Claim Review and Appeals Procedures

The following information does not apply to these programs:

• OptumRx prescription drug program, contact the plan directly for guidance
• Anthem Blue Cross HMO program, contact the plan directly for guidance
• Kaiser Permanente HMO program, contact the plan directly for guidance
• Health Plan of Nevada HMO program, contact the plan directly for guidance
• United Healthcare Group Medicare Advantage PPO program, contact the plan directly for guidance
• Carelon Behavioral Health (CBH) Mental Health and Substance Abuse, and Member Assistance Program, contact the plan directly for guidance
• United Concordia Preferred Dental PPO program, contact the plan directly for guidance
• United Concordia Plus Dental HMO program, contact the plan directly for guidance
• Delta Dental PMI Dental HMO program, contact the plan directly for guidance
• Western Dental (MIB) HMO program, contact the plan directly for guidance

If you are enrolled in one of the above plans, please refer to their materials for information on their claim review and appeals procedures.

Types of Claims

• Urgent Claim means a claim for medical care or treatment that requires review sooner than other claims to avoid the possibility of:
  • Serious jeopardy to your life or health or your ability to regain maximum function; or
  • Severe pain that could not be adequately managed without the care or treatment that is the subject of the claim if this is the opinion of a physician who knows your medical condition.
  Note: Claims that do not require prior approval before incurring services or treatment are not Urgent Claims. Also, the Urgent Claim procedures do not apply to Emergency Care. If you experience a medical emergency you should go directly to the nearest hospital emergency room. The term “Emergency” means the sudden onset of a condition requiring immediate treatment including, but not limited to, heart attack, poisoning, loss of consciousness or convulsions. The charges for these services will be submitted as Post-Service Claims and are subject to the Plan’s limitations and exclusions.
• Pre-Service Claim means any claim for benefits for which the Plan requires you to obtain approval before obtaining medical care.
  Note: Except as required under the Dental Plan or the Prescription Drug Plan, the Plan does not require prior approval of benefits.
• Post-Service Claim means any claim for payment of treatment, services or supplies that have already been provided to you.
• Concurrent Claim means any claim that is reconsidered after an initial approval was made and which results in a reduced or terminated benefit.
  Note: Currently, the Plan does not require reconsideration of treatment that was pre-authorized. Therefore, the Plan will not treat any claim as a Concurrent Claim.
• Disability Claim means any claim that requires a finding of disability as a condition of eligibility. For example, claims for Weekly Disability Benefits for Participants in Southern Nevada are treated as Disability Claims.

Authorized Representative

An authorized representative, such as your spouse, may complete the claim form for you if you are unable to complete the form yourself. Another Dependent or a friend may also complete the claim form for you if you are unable to complete the form yourself and you have previously designated the individual to act on your behalf. A form to designate an authorized representative may be obtained from the Fund Office or on the Plan’s website at www.oefi.org.

A health care professional with knowledge of your medical condition may act as an authorized representative in connection with an Urgent Claim without you having to complete the special authorization form.

Initial Claim Determination

The guidelines below are time-frames within which a claim must be decided for approval or denial. These are not the periods within which claim payments that have been granted must actually be paid, or services that have been approved must actually be rendered. The payment of a claim or the provision of a service following Plan approval is done so in a time-frame appropriate with applicable law.

Claim Appeals Procedures

If your claim is denied, in whole or in part, you may request a review of an initial benefit determination. Your request must be made in writing (except for Urgent Claims which may be made verbally), must state the reason for disputing the denial and must be accompanied by any pertinent documents not already furnished including date of service, facility name, patient’s name, and participant’s Social Security, Local 12 Registration or OEID number. The request for review must be filed with the Fund Office within 180 days after you receive the notice of denial.

The Plan has two levels of appeal, an internal review performed by the Board of Trustees and an external review performed by an independent review organization (IRO).

Internal Review

You will be notified of the decision of the Board of Trustees in writing. The decision of the Board of Trustees is final and binding on all parties, subject only to external review or judicial review as provided by federal law.

Standard External Review

You have the right to request an external review of your claim if the request is filed within 4 months of the date of receipt of an initial denial or final internal adverse benefit determination.

The Board of Trustees will complete a preliminary review of your request within 5 days of receipt of the request for an external review. The preliminary review will determine that the claimant was eligible at the time the service was provided, the prior denial does not relate to the claimant’s failure to meet the Plan’s eligibility requirements, the petitioner has exhausted the internal appeal process, and the claimant has provided all information necessary to process the external review.

You will be notified, in writing, within one business day after the Board of Trustees has completed its preliminary external review.

Assignment to an IRO (Independent Review Organization)

If all requirements for an external review have been satisfied, the claim will be referred to an independent review organization (IRO) to conduct the external review. The IRO will notify you when they receive the external review request. The notice will include a statement that you may submit additional information for the IRO to consider. The information should be submitted within 10 business days of receiving the notice. The IRO may accept and consider additional information submitted after the 10-day period but is not required to do so.

The Plan will provide the IRO any documents and information used in denying the claim or denying the internal review within five business days after the external review is assigned to the IRO. If the Plan fails to do so, the IRO may terminate the external review and make a decision to reverse the denial. Within one business day after making such decision, the IRO must notify you and the Plan.

Upon receipt of any information submitted by you in connection with the external review, the IRO will forward it to the Plan within one business day. Upon receipt of the information, the Plan may reconsider its claim denial or internal review denial. The Plan will provide written notice to you and the IRO if it reverses its previous decision within one business day of such reversal. The IRO will then terminate the external review.

External Review Decision

The IRO will review all information and documents timely received and use experts where appropriate to make coverage determinations under the Plan. The IRO is not bound by any decisions or conclusions reached during the initial benefit denial or internal appeal. In addition to the documents and information provided, the IRO will consider the following, as it determines appropriate, when making its decision:

• The claimant’s medical records
• The attending health care professional’s recommendation
• Reports from appropriate health care professionals and other documents submitted by the Plan, you or your treating provider
• The applicable provisions of the Plan Rules and Regulations
• Appropriate medical practice guidelines, including evidence-based standards
• Any applicable clinical review criteria developed and used by the Plan unless such criteria are inconsistent with the Plan Rules and Regulations or applicable law
• The opinion of the IRO’s clinical reviewer

The IRO will provide written notice of the final external review decision to you and the Plan within 45 days after the IRO receives the external review request. This notice will include:

• An explanation of the primary reason for the IRO’s decision including the rationale for its decision and any evidence-based standards that were relied on in making its decision
• References to the evidence or documentation considered in making its decision, including specific coverage provisions and evidence-based standards considered in reaching its decision
• A statement that the determination is binding except to the extent that other remedies may be available under state or federal law
• A statement that judicial review may be available
• Current contact information, including phone number, for any applicable office of health insurance consumer assistance or ombudsman established under federal law

If the IRO reverses the previous adverse benefit determination, the Plan will immediately provide coverage or payment for the claim.

Expedited External Review

The Plan will allow a claimant to make a request for an expedited external review at the time the claimant receives:

• An adverse benefit determination if such determination involves a medical condition for which the timeframe for completion of an expedited internal appeal would seriously jeopardize the life or health of the claimant or would jeopardize the claimant’s ability to regain maximum function, and the claimant has filed a request for an expedited internal appeal; or
• A final internal adverse benefit determination if the claimant has a medical condition for which the timeframe for completion of a Standard External Review would seriously jeopardize the life or health of the claimant or would jeopardize the claimant’s ability to regain maximum function or if the final internal adverse benefit determination concerns an admission, availability of care, continued stay, or health care item or service for which the claimant received emergency services, but has not been discharged from a facility.

Immediately upon receipt of the request for expedited external review, the Plan will determine whether the request meets the requirements and will send a notice to the claimant of its determination. If the request meets the requirements for an expedited external review, the Plan will assign an IRO and provide all necessary documents and information electronically or by telephone or by facsimile or other expeditious
method.

The IRO will provide a notice of the final expedited external review decision as expeditiously as the claimant’s medical condition or circumstances require, but no more than 72 hours after the IRO receives the request. If such notice is not in writing, the IRO will provide written confirmation of its decision within 48 hours after providing the notice.

Revised 07/2024