 2 Grievance with Empire. Empire must receive your request for a Level 2 Grievance by the end of the 60 th business day after you receive our notice of determination on your Level 1 Grievance. If the Level 1 Grievance is not submitted within that time frame, Empire will not review it and Empire s decision on the Level 1 Grievance will stand. Empire will acknowledge receipt of the Level 2 Grievance within 15 days of receipt. The written acknowledgement will include the name, address and telephone number of the department that will respond to the grievance. A qualified representative (including clinical personnel where appropriate) who did not participate in the Level 1 Grievance decision will review the Level 2 Grievance. Empire will make a decisions within the following time frames for Level 2 Grievance: Pre-service grievance for services that have not been rendered Empire will complete a review of a pre-service grievance within 15 calendar days of the receipt of the grievance. Post-service grievance for services that already have been provided Empire will complete a review of a post-service grievance within 30 calendar days of receipt of the grievance.

6 Expedited Grievances You can file an expedited Level 1 or Level 2 Grievance and receive a quicker response if a delay in resolution of the grievance would: pose an imminent or serious threat to your health or ability to regain maximum functions; or subject you to severe pain that cannot be adequately managed within the care or treatment that is the subject of the claim. Expedited Grievances may be filed by telephone and in writing. When you file an expedited grievance, Empire will respond as quickly as possible given the medical circumstances of the case, subject to the following maximum time frames: Empire will make a decision within two business days of receipt of all necessary information, but in any event within 72 hours of receipt of the appeal; and Empire will notify you immediately of the decision by telephone, and within two business days in writing. How to File a Appeals or Grievances with Empire To submit an appeal or grievance with Empire, call Member Services at , or write to the following address with the reason why you believe Empire s decision was wrong. Please submit any data to support your request and include your Empire Member ID number and the claim number and date of service. The address for filing an appeal or grievance with Empire is: Empire BlueCross BlueShield P.O. Box 1407 Church Street Station New York, NY If your appeal or grievance concerns behavioral health care, call or write to: Empire Behavioral Health Services 370 Bassett Road Building 3, 2 nd Floor North Haven, CT Appealing Empire Benefit Denials to the Fund If, after exhausting the Empire BlueCross BlueShield appeals procedures described above, a participant believes that Empire has wrongfully denied a claim, he or she may bring the matter to the attention of the Fund Administrator. The Fund Administrator shall review the matter with the participant and Empire and attempt to resolve it. If the matter is not resolved, either the Fund Administrator or the participant may bring the claim to the attention of the Board of Trustees. If the Trustees determine that the claim should be given further consideration, they may, at their discretion, pursue appropriate legal and contractual remedies to enforce the Fund s contract with Empire BlueCross BlueShield or otherwise assist the participant.

7 Appealing Healthplex Supplemental Dental Benefit Denials You can make inquiries relating to your dental coverage and claims directly to Healthplex. If you disagree with Healthplex s determination of benefits, or if Healthplex denies your claim, you may make a written appeal within 60 days of the date you receive the determination or denial. Send your appeal to: Healthplex, 333 Earle Ovington Blvd., Ste. 300, Uniondale, NY If, after exhausting the Healthplex Supplemental Dental Plan appeals procedure, a participant believes that Healthplex has wrongfully denied a claim, he or she may bring the matter to the attention of the Fund Administrator. The Fund Administrator shall review the matter with the participant and Healthplex and attempt to resolve it. If the matter is not resolved, either the Fund Administrator or the participant may bring the claim to the attention of the Trustees. If the Trustees determine that the claim should be given further consideration, they may at their discretion pursue appropriate legal and contractual remedies to enforce the Fund s contract with Healthplex Supplemental Dental Plan or otherwise assist the participant. Appealing Tuition Reimbursement, Optical Coverage and Physical Examination Benefit Denials If you or your covered dependents believe that benefits have been incorrectly denied under the Tuition Reimbursement Plan, Optical Coverage Plan, or the Physical Examination Plan, you may submit a claim for review within 60 days of the date the claim was denied. The Fund Office will provide you with a claim form to assist you in providing all the necessary information. Along with the form, or a letter from you, you should submit a copy of any correspondence from the service provider to the Fund. All requests for a review of a denied claim should be submitted to: District Council 1707 Local 95 Head Start Employees Welfare Fund 75 Varick Street, Suite 1500 New York, NY Attention: Fund Administrator Within 90 days after the Fund Administrator receives your claim for review, the Fund Administrator shall notify you whether the claim has been approved or denied, unless the Fund Administrator determines that special circumstances require additional time for processing the claim. If any extension of time for processing the claim is needed, a written notice shall be provided to you within the initial 90-day period stating the circumstances requiring the extension and the date by which a decision can be expected, which shall be no more than 180 days from the date the claim was filed. If the claim is denied, in whole or in part, the Fund Administrator shall send you a written notice that: (i) (ii) (iii) states the specific reason or reasons for the denial; refers to the Plan provision(s) on which the denial is based; provides a description of any additional material or information necessary for the claimant to perfect the claim, and an explanation of why such information is needed; and

8 (iv) includes a copy of this claim review procedure, including a statement of your right to bring a civil action under ERISA Section 502(a) in the event of an adverse benefit determination on appeal. If the Fund Administrator denies the claim, you may make a written appeal within 60 days of notification of such denial to the Claims Committee of the Board of Trustees for a full and fair review of the Fund Administrator s determination. You may submit written comments, documents, records and other information relating to the claim, and may also include a request for copies of, or schedule an appointment to review, the documents, free of charge, that the Fund Administrator relied upon in making the claim determination, and other pertinent documents from the Fund Administrator. Your appeal should be addressed to: District Council 1707 Local 95 Head Start Employees Welfare Fund 75 Varick Street, Suite 1500 New York, NY Attention: Claims Appeals Committee The Claims Committee shall notify you of the disposition of its review. However, the Claims Committee may refer the claim to the full Board of Trustees of the Fund for a determination if they are unable to reach a consensus. The decision of the Claims Committee (or, if applicable, the full Board of Trustees) shall be in writing and shall be made within 60 days after the appeal request is received. If it is determined that special circumstances require an extension of this time period, the Claims Committee may extend such period for an additional 60 days, and shall notify you in writing of such extension. The notice shall state the special circumstances requiring the extension and the date by which a decision can be expected. If the time period is extended due to your failure to submit information necessary to decide a claim, the period for making the determination of appeal shall be tolled from the date on which the notification of the extension is sent to you until the date on which you respond to the request for additional information. If the claim denial on appeal is upheld, the Claims Committee (or, if applicable, the Board of Trustees) shall provide you written notification of: (i) (ii) (iii) (iv) the specific reason or reasons for the adverse determination on appeal; the Plan provision(s) on which the denial is based; a statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of all documents, records, and other information relevant to your claim; and a statement of your right to bring a civil action under ERISA Section 502(a).

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