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Section IX: Claims And Appeals Procedure
How to File Claims
Claims matters are handled by:
Administrative Office
5841 Newman Court
Sacramento, California 95819
Telephone: (916) 457-0155 |
All claims for benefits must be filed on forms provided by the Plan, which are
available from the administrative office, except as required by law. A claim
shall be considered to have been filed as soon as it is received at the administrative
office or such other location as may be indicated on the claim form, provided
it is substantially complete, with all necessary documentation required by the
form. If the form is not substantially complete, or if required documentation
has not been furnished, the claimant will be notified as soon as reasonably
possible of what is necessary to complete the claim.
The Plan may require additional evidence to establish whether or not any claim
should be paid. The Plan may, for example, require supplementary documentation
or the results of a physical examination or laboratory test
in order to adjudicate a medical claim. If the patient fails to cooperate with
such requests, the claim may be denied.
You must file your claims within 90 days after the expenses are incurred.
Claims will still be considered for payment when it is not possible to provide
notification within 90 days, but you should always file your claims as soon
as possible.
Claims will not be paid if they are submitted more than 12 months after the
expense was incurred, except in the absence of legal capacity. Where medical
benefits exceed $200 and the provider statement shows a balance due, payment
shall be made directly to the provider.
Claims Denials
If your claim for benefits is wholly or partially denied, you will receive a
written notice of denial which will contain the following information:
- The specific reason for the denial with specific reference to pertinent
Plan provisions on which the denial is based:
- A description of any additional material or information necessary for you
to perfect the claim and an explanation of why such material is necessary;
and
- Appropriate information as to the steps to be taken if you wish to submit
the claim for review.
The notice of denial shall be given within 90 days after the claim is filed, unless
special circumstances require an extension of time for processing the claim. If
such an extension is required, you will be sent written notice within 90 days
of the time the claim is filed, stating the special circumstances requiring the
extension and the date by which a decision on the claim can be expected. The final
date for the decision shall not be more than 180 days from the date the claim
was filed. If such notice of denial is not given within the time required, you
may proceed to the review stage described in the material that follows, as though
the claim had been denied.
Claims Appeal Procedure
Within 60 days after receipt of a written notification of denial, you or your
authorized representative may request a review of the claim by filing a written
application with the joint Board of Trustees. A late application may be considered
by the Board, if it concludes the delay in filing was for a reasonable cause.
When an application for review is received, the claim and its denial shall receive
a full and fair review by the Board of Trustees. The Board has discretion to
interpret all Plan documents and to make all factual determinations incident
to the appeal. The decision of the Board is subject to judicial review only
for abuse of discretion. If the benefits involved are provided by an insurance
company, insurance service, health maintenance organization, or other similar
organization, that organization may be entitled to conduct the review and make
the decision. Disputes concerning benefits provided by an HMO or Delta Dental
generally must be resolved using the appeal procedure established by that organization.
See the applicable HMO or Delta Dental brochure for details of the organizations’
claims and appeals procedures. As part of the review procedure you or your authorized
representative may review pertinent documents and submit issues and comments
in writing.
The decision of the reviewing group shall be furnished to you as promptly
as possible after a decision is reached. The notice of the decision shall include
the specific reasons for the decision and reference to the specific Plan provision
on which it is based. Unless special circumstances arise which require an extension
of time for processing, the decision shall be made within 60 days following
receipt of the request for review. If additional time is required, written notice
of the extension shall be furnished to the claimant before the extension period
begins. In no case shall the decision take longer than 120 days from the receipt
of the request for review. If the decision is not furnished within that time
period, you may consider the claim to have been denied.
