SECTION ELEVEN: FILING YOUR CLAIMS

Filing a Claim for Benefits

Generally, if you use a provider who participates in the network, whether through the Medical, Dental, Vision or Prescription Drug program, you do not have to file any claims. The network provider will file them for you. If you do need to file a claim, you should use the appropriate claim form, available at the Fund Office.

Medical Claims for Non-Network Care

For out-of-network medical care, you should file your claims with UnitedHealthcare within one year of receiving a covered service. To file a claim, send an itemized bill to UnitedHealthcare, Attention: 
P.O. Box 740800, Atlanta, GA 30374-0800. Be sure to include the following:

  • The patient's name;
  • Your UnitedHealthcare identification number;
  • The name, address, telephone , and tax identification number,of the provider who performed the service;
  • The date and description of the service; and
  • The charge for that service.

If Your Claim Is Denied

If your claim is denied or partially denied, you will be notified within 90 days of receipt of your claim by the Fund Office, or for medical claims, by UnitedHealthcare. If you have a question about why your medical claim was denied, you may call the UnitedHealthcare Customer Service Department at (866) 527-9596. If you are not satisfied after the discussion, you may file a written complaint within 180 calendar days of receiving of the original denial.

Filing A Written Complaint

To file a written complaint to UnitedHealthcare, send the following information:

  • Your name and address;
  • Your UnitedHealthcare identification number;
  • The date of service
  • A summary of the reasons for the complaint, any previous contact with UnitedHealthcare, and the resolutions you are seeking.
  • Any additional information such as referral forms, claims, or other documentation you would like us to review;
  • Your signature.

UnitedHealthcare will notify you of a final decision within 30 days of receiving your written appeal. If more research is necessary to resolve your claim issue, UnitedHealthcare will notify you of this fact and will make a decision within 30 days of receiving the appeal.

Filing an Appeal of a Utilization Review Determination

An "appeal of a utilization review determination" is an application made by you to request a reconsideration of a prospective, concurrent, or retrospective determination made by UnitedHealthcare or any entity acting on its behalf, not to provide reimbursement coverage for a service requested by you, your doctor or other health care provider. If UnitedHealthcare makes a utilization review determination not to provide coverage for a requested service, you will receive a denial in writing within 15 business days of UnitedHealthcare's receipt of all information necessary to conduct its review or, for concurrent determinations, prior to the end of the certified period. Upon a denial, you will receive information on the appeal procedures available. You are entitled to the following levels of review when seeking an appeal:

First Level Appeal of a Utilization Review Determination

A first level appeal of a utilization review determination must be submitted in writing (except in a case of an expedited appeal) within 180 calendar days of the initial determination. You will receive written notification of a determination on a first level appeal within 15 business days following UnitedHealthcare's receipt of all necessary medical information required to conduct a review. NOTE: You may request an expedited review of denied services if the circumstances are urgent or you are an inpatient by calling the Customer Service Department.

Second Level Appeal of a Utilization Review Determination

If the denial of services was confirmed during the first level appeal process, you may submit a written request for a second level appeal within 60 calendar days of the receipt of the determination of the first level appeal. You will be given the opportunity to inspect the utilization review file and add information to the file. The process for inspecting your file is outlined in the confidentiality act. You will receive written notification of a determination on a second level appeal within 15 business days following receipt of all necessary medical documentation.  If the service for which you are requesting a review was denied after you already obtained the service (retrospectively), you will receive written notification of a determination within 30 calendar days of receipt of all necessary documentation.

External Appeal

If you remain dissatisfied with the determinations of UnitedHealthcare's internal review process after completion of a second level review appeal, you may request an external appeal by an objective appeal agency approved by the Department of Health. You will be responsible for 50% of the predetermined fee of the external appeal agency; UnitedHealthcare will pay the remaining 50%. To request an external review, you must submit your request within 180 calendar days of receipt of your second level of appeal denial notification. The external appeal agency will complete its review and make a final determination within ten business days for all non-urgent appeals, and within two business days for expedited appeals. The external agency will notify you directly of its decision.

Judicial Review

If you are dissatisfied with the final decision of the external appeal agency, you are entitled to a judicial review in an appropriate court of law. If you choose to file suit, you cannot recover payment for a claim through legal actions unless you notify UnitedHealthcare in writing that you intend to take such action.

Grievances Unrelated to Claims

UnitedHealthcare encourages you to discuss any complaint that you may have about any aspect of your medical treatment with the health care provider that furnished the care. In most cases, issues can be more easily resolved when they are raised sooner. If, however, you are dissatisfied with a service or UnitedHealthcare's administration of covered benefits, you may access any of UnitedHealthcare's grievance procedures. In order to initiate a grievance, please call the Customer Relations Department at (866) 527-9596.

The grievance procedures described in this section do not apply to utilization review determinations, claims appeals, claims of medical malpractice or to allegations that UnitedHealthcare is liable for the professional negligence of any doctor, hospital, health care facility or other health care provider furnished covered services.

Weekly Accident and Sickness Claims

To submit a claim for the Weekly Accident and Sickness Benefit:

  • Notify and request the appropriate form from the Fund Office;
  • Have the required paperwork completed by Rhode Island TDI, if employed in Rhode Island;
  • Have the appropriate paperwork completed by your physician;
  • Return the appropriate forms to the Fund office within forty-five days of the date of the covered incident;
  • If requested by the Fund, undergo a physical examination by the Fund's independent doctor at any time while you are seeking or receiving benefits.

The “date of the covered incident” is the first date on which you are unable to perform work due to an illness, non-work related injury or accident.

Your claim will be denied after the expiration of the forty-five day period However, you may make an appeal to the Board of Trustees in accordance with Section Twelve.

Life Insurance, Accidental Death and Dismemberment, and Personal Accident Coverage Claims

The Life Insurance benefit will be paid in full in accordance with the terms of the insurance certificate to the last named beneficiary on file at the Fund Office upon receipt of the Certified Death Certificate. Accidental Death and Dismemberment benefits will be paid to you, or in the event of your death, to your beneficiary.

Proof of Loss

Aetna must be given written proof of the loss for which claims is made under the coverage. This proof must cover the occurrence, character and extent of that loss. It must be furnished within 90 days after the date of loss or as soon as reasonable possible. Aetna, at its own expense, has the right to examine the person whose loss is the basis of claim.
Benefits are paid when Aetna received the written proof of the loss.

Legal Action

No action at law or in equity shall be brought to recover on the group contract earlier than 60 days after the written proof of loss is furnished and no later than three years after the end of the time within which the proof of loss is required.

Coordination of Benefits

Members of a family are often covered under more than one plan of group benefits. Because of this, there are many instances of duplication of coverage — two plans paying benefits for the same hospital and medical expenses. For this reason, the Plan will take into account any coverage an eligible person has under other benefit programs, including Medicare. UnitedHealthcare determines which insurance pays first according to the rules summarized below. After that, benefits are provided only up to the amount which, when added to the benefits paid by the other group plan, may equal but not exceed 100% of reasonable charges for eligible health care expenses.

Who Pays First?

When duplicate coverage arises, and both plans contain a Coordination of Benefits provision, the plan that insures the person incurring the claim as an employee is the primary plan and the plan that insures the person as an active employee will pay before a plan that insures the person as a laid off or retired employee. If an individual is insured under two plans through two jobs, the plan that has insured the person for the longer time pays first. If a claim is filed for a child, the group plan that insures the parent whose birth date — month and day (not year) — occurs earliest in the calendar year is primary. When another plan does not contain a Coordination of Benefits provision, it will always be considered the primary plan. Payment under the secondary plan is made after the amount payable under the primary plan has been determined.
There are exceptions to this general rule:

  • When parents are separated or divorced and the parent with custody of a child is not remarried, the benefits of a plan that covered the child as a dependent of the parent with custody will be determined before the benefits of a plan that covers the child as a dependent of the parent without custody.
  • When the parents are divorced and the parent with custody of the child has remarried, the benefits of a plan that covers the child as a dependent of the parent with custody will be determined before the benefits of a plan that covers that child as a dependent of the step-parent, and the benefits of a plan that covers that child as a dependent of the step-parent will be determined before the benefits of a plan that covers that child as a dependent of the parent without custody.
  • If there is a court decree that would otherwise establish financial responsibility for the medical, dental or other health care expenses with respect to the child, the benefits of a plan that covers the child as a dependent of the parent with such financial responsibility shall be determined before the benefits of any other plan that covers the child as a dependent.

Coverage Under Two or More UnitedHealthcare Contracts

If a member or dependent is covered under more than one UnitedHealthcare contracts he will be entitled to receive credit for the benefits of both contracts, up to but not to exceed the cost for hospital or physicians charges for covered services.

Coordination with Medicare

If you (or your covered spouse) become eligible for Social Security Retirement Benefits at age 65, you (or your spouse) are also eligible for Medicare. If you are covered by this Plan and by Medicare, then as long as you remain actively employed, this Plan pays first and Medicare pays second. This means that after the Plan pays benefits for your eligible expenses, you may submit a claim to Medicare for any unpaid balances for consideration. These rules also apply to your covered spouse who is age 65 or older whether or not you are also age 65 or older.

However, if you are under the age of 65 and become entitled to Medicare because of disability, you will no longer be considered actively employed and Medicare pays first and this Plan pays second with respect to all family members.

If any family member becomes entitled to Medicare because of end-stage renal disease (ESRD) and this Plan was primary at that time, this Plan pays first and Medicare pays second for a limited period of time.
Medicare imposes a three-month waiting period at the onset of end-stage renal disease before Medicare becomes effective. Medicare waives this waiting period if the patient enrolls in a self-dialysis training program within the first three months of the diagnosis of end-stage renal disease or receives a kidney transplant within the first three months of being hospitalized for the transplant. If there is a waiting period, this Plan continues to be the primary plan for the three-month waiting period. This Plan will then be the primary plan for the next 30 months. Medicare is the primary payor after the 30-month period.

Reimbursement and Subrogation

If you suffer an illness or injury as a result of an act or omission of another (including a legal entity), you must notify the Fund and execute a subrogation agreement. 

The Fund shall pay benefits for covered expenses related to such illness and injury only after the Participant or Eligible Dependent (and his or her attorneys, if applicable) has entered into a written subrogation agreement with the Fund. In addition, as set forth more fully below, to the extent of such recovery, the Participant and/or Eligible Dependent (and any agents and representatives) agree to act as a constructive trustee and the Fund maintains an equitable lien by agreement in such amounts.

By accepting benefits related to such illness or injury, the Participant and/or Eligible Dependent (collectively “you”) agree:

  • that the Fund has established an equitable lien on any recovery received by you (or your dependent, legal representative or agent);
  • to notify any third party responsible for your illness or injury of the Fund’s right to reimbursement for any claims related to your illness or injury;
  • to hold any reimbursement or recovery received by you (or your dependent, legal representative or agent) in trust on behalf of the Fund to cover all benefits paid by the Fund with respect to such illness or injury, and to reimburse the Fund promptly for the benefits paid, even if you are not fully compensated (“made whole”) for your loss;
  • that the Fund has the right of first reimbursement against any recovery or other proceeds of any claim against the other person (whether or not the participant or dependent is made whole) and that the Fund’s claim has first priority over all other claims and rights;
  • to reimburse the Fund in full up to the total amount of all benefits paid by the Fund in connection with the illness or injury from any recovery received from a third party, regardless of whether the recovery is specifically identified as a reimbursement of medical expenses. All recoveries from a third party, whether by lawsuit, settlement, insurance or otherwise, must be turned over to the Fund (and prior to turnover held in constructive trust) as reimbursement up to the full amount of the benefits paid;
  • that the Fund’s claim is not subject to reduction for attorney’s fees or costs under the “common fund” doctrine or otherwise;
  • that, in the event that you elect not to pursue your claim(s) against a third party, the Fund shall be equitably subrogated to your right of recovery and may pursue your claims;
  • to assign, upon the Fund’s request, any right or cause of action you may have to the Fund;
  • not to take or omit to take any action to prejudice the Fund's ability to recover the benefits paid and to cooperate with the Fund in doing what is reasonably necessary, in the sole discretion of the Fund, to assist the Fund in obtaining reimbursement;
  • to cooperate in doing what is necessary, in the sole discretion of the Fund, to assist the Fund in recovering the benefits paid or in pursuing any recovery;
  • to forward any recovery to the Fund or to notify the Fund as to why you are unable to do so within ten days of disbursement by the third party; and
  • to the entry of judgment against you and, if applicable, your dependent, in any court for the amount of benefits paid on your behalf with respect to the illness or injury to the extent of any recovery or proceeds that were not turned over as required and for the Fund’s cost of collection, including but not limited to the Fund’s attorneys’ fees and costs.

No benefits will be payable for charges and expenses which are excluded from coverage under any other provision of the Plan. The Fund may enforce its right to reimbursement by filing a lawsuit, recouping the amount owed from a Participant's or an Eligible Dependent's future benefit payments (regardless of whether benefits have been assigned by a participant or Eligible Dependent to a doctor, hospital or other provider), or any other remedy available to the Fund.

By accepting benefits (whether the payment of such benefits is made to you, your covered dependent or on your or your covered dependent's behalf to any provider) from the Fund, you and your covered dependents agree that a court proceeding with respect to these provisions may be brought in such court of competent jurisdiction as the Fund may elect. By accepting such benefits, you and your covered dependents (and your or your covered dependent's representatives, agents, assigns, guardians, estates, heirs or beneficiaries) hereby submit to each such jurisdiction, waiving whatever rights may correspond to you or your covered dependents (or your or your covered dependent's representative, agent, assign, guardian, estate, heir or beneficiary) by reason of your or your covered dependents' (or their) present or future domicile.

The Fund may need additional facts or information to properly apply the coordination of benefits, subrogation or right of recovery provisions. By filing a claim for benefits under the Fund, you and your covered dependents authorize the Fund to obtain such information as the Fund deems necessary for the enforcement or administration of the Fund's coordination of benefits, subrogation or right of recovery provisions.

The Fund may permit you to turn over less than the full amount of benefits paid and recovered as it determines in its sole discretion. Any reduction of the Fund’s claim is subject to prior written approval by the Board of Trustees.

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