Health and Welfare Summary Plan Description

APPENDIX C

San Francisco Electrical Workers Health & Welfare Plan
Claim and Appeal Procedures for Non-HMO Benefits

C.1 General Rules

Applicability of These Procedures. These procedures apply to any claim for Plan benefits other than the Kaiser HMO, the Blue Shield HMO and any benefit provided under an insurance policy. A claim for dental or vision benefits under the Plan is treated the same as a Self-Funded PPO Claim under these procedures.
Overview and Where to Submit a Claim. A claim for benefits is considered to have been filed when it is received by the Plan Office, provided it is substantially complete with all necessary documentation. If the documentation is not substantially complete, the Claimant will be notified as soon as is practicable of what information or documentation is necessary to complete the claim. A claim must be filed within 24 months from the date of treatment. In- and Out-of-Network PPO claims should be sent directly to Blue Shield at P.O. Box 272540, Chico CA 95927. Dental claims for services from non-Delta Dental dentists should be submitted to Delta Dental at P.O. Box 997330, Sacramento, CA 95899-7330. Vision service claims for services from non-VSP providers should be submitted to Vision Service Plan, Attn.: Out-of-Network Claims, P. O. Box 997100, Sacramento, CA 95899-7100. Other claims should be sent directly to the Plan Office at 720 Market Street, Suite 700, San Francisco, CA 94102-2509; Tel: (415) 263-3670.
Medicare Eligible Individuals. Medicare-eligible Covered Individuals should have their Hospital and Physicians submit claims with the Medicare Explanation of Benefits Worksheet to Blue Shield after Medicare has made payment.
Casual and General Inquiries. These procedures do not apply to casual or general inquiries regarding eligibility or specific Plan benefits. In order for a claim to constitute a claim for benefits that invokes these procedures, the Claimant must submit a written claim for benefits to either Blue Shield or the Plan Office in accordance with Section C.3. Submission of such a written claim invokes these procedures.
HMO and Other Insured Claims. A Claimant who wishes to make a claim for benefits under the Kaiser HMO, the Blue Shield HMO, or any group insurance policy must follow the claims procedures under the applicable HMO contract or insurance policy that applies to that benefit. This policy does not apply to HMO or insured benefits.
Named Fiduciary. For purposes of determining the amount of or entitlement to benefits under Section C.3 of these procedures, the Plan Office, with assistance from Blue Shield, is the named fiduciary with full power to make factual determinations for the Plan and interpret and apply the Plan's terms as they relate to the claim. The Plan Office will decide a claim in accordance with these procedures and may obtain independent medical advice and require such other evidence as it deems necessary to decide the claim. If the Plan Office denies a claim, in whole or in part, the Claimant will receive written notification setting forth the reason(s) for the denial. Claimant may appeal to the Board for a review of the denied claim, and the Board will decide the appeal in accordance with these procedures consistent with ERISA.
Authorized Representative. An authorized representative, such as a Spouse, Domestic Partner or adult child, or a service provider, may submit a claim or appeal on behalf of a Claimant if the Claimant has previously designated the person to act on the Claimant's behalf, provided the designation is reasonably clear to the Plan Office. The Plan Office may request additional information to verify that the designated person is authorized to act on the Claimant's behalf.

C.2 Definitions

For the purposes of these procedures, the following capitalized terms have the following meanings unless otherwise specified herein.

"Claimant" meansa Covered Individual, or such individual's representative or health care provider who is designated by such individual to act on his behalf, who submits a claim under these procedures.

"Complete Claim" means aclaim that contains all of the necessary information and supporting documentation, if applicable, to render a decision on the claim and is submitted within the prescribed timeframe under these procedures.

"Concurrent Care Claim"means a claim to continue (i) a previously approved course of treatment under the Self-Funded PPO for a specific time period or number of treatments that has been reduced or terminated before the end of the approved course of treatment or (ii) a course of treatment beyond the specific time period or number of treatments previously approved under the Self-Funded PPO.

"Denial" or "Denied" means a denial, reduction, termination of, or failure to provide or make payment for, in whole or in part, a claimed benefit.

"Disability Claim" means a claim for a disability benefits under the Plan.

"Other Claim" means a claim that is neither a PPO Claim, a Disability Claim nor a claim to which an HMO's or an insurer's procedures apply, and includes a claim for Plan eligibility.

"Pre-Service Claim" means a claim for benefits for which the Plan requires Claimant to obtain authorization before services are provided or received by Claimant.

"Post-Service Claim" means a claim for a benefit under the Self-Funded PPO for reimbursement or consideration of payment for the cost of medical care that has already been rendered, and that is not a Concurrent Care Claim. It includes a claim relating to rescission of coverage.

"PPO Claim" means an In- or Out-of-Network claim under the Self-Funded PPO that is either a Post-Service Claim or a Concurrent Care Claim. A claim for dental or vision benefits is treated as a Self-Funded PPO Claim for purposes of these procedures.

C.3 Initial Claim Procedure and Time Limits

A Covered Individual who wishes to object to the rejection, by Blue Shield, Magellan or Beat It on behalf of the Self-Funded PPO, by Delta Dental or by VSP, of a request to provide a benefit, should file an initial claim for benefits with the Plan Office under this section. A Covered Individual may, in the alternative, submit a PPO claim to Blue Shield, though Blue Shield will generally forward the claim on to the Plan Office for determination. Such a claim will be decided by the Plan Office within the applicable timeframe under these procedures, regardless of whether all information required to perfect the claim is included. The timeframe for decision begins upon receipt of the claim by the Plan Office and depends upon the type of claim submitted, whether the claim is complete or incomplete, whether additional information is required and whether an extension is required to make a decision on the claim. The Plan Office may not suspend a claim on the basis that the claim submission is incomplete without approval from the Claimant. For some claims, Blue Shield will make the initial determination in order to expedite the claim.

Urgent Care Claim.
1. If an Urgent Care Claim is submitted complete, the Plan Office shall render a decision within 72 hours after receipt of the claim, unless the Claimant fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan. If the Claimant fails to provide sufficient information, the Plan shall notify the Claimant within 24 hours after receipt of the claim of the specific information necessary to complete the claim. The Claimant shall be afforded at least 48 hours to provide the specified information. Thereafter, the Plan will notify the Claimant of its benefit determination no later than 48 hours after the earlier of: (i) the Plan's receipt of the specified information, or (ii) the end of the period afforded to the Claimant to provide the specified additional information.
2. Any Urgent Care Claim that requests to extend the course of treatment beyond the period of time or number of treatments, shall be decided within 24 hours after receipt of the claim, provided that any such claim is made to the Plan at least 24 hours prior to the expiration of the initially approved period.
3. If the Claimant fails to follow the proper procedure for filing an Urgent Care Claim, the Claimant will be notified of the failure and the proper procedures to be followed to file a claim within 24 hours after the Plan's receipt. The Claimant may be notified orally, unless written notification is requested. The Claimant will receive notice if the claim or communication fails to include any of the following information: (i) the name of the specific claimant; (ii) a specific medical condition or symptom, and (iii) a specific treatment, service or product for which Plan approval is requested.
4. If an Urgent Claim is denied, notice of the claim decision may be furnished orally within 72 hours after receipt of the claim or within 48 hours after receipt of the specified additional information, and will be followed by a written or electronic notification containing applicable notification information as required under ERISA no later than 3 days after the oral notification to the Claimant.
Pre-Service Claim
1. If a Pre-Service Claim as submitted is complete, the Plan Office shall render a decision within 15 days from the date the Complete Claim is received by the Plan. The Plan Office may extend this time period by 15 additional days, if the Claimant is notified of the need for such extension before the expiration of the initial 15-day decision period. Notification of the extension shall include the reason for the extension, an approximate decision date and other applicable notification information as required under ERISA.
2. If a Pre-Service Claim as submitted is incomplete, the Plan Office shall notify the Claimant within 15 days of receiving the incomplete claim. Such notice may request additional information required to render a decision on the claim and explain why such information is necessary. The notice will suspend the 15-day time period to render a decision. The Claimant shall be afforded 45 days to provide the requested information. If the requested information is not received within this time period, then the Plan Office will render a decision at the end of the 45-day period. If the requested information is received before the end of the 45-day period, the suspension on the time frame for decision is lifted and the Plan Office will render a decision within the time remaining of the initial 15-day period, subject to permissible extension.
3. If the Claimant fails to follow the proper procedure for filing a Pre-Service Claim, the Claimant will be notified of the failure and the proper procedures to be followed to file a claim within 5 days after the Plan's receipt. Claimant may be notified orally, unless written notification is requested. The Claimant will receive notice if the claim or communication fails to include any of the following information: (i) the name of the specific claimant; (ii) a specific medical condition or symptom, and (iii) a specific treatment, service or product for which Plan approval is requested.
Post-Service Claim
1. If a Post-Service Claim as submitted is complete, the Plan Office shall render a decision (i) within 30 days from the date the Complete Claim is received from Blue Shield or (ii) 60 days from the date the Claimant submitted the Complete Claim to Blue Shield. The Plan Office may extend this time period by 15 additional days, if the Claimant is notified of the need for such extension before the expiration of the initial 30-day decision period. Notification of the extension shall include the reason for the extension, an approximate decision date and other applicable notification information as required under ERISA.
2. If a Post-Service Claim as submitted is incomplete, the Plan Office shall notify the Claimant within 30 days of receiving the incomplete claim. Such notice may request additional information required to render a decision on the claim and explain why such information is necessary. The notice will suspend the 30-day time period to render a decision. The Claimant shall be afforded 45 days to provide the requested information. If the requested information is not received within this time period, then the Plan Office will render a decision at the end of the 45-day period. If the requested information is received before the end of the 45-day period, the suspension on the time frame for decision is lifted and the Plan Office will render a decision within the time remaining of the initial 30-day period, subject to permissible extension.
3. If a Post-Service Claim is denied, notice of the claim decision shall be furnished promptly to the Claimant, shall be written in a manner understandable to the Claimant and shall contain applicable notification information as required under ERISA.
Concurrent Care Claim
1. If a Concurrent Care Claim requesting an extension of a course of treatment is submitted, the Plan Office shall render a decision according to the Post-Service Claim procedures.
2. In the event a Claimant's pre-approved course of treatment for a specific time period or specific number of treatments is reduced or terminated before the end of such treatment, the Claimant must be notified of the reduction or termination by the Plan Office and be given a reasonable period of time to appeal the decision before the treatment is reduced or eliminated. The Plan Office shall render a decision before the previously approved treatment is reduced or terminated.
3. If a Concurrent Care Claim is denied, notice of the claim decision shall be furnished promptly to the Claimant, shall be written in a manner understandable to the Claimant and shall contain applicable notification information as required under ERISA.
Disability Claim
1. A Disability Claim must be submitted to the Plan Office within 90 days after the date of the onset of the disability. The Plan Office will decide on a completed Disability Claim and notify the claimant of the decision within 45 days after receipt of the Claim by the Plan Office.
2. The Plan Office may under special circumstances extend this time period by 30 additional days if the Claimant is notified of the need for such extension before the expiration of the initial 45-day period. The Plan Office may under special circumstances extend the initial extension period by an additional 30 days if the Claimant is notified of the need for such additional extension before the expiration of the initial 30-day extension. Notification of any extension shall include the reason for the extension, an approximate decision date, and other applicable notification information as required under ERISA.
3. If a Disability Claim as submitted is incomplete, the Plan Office may notify the Claimant within 45 days of receiving the incomplete claim. The notice may request additional information required to render a decision on the claim and explain why such information is necessary. The notice will suspend the 45-day time period to render a decision, and the Claimant shall be afforded 45 days to provide the requested information. Subject to the Plan Office's ability to extend the decision period as described in the preceding subparagraph, if the requested information is not received within this time period, then a decision will be rendered at the end of the initial 45-day period, and if the requested information is received before the end of the 45-day period, the suspension on the time frame for decision is lifted and a decision will be rendered within the time remaining of the initial 45-day period, subject to permissible extension.
4. Notice of a claim decision shall be furnished promptly to the Claimant, shall be written in a manner understandable to the Claimant, and shall contain applicable notification information as required under ERISA.
Other Claims
1. Unless otherwise provided in the preceding subparagraphs, the Plan Office shall render a decision on a claim not otherwise described above (such as a claim for Plan eligibility) in accordance with either Pre-Service or Post-Service claims, as appropriate.
2. If the claim is denied, notice of such decision shall be furnished promptly to the Claimant, shall be written in a manner understandable to the Claimant, and shall contain applicable notification information as required under ERISA.

C.4 Notification of Initial Claim Decision

General Rules. Upon making a claim determination, the Plan Office shall provide the Claimant with written or electronic notice of the claim determination to the extent required under ERISA, that includes those items listed in subsection (b), as applicable, and shall be written in a culturally and linguistically appropriate manner.
Contents of Notice. Notice provided to a Claimant of a claim determination shall contain:
1. information sufficient to identify the claim involved, including the date of service, health care provider, claim amount, diagnosis code (and meaning), and treatment code (and meaning);
2. the specific reason(s) for the denial;
3. a reference to the specific Plan provisions upon which the denial was based;
4. a description of any additional material or information necessary for the Claimant to perfect the claim and an explanation of why such material or information is necessary (if applicable);
5. a description of the appeal procedures and the time limits applicable to appealing the claim decision;
6. a statement of the Claimant's right to bring legal action under ERISA;
7. an explanation of any internal rule, protocol, procedure, guideline, or other criterion upon which the denial was based or a statement that explains the Claimant's right to receive a copy of such information free of charge upon request; and
8. if the denial was based on Medical Necessity, experimental treatment or similar exclusion or limit, the notice shall contain either (i) an explanation of the clinical or scientific judgment for making such decision, applying the terms of the Plan to the Claimant's medical condition, or (ii) a statement that such explanation is available free of charge upon request.
Additional Contents of Notice.
1. Urgent care claims. In addition to the contents listed in subsection (b), a claim determination concerning urgent care shall include a description of the expedited review process applicable to such claims.
2. Disability Claims. In addition to the notice requirements listed in subsection (b) above, a claim determination with respect to disability benefits will include:
Discussion of the decision, including an explanation of the basis for disagreeing with or not: (i) the views presented by the Claimant to the Plan of health care professionals treating Claimant and vocational professionals who evaluated the Claimant; (ii) the views of medical or vocational experts whose advice was obtained on behalf of the Plan, without regard to whether the advice was relied upon in making the benefit determination; and (iii) the Social Security Administration disability determination presented by the claimant to the Plan, if any.
In the event no rule, protocol, procedure, or standard under section C.4(b)(7) exists, the Plan will provide a statement notifying the Claimant of the lack of existence.
The Claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to Claimant's claim for benefits.

C.5 Appeal Procedures

Commencement of Appeal and Disclosure of Information
1. If a Claimant's initial claim for benefits is wholly or partially Denied, the Claimant may voluntarily request a review on appeal by the Board of the Denial. The Claimant must complete all of the administrative review steps available through the Plan Office under Section C.3 before an appeal to the Board is permitted under this Plan. Any request for a review on appeal made by a service provider shall not be treated as an appeal subject to these procedures unless such request is clearly on behalf of, and authorized by, a Claimant.
2. Written requests for review of a Denied Self-Funded PPO Claim or Disability Claim on review must be made within 180 days of the Denial (60 days for Other Claims) and must include the Claimant's name and identification number from the ID card, the date(s) of service(s), as applicable, the provider's name, as applicable, a copy of the Denial letter(s), and the basis of the appeal. The Claimant may submit additional comments, documents, written evidence, written testimony, records and other materials with his or her written request for appeal.
  
  For a claim involving Urgent Care, a Claimant may make an oral or written request for an expedited appeal. All necessary information shall be transmitted by telephone, facsimile, or other available similarly expeditious method.
3. Within 15 days of the receipt of the appeal, the Plan Office will provide written communication (such as an acknowledgement) indicating receipt of the appeal. The Plan shall, free of charge, provide the Claimant with reasonable access to, and copies of, all documents, records and other information relevant to the appeal. Relevant information means information (i) relied upon in the initial benefit claim determination, (ii) submitted, considered or generated in the course of the initial benefit claim determination, or (iii) that constitutes a statement of policy or guidance with respect to the Plan concerning the Denial, regardless of whether it was relied upon in making the benefit determination, and (iv) that demonstrates compliance with the administrative processes and safeguards required in making the determination. In addition, the Plan will provide the Claimant, free of charge, any new or additional evidence considered, relied upon or generated by the Plan in connection with the claim, and any new or additional rationale that will be a basis for any final internal Denial. Such evidence and rationale will be provided as soon as possible and sufficiently in advance of the final decision so as to give the Claimant a reasonable opportunity to respond prior to the decision.
4. If a medical or vocational expert was consulted in connection with the Claimant's initial claim, the expert will be identified, regardless of whether the expert's opinion was used to render the initial claim decision. If a medical or vocational expert is consulted during the course of the appeal, the expert consulted on appeal shall be different than, and not a subordinate of, the expert consulted during the initial claim process.
5. A claim on appeal will be given a full and fair review by the Board and shall include a review of all materials used to reach the initial claim decision; however, deference shall not be given to the initial claim decision. If the appeal is related to clinical maters, the review will be done in consultation with a health care professional with appropriate expertise in the field who was not involved in the prior determination.

Deadlines for Decision on Appeal

Upon timely receipt of a Claimant's request for review on appeal, the Board will evaluate the claim and make a final determination within the following determination periods, which shall begin to run upon the Plan Office's receipt of the appeal regardless of whether or not all information required to perfect the claim is included in the Claimant's request for review on appeal:

Type of Claim	Appeal Determination Period
Concurrent Care Claim	See (2) below
Disability Claim	See (4) below
Pre-Service Claim	30 Days
Post-Service Claim	See (4) below
Other Claim	See (3) below
Urgent Care Claim	72 hours

With respect to Concurrent Care Claims, if an on-going course of treatment was previously approved for a specific period of time or number of treatments, and the Claimant requests to extend treatment, the Claimant's request will be considered a new claim and decided according to Post-Service timeframes.
The Board may not extend the time period for decision on a PPO Claim appeal unless the Claimant voluntarily agrees to such extension. With respect to Disability Claims Post-Service, and Other Claims, the Board, under special circumstances, may extend the appeals determination period by a number of days equal to the number of days included in the initial appeals determination period, provided the Claimant is notified of the extension prior to the end of the initial appeals determination period, and the Board includes in such notice the reason for the extension and an estimate of the date on which the appeal determination will be made.
Ordinarily, a decision on the appeal of a Post Service Claim or a Disability Claim will be made at the next regularly scheduled meeting of the Board following receipt of Claimant's request for review (or the second following regularly scheduled meeting in the case of a request for review that is received within 30 days before the next regularly scheduled meeting). In special circumstances, a delay until the following regularly scheduled meeting may be necessary. The Claimant will be advised in writing in advance if this extension will be necessary. Once a decision on review of the claim has been reached, the Claimant will be notified of the decision generally within 5 days after the decision has been reached.

Notice of Determination on Appeal. Upon denying an appeal, the Board shall provide the Claimant written or electronic notice of the claim determination, which shall be written in a culturally and linguistically appropriate manner, and which, if Denied, shall contain:
1. the specific reason(s) for the Denial;
2. a reference to the specific Plan provisions upon which the Denial was based;
3. a statement that the Claimant is entitled to receive, free upon request, copies of and reasonable access to documents, records and other information relevant to the claim;
4. a statement describing any voluntary appeal procedure, if available, and the right to obtain information regarding such procedure, as well as a statement of the Claimant's right to bring legal action under ERISA;
5. an explanation of any rule, protocol, procedure or guideline upon which the Denial was based or a statement that explains the Claimant's right to receive a copy of such information free of charge upon request; and
6. if the denial was based on Medical Necessity or other similar exclusion or limit, the notice shall contain either:
  1. an explanation of the clinical or scientific judgment for making such decision, applying the terms of the plan to the Claimant's medical condition; or
  2. a statement that an explanation is available free of charge upon request.
  If the Denial involves a Disability Claim, in addition to the above, the notification will describe any applicable contractual limitations period that applies to the Claimant's right to bring legal action. The notice will also include:
  1. Discussion of the decision, including an explanation of the basis for disagreeing with or not: (i) the views presented by the Claimant to the Plan of health care professionals treating Claimant and vocational professionals who evaluated the Claimant; (ii) the views of medical or vocational experts whose advice was obtained on behalf of the Plan, without regard to whether the advice was relied upon in making the benefit determination; and (iii) the Social Security Administration disability determination presented by the claimant to the Plan, if any.
  2. In the event no rule, protocol, procedure, or standard under section C.5(c)(5) exists, the Plan will provide a statement notifying the Claimant of the lack of existence.

C.6 External Review

The Plan will arrange for the external review of any Denial of a PPO Claim on final appeal if requested by the Claimant within four months of the decision on final appeal.

C.7 Action for Recovery

No Covered Individual may commence a lawsuit to obtain Plan benefits under a claim subject to these procedures until these claim procedures have been exhausted. These claim procedures will be exhausted when (i) the Covered Individual has submitted a claim under these procedures and a final decision on appeal has been provided or (ii) the applicable time frame described above has elapsed since the Covered Individual filed an appeal and no final decision (or notice that an extension will be necessary) has been provided. No lawsuit may be commenced more than two years after the end of the year in which these procedures were exhausted.