SECTION IX: CLAIMS FILING AND APPEAL PROCEDURES

The claims filing and appeals procedures described below will apply to claims and appeals over which the Board of Trustees has discretion, solely for benefits covered under the Indemnity Plan. Generally, except for questions of eligibility under the Plan, the Board of Trustees does not have any say over benefit determinations made by an HMO or other provider or insurance carrier. Claims for benefits under such arrangements must be pursued using the claims and appeals procedures provided by such HMO, provider or insurance carrier. In other words, DO NOT USE THE SAN FRANCISCO ELECTRICAL WORKERS HEALTH AND WELFARE PLAN’S CLAIMS FILING AND APPEALS PROCEDURE for benefit determinations made by Kaiser, PacifiCare, Secure Horizon, Delta Dental, VSP or PacifiCare Behavioral Health claims. Instead, for HMO, Dental or Vision claims, please refer to the claims procedures in the Supplemental Summaries of those programs available in the Plan Office.

IMPORTANT NOTE: In all cases, provisions under the HMO provider and the Indemnity Plan procedures require that claims for benefits or reimbursement for medical services and appeals from the denial of claims must be submitted within a specific period of time. A failure to meet these time limits may bar the claim or appeal. Study the following and the enclosed brochures for additional details regarding the making of a claim or the taking of an appeal.

Topics In This Section

A. How To File A Claim
B. Claims And Appeals Procedures B Definitions
C. Notice Of Claim Denial