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
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
- 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
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
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
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
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.
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
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
- 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.