Appeals & Grievances
Claims and Appeals Procedures
This provision shall apply to all benefits provided under any section of the C and O Employees’ Hospital Association Active and Retired, Non-Medicare Plans.
The claims procedures described below are effective January 1, 2003 and supercede any conflicting language in these Rules and Regulations.
If a member’s claim under the Plan is wholly or partially denied, he or she will be notified of the decision, after the Plan’s receipt of the claim, within:
(i) 72 hours for an urgent care claim,
(ii) 15 days for a pre-service claim,
(iii) 30 days for a post-service claim, or
(iv) 45 days for a disability claim, as applicable.
A determination regarding a request for the Plan to approve an on-going course of treatment will be made in sufficient advance of the proposed reduction or termination of treatment to allow the member to appeal before the benefit is reduced or terminated.
Under special circumstances, the notice period may be extended for an additional:
- 48 hours for urgent care claims,
- 24 hours for concurrent care decisions,
- 15 days for pre-service claims,
- 15 days for post-service claims, or
- 30 days for disability claims.
If an extension is required, the member will be notified of the special circumstances involved and the date by which the Plan Administrator expects to render a final decision.
If the member’s claim is denied, the Plan Administrator will provide the member with a written or electronic notification of an adverse benefit determination. The notice will:
(i) provide the specific reason(s) for the denial,
(ii) refer the member to the pertinent Medicare Supplemental Handbook provisions on which the denial is based,
(iii) describe any additional information necessary for the member to perfect his or her claim and explain why such information is necessary,
(iv) describe the Plan’s review procedure and time limits applicable to the member’s right to bring a civil action under ERISA Section 502(a) following an adverse benefit determination on review,
(v) (A) in the case of an adverse benefit determination, refer the member to the criteria that was relied upon in making the adverse determination, or a statement that certain criteria was relied upon and that a copy of such rule(s) will be provided to the member free of charge upon request, or (B) if the adverse determination is based on a medical necessity, experimental treatment or similar exclusion or limit, provide either an explanation of the clinical judgment for the determination or a statement that such an explanation will be provided free of charge, upon request,
(vi) in the case of an adverse determination for urgent care, describe the expedited review process applicable to such claims, and
(vii) in the case of an adverse benefit determination, identify the claim involved by providing the date of service, the health care provider, the claim amount (if applicable), and upon request, the diagnosis code (if available)..
In the case of an adverse benefit determination involving a claim for urgent care, the information described above may be provided to the member orally within the permitted time frame provided that written or electronic notification is furnished to the member no later than three days after such oral notification.
Appeal of Denied Claims
If the member’s claim is denied, the member will be provided:
(i) a full and fair review with at least 180 days to appeal an adverse benefit determination,
(ii) a review that does not defer to the initial adverse benefit determination, and is conducted by an appropriate named fiduciary who is not involved with the adverse appeal,
(iii) a determination which is based on a medical judgment and for which the named fiduciary has consulted with a healthcare professional with suitable expertise related to the area of medicine required, and
(iv) the identity of the experts whose advice was solicited on behalf of the Plan, without regard to whether the advice was relied upon in making the benefit determination.
Further, the review must provide that the consulted healthcare provider was not consulted upon for the adverse determination which is subject to the appeal (nor his or her subordinate) and provide, in the case of an urgent care claim, an expedited review process, to which the member’s request may be submitted orally or in writing. All necessary information may be transmitted between the Plan and the member by telephone, facsimile, or other available method.
The Plan Administrator will notify the member of the Plan’s benefit determination upon review of a denied claim within:
(i) for an urgent care claim, within 72 hours;
(ii) for pre-service claims, within a reasonable period of time appropriate to the medical circumstances. The notification shall be provided no later than 30 days after the Plan’s receipt of the member’s request of a review of an adverse benefit determination;
(iii) for post-service claims, within a reasonable period of time. If the appeal is received within the 60-day period immediately preceding the regular meeting of the Finance Committee, the appeal will be decided at that meeting unless special circumstances require an extension of time for processing. If there is no regular meeting of the Finance Committee within the 60-day period after receipt of the appeal, the Finance Committee shall convene a special meeting to discuss the appeal, and such meeting shall occur within 60-days of receipt of the appeal, unless special circumstances require an extension of time for processing. Whenever there are "special circumstances" that require additional time, the member shall be advised in writing of why the extension of time was needed and when the appeal will be decided. The Plan will mail the member written notice of the Finance Committee’s decision within 5 days after the decision has been made.
The Plan’s decision on review may be either a written or electronic notification. The notification will set forth for the member:
(i) the specific reason for the adverse determination;
(ii) reference the specific Plan provisions on which the benefit determination is based;
(iii) 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 the claim for benefits;
(iv) a statement describing any voluntary appeal procedures offered by the Plan and the member’s right to obtain the information about such procedures, and a statement regarding the member’s right to bring an action under ERISA Section 502(a);
(v) if an internal rule or protocol was relied upon in making the adverse determination, a copy of such rule or protocol shall be provided free of charge to the member upon request;
(vi) if the adverse determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the member’s medical circumstances, or a statement that such explanation will be provided free of charge upon request; and the following statement: "You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Dept. of Labor Office and your State insurance regulatory agency."; and
(vii) in the case of an adverse benefit determination, identify the claim involved by providing the date of service, the health care provider, the claim amount (if applicable), and upon request, the diagnosis code (if available).
EXTERNAL REVIEW PROCESS AND STANDARDS
The Plan is intended to constitute a self-insured group health plan subject to ERISA which shall be administered as a group health plan that follows standards to comply with the Federal External Review regulations and process or private accredited Independent Review Organization (IRO) process as described in regulations and guidance published by the Department of Labor and Internal Revenue Service. The external review process is available at no charge to Plan participants.
An adverse benefit determination includes medical judgments or rescissions of coverage. Medical judgments include medical necessity, appropriateness, health care setting, level of care, effectiveness of a covered benefit, experimental or investigational treatments, reasonable alternative standards for a reward under a wellness program, compliance with the nonquantitative treatment limitation provisions of IRC Section 9812 and its regulations thereunder, and eligibility under the Plan.
If the participant’s claim is denied on appeal, the participant may file a request for an external review with the Plan Administrator within four (4) months, or the first day of the fifth (5th) month if earlier, after the date of receipt of a notice of final internal adverse benefit determination. If the last filing date would fall on a Saturday, Sunday, or Federal holiday, the last filing date is extended to the next day that is not a Saturday, Sunday, or Federal holiday.
Within five (5) business days following the date of receipt of the external review request, the Plan Administrator must complete a preliminary review of the request to determine whether:
(i) The member is or was covered under the Plan at the time the health care item or service was requested or, in the case of a retrospective review, was covered under the Plan at the time the health care item or service was provided;
(ii) The final internal adverse benefit determination does not relate to the member's failure to meet the requirements for eligibility under the terms of the Plan;
(iii) The participant has exhausted the Plan's internal appeal process; and
(iv) The participant has provided all the information and forms required to process an external review.
Within one (1) business day after completion of the preliminary review, the Plan Administrator must issue a notification in writing to the participant. If the request is complete but not eligible for external review, such notification must include the reasons for its ineligibility and current contact information, including the phone number, for the DOL - Employee Benefits Security Administration. If the request is not complete, such notification must describe the information or materials needed to make the request complete, and the Plan must allow a participant to perfect the request for external review within the four-month filing period or within the 48 hour period following the receipt of the notification, whichever is later.
The IROs must be accredited by URAC or a similar nationally-recognized accrediting organization. The IROs may not be eligible for any financial incentives based on the likelihood that the IRO will support the denial of benefits. The IRO may not impose any costs on the participant requesting the review. The Plan must provide or transmit all necessary documents and information considered in making the final internal adverse benefit determination to the assigned IRO electronically, or by telephone, facsimile or any other available expeditious method.
The Plan must include the following standards in the IRO contract between the Plan and the IRO:
(i) The assigned IRO will utilize legal experts where appropriate to make coverage determinations under the Plan or coverage;
(ii) The assigned IRO will timely notify a participant in writing whether the request is eligible for external review. This notice will include a statement that the participant may submit in writing to the assigned IRO, within ten (10) business days following the date of receipt of the notice, additional information. This additional information must be considered by the IRO when conducting the external review. The IRO is not required to, but may, accept and consider additional information submitted after ten (10) business days;
(iii) Within five (5) business days after the date of assignment of the IRO, the Plan must provide to the assigned IRO the documents and any information considered in making the final internal adverse benefit determination. Failure by the Plan to timely provide the documents and information must not delay the conduct of the external review. If the Plan fails to timely provide the documents and information, the assigned IRO may terminate the external review and make a decision to reverse the final internal adverse benefit determination. Within one (1) business day after making the decision, the IRO must notify the participant and the Plan;
(iv) Upon receipt of any information submitted by the participant, the assigned IRO must within one (1) business day forward the information to the Plan. Upon receipt of any such information, the Plan may reconsider its final internal adverse benefit determination that is the subject of the external review. Reconsideration by the Plan must not delay the external review. The external review may be terminated as a result of the reconsideration only if the Plan decides, upon completion of its reconsideration, to reverse its final internal adverse benefit determination and provide coverage or payment. Within one (1) business day after making such a decision, the Plan must provide written notice of its decision to the participant and the assigned IRO. The assigned IRO must terminate the external review upon receipt of the notice from the Plan;
(v) The IRO will review all of the information and documents timely received. In reaching a decision, the assigned IRO will review the claim de novo and not be bound by any decisions or conclusions reached during the Plan's internal claims and appeals process. In addition to the documents and information provided, the assigned IRO, to the extent the information or documents are available and the IRO considers them appropriate, will consider the following in reaching a decision:
A. The participant’s medical records;
B. The attending health care professional's recommendation;
C. Reports from appropriate health care professionals and other documents submitted by the Plan, participant, or the participant’s treating provider;
D. The terms of the participant's Plan or coverage to ensure that the IRO's decision is not contrary to the terms of the Plan or coverage, unless the terms are inconsistent with applicable law;
E. Appropriate practice guidelines, which must include applicable evidence-based standards and may include any other practice guidelines developed by the Federal government, national or professional medical societies, boards, and associations;
F. Any applicable clinical review criteria developed and used by the Plan, unless the criteria are inconsistent with the terms of the Plan or coverage or with applicable law; and
G. To the extent the final IRO decision maker is different from the IRO's clinical reviewer, the opinion of such clinical reviewer, to the extent the information or documents are available and the clinical reviewer or reviewers consider such information or documents appropriate.
(vi) The assigned IRO must provide written notice of the final external review decision within 45 days after the IRO receives the request for the external review. The IRO must deliver the notice of the final external review decision to the participant and the Plan; and
(vii) The assigned IRO's written notice of the final external review decision must contain the following:
A. A general description of the reason for the request for external review, including information sufficient to identify the claim (including the date or dates of service, the health care provider, the claim amount (if applicable), and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, the treatment code and its corresponding meaning, and the reason for the Plan's denial);
B. The date the IRO received the assignment to conduct the external review and the date of the IRO decision;
C. References to the evidence or documentation, including the specific coverage provisions and evidence-based standards, considered in reaching its decision;
D. A discussion of the principal reason or reasons for its decision, including the rationale for its decision and any evidence-based standards that were relied on in making its decision;
E. A statement that the IRO's determination is binding except to the extent that other remedies may be available under State or Federal law to either the Plan or to the participant, or to the extent the Plan voluntarily makes payment on the claim or otherwise provides benefits at any time, including after a final external review decision that denies the claim or otherwise fails to require such payment or benefits;
F. A statement that judicial review may be available to the participant;
G. Current contact information, including phone number, for any applicable office of health insurance consumer assistance or ombudsman established under PHS Act Section 2793;
H. After a final external review decision, the IRO must maintain records of all claims and notices associated with the external review process for six (6) years. An IRO must make such records available for examination by the participant, Plan, or State or Federal oversight agency upon request, except where such disclosure would violate State or Federal privacy laws; and
I. Upon receipt of a notice of a final external review decision reversing the final adverse benefit determination, the Plan immediately must provide coverage or payment (including immediately authorizing care or immediately paying benefits) for the claim.
The Plan must comply with the following standards with respect to an expedited external review:
(i) The Plan must allow a claimant to make a request for an expedited external review with the Plan at the time the participant receives a final internal adverse benefit determination, if the participant has a medical condition where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the participant or would jeopardize the participant'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 participant received emergency services, but has not been discharged from the facility; and
(ii) Immediately upon receipt of the request for expedited external review, the Plan must determine whether the request meets the reviewability requirements set forth above and notify the participant of its eligibility determination.
Upon a determination that a request is eligible for expedited external review following the preliminary review, the Plan will assign an IRO. The IRO will be one of three IROs contracted by the Plan which rotate among them. In reaching a decision, the assigned IRO must review the claim de novo and is not bound by any decisions or conclusions reached during the Plan's internal claims and appeals process.
The Plan's contract with the assigned IRO must require the IRO to provide notice of the final external review decision as expeditiously as the participant's medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request for an expedited external review. If the notice is not in writing, within 48 hours after the date of providing that notice, the assigned IRO must provide written confirmation of the decision to the participant and the Plan.