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HOW
TO IDENTIFY YOURSELF |
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The
Fund uses the Social Security Number of the participant or a Health Care
Identification number (HCID) as an identification
number for all transactions. The HCID
number starts with "OE" and may be found on your ID card. The
Union Register Number is also used as a cross reference.
Always include the member's Social Security number or HCID number on any claim or
correspondence that you submit to the Fund Office. A MISSING SOCIAL
SECURITY NUMBER OR HCID NUMBER CAN SIGNIFICANTLY DELAY PAYMENT OF YOUR CLAIMS. |
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PLAN
RULES AND REGULATIONS |
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A
booklet is provided upon request to each participant which includes the Rules
and Regulations of each of the Funds in which you may be a participant.
The Rules and Regulations govern every aspect of Plan operations. They
are the Plan's "legal
document" - the basis for all eligibility and benefit provisions in
each Plan. Periodically those Rules
and Regulations are amended and updated and revised pages are available from the
Fund Office. If you do not have a
current booklet or if you have misplaced or lost it, you can obtain a copy by requesting one from the Fund Office in writing. |
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CHANGE
OF ADDRESS |
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It is important that you keep the
Fund Office advised at all times of any change of address.
Changes of address
will not be accepted by the Fund Office unless the change is in writing
and the written notice has been signed by the eligible participant.
Any other change of address will not be accepted.
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All
address changes must be in writing - telephone changes cannot be accepted. |
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All
mailings from the Fund Office will be made to your last known address.
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CLAIM REVIEW
AND APPEALS
PROCEDURES |
The information below does not apply to Health Net, Health
Plan of Nevada or Kaiser Permanente. If you are enrolled in one of those
medical plans, see their materials for information on their claims review
procedures.
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Types of Claims and Initial Determination of Approval or
Denial |
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Urgent Claim |
Urgent Claim means a claim for medical care or
treatment, that requires review sooner than other claims to avoid the
possibility of:
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serious jeopardy to your life or health or your
ability to regain maximum function; or |
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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 will be subject to the Plan’s
limits and exclusions.
Initial Determination: You will be notified of a
determination within 72 hours from the receipt of the claim by the Fund
Office.
If the Fund Office determines that additional information
is needed in order to make an initial determination of an urgent claim the
Fund Office will notify you if you have failed to provide necessary
information. The notification will specify the information required within
24 hours of the receipt of the urgent claim. You and/or your doctor must
provide the specified information within 48 hours. The time limit within
which the urgent claim must be resolved will be suspended for 48 hours or
until the Fund Office receives the requested information, whichever occurs
first. Notice of the decision will be provided no later than 48 hours
after receipt of the specified information, but only if the information is
received within the required time frame. |
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Pre-Service Claim |
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 under the
Contract Prescription Drug Plan, the Plan does not require prior approval
of benefits.
Initial Determination: You will be notified of a
determination within 15 days from the receipt of the claim by the Fund
Office, unless additional time is needed. If the Fund Office determines
that an extension of time is required to make an initial determination on
a pre-service claim due to matters beyond the control of the Fund Office,
the time limit within which the initial determination must be made by the
Fund Office may be extended for 15 days if the Fund Office notifies you of
the extension within the time limit initially set for processing the
pre-service claim.
If an extension is needed because the Fund Office needs
additional information in order to make an initial determination of a pre-service claim, the Fund Office will
notify you of the information required to complete the claim. In that
case, you and/or your doctor will have 45 days to supply the additional
information. The time limit within which the pre-service claim must be
resolved will be suspended for 45 days or until the Fund Office receives
the requested information, whichever occurs first. The Plan then has 15
days to make a decision and notify you of the determination.
If your provider improperly files a Pre-Service Claim,
you and/or your provider will be notified as soon as possible but not
later than 5 days after receipt of the claim, of the proper procedures to
be followed in filing a claim. Notice of an improperly filed Pre-Service
claim will only be sent if the claim includes (i) your name, (ii) your
specific medical condition or symptom, and (iii) a specific treatment,
service or product for which approval is requested. Unless the claim is
re-filed properly, it will not constitute a claim. |
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Post-Service Claim |
Post-Service Claim means any claim for payment of
treatment, services or supplies that have already been provided to you.
You may obtain a claim form by calling the Fund Office. Be sure to specify
what type of claim you are filing as there are separate forms for medical,
dental, life insurance and weekly disability benefits.
Initial Determination: You will be notified of a
determination on your post-service claim within 30 days from the receipt
of the claim by the Fund Office. If the Fund Office determines that an
extension of time is required to make an initial determination on a
post-service claim due to matters beyond the control of the Fund Office,
the time limit within which the initial determination must be made by the
Fund Office may be extended for 15 days if the Fund Office notifies you of
the extension within the time limit initially set for processing the
post-service claim.
If an extension is needed because the Fund Office needs
additional information in order to make an initial determination of a
post-service claim, the Fund Office will notify you of the information
required to complete the claim. In that case, you and/or your doctor will
have 45 days to supply the additional information. The time limit within
which the post-service claim must be resolved will be suspended for 45
days or until the Fund Office receives the requested information,
whichever occurs first. The Plan then has 15 days to make a decision and
notify you of the determination. |
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Concurrent Claim |
Concurrent Claim means any claim that is
reconsidered after an initial approval was made and which results in a
reduced or a 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. |
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Disability 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 Active Employees in Southern Nevada will be
treated as Disability Claims.
Initial Determination: You will be notified of a determination on your
disability claim within 45 days from the receipt of the claim by the Fund
Office. If the Fund Office determines that an extension of time is
required to make an initial determination on a disability claim due to
matters beyond the control of the Fund Office, the time limit within the
initial determination must be made by the Fund Office may be extended for
two (2) periods of 30 days each if the Fund Office notifies you of the
extension within the time limit initially set for processing the
disability claim.
If an extension is needed because the Fund Office needs
additional information in order to make an initial determination of a
disability claim, the Fund Office will notify you of the information
required to complete the claim. In that case, you and/or your doctor will
have 45 days to supply the additional information. The time limit within
which the disability claim must be resolved will be suspended for 45 days
or until the Fund Office receives the requested information, whichever
occurs first. Once you respond to the Plan’s request for the information,
you will be notified of the Plan’s decision on the claim within 30 days. |
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If your claim has been denied in whole or in part by the
Fund Office, you will be notified in writing within the time limits
indicated above. However, for urgent claims, the notice may be provided
orally and confirmed in writing within three (3) calendar days after the
oral notice.
The notice of the denial of the initial benefit
determination will state the following:
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The specific reason or reasons for the denial. |
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A reference to the provision in the plan Rules and
Regulations upon which the denial was based. |
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A statement of any additional information or material
required for the processing of the claim and the reason such additional
information is needed. |
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A statement of information sufficient to
inform you of the Fund’s procedures for the appeal of denied claims. The
notice will include copies of any internal rules, guidelines, protocols
or other criteria relied upon by the Fund Office in denying the claim
unless you are notified in writing that such material is available and
will be provided to you at no cost upon your request. |
If your claim is denied, you may ask the Board of
Trustees to review the denial (an appeal). Your request for review
must be made in writing to the Fund Office. Your request must state in
clear and concise terms the reason or reasons why you disagree with the
denial. You must send the Board any document not already provided that
supports your claim, and you must file it with the Fund Office within 180
days after you receive notice of the denial of your claim. You or your
authorized representative will be permitted to review pertinent documents
and to submit issues and comments in writing.
A request to review the denial of an Urgent Claim may be
made orally instead of writing if you prefer.
If you have a good reason, the Board of Trustees will
permit the petition to be amended or supplemented and may, in its sole
discretion, grant a hearing on the petition before a hearing panel
consisting of at least one Employer Trustee and one Union Trustee to
receive and hear any evidence or argument which cannot be presented
satisfactorily by correspondence. If you fail to file a petition for
review within the 180 day period or fail to appear and participate in any
hearing you will lose your right to review by the Trustees. However, the
Board may allow you to file your request for review late if application to
do so is made within one year after the date shown on the notice of
denial.
You have the right to submit comments, documents, records
and other information in support of your claim for benefits. Upon request
and free of charge, the Plan will provide you with reasonable access to
and copies of all documents, records or other information relevant to your
claim.
Upon request, you will be provided with the identification
of medical or vocational experts, if any, that gave advice to the Plan on
your claim, without regard to whether their advice was relied upon in
deciding your claim.
A different person will review your claim and such person
will not be a subordinate of the person who originally denied your claim.
The reviewer will not give deference to the initial adverse benefit
determination. The decision will be made on the basis of the record,
including such additional documents and comments that may be submitted by
you relating to the claim.
If your claim was denied on the basis of a medical
judgment (such as a determination that the treatment or service was not
medically necessary or was investigational or experimental), a health care
professional who has appropriate training and experience in a relevant
field of medicine will be consulted. Such professional will not be an
individual who was consulted in connection with the initial determination
that is the subject of the appeal or any subordinate of such individual.
A decision by the Board of Trustees will be made promptly,
but in no event will it exceed the following time limits:
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Urgent Claims: within 72 hours from the receipt
of the appeal by the Fund Office. |
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Pre-Service Claims: within 30 days from the
receipt of the appeal by the Fund Office. |
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Post-Service Claims:
within 60 days from the
receipt of the appeal by the Fund Office. |
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Disability Claims:
within 45 days from the
receipt of the appeal by the Fund Office. The Fund Office may extend
this period by an additional period of 45 days if the Fund Office
provides notice to you of the circumstances requiring the extension
within the first 45-day period. |
The Board of Trustees, as permitted by federal law and
regulation, may defer the decisions on adverse benefit determination
appeals until the next regularly scheduled meeting of the Fund’s benefit
appeals committee.
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If Your Appeal is Denied
You will be notified of the decision of the Board of
Trustees in writing. The decision will include all of the same information
which is required to be provided by the Fund Office for an initial benefit
determination as outlined above.
The decision of the Board of Trustees on the petition for
review will be final and binding upon all parties involved with the claim,
including the applicant, claimant or petitioner, subject only to judicial
review as provided in the plan Rules and Regulations.
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USEFUL
TELEPHONE NUMBERS |
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If
you need assistance or information regarding the Plan benefits, you may call the
appropriate department listed below:
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Claims
Information Center & Eligibility:
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(888)
512-5279 (626) 356-1004 |
Death
Benefits: |
(626)
356-1063 |
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Pension:
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Vacation-Holiday: |
(626)
356-1050 |
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Last names A-G |
(626)
356-1060 |
Switchboard: |
(626)
356-1000 |
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Last
names H-O |
(626)
356-1061 |
Administration: |
(626)
356-1098 |
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Last
names P-Z |
(626) 356-1063 |
Las Vegas Fund Office |
(702) 949-1212 |
| If you would like to FAX
information to the Fund Office, you may use the Department numbers listed below: |
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Employer Compliance |
(626)
796-4742 |
Administration Department |
(626) 356-1065 |
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Pension Department |
(626)
796-4742 |
Las Vegas Fund Office |
(702) 949-1221 |
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Vacation-Holiday Dept. |
(626)
796-4742 |
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To
avoid the expense of a long distance call, use the Facsimile (FAX) system.
Call the local District Office of I.U.O.E., Local 12 and ask them to fax
your inquiry or paperwork to the Fund Office. |
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District No.1
- Pasadena
District No.1 - Lancaster |
(626) 792-2519
(626) 942-1175 |
District
No.5 - Redlands
District No.5 - Palm Desert |
(909) 307-8700
(760) 779-0299 |
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District No.2 -
Ventura
District No.2 - Arroyo Grande |
(805)
643-8740
(805) 489-1533 |
District
No.6 - Las Vegas |
(702) 598-1212 |
| District
No.3 - Bakersfield |
(661)
325-9491 |
District No.7 - Anaheim |
(714) 827-4591 |
| District
No.4 - San Diego |
(619)
295-3186 |
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Your
best method of getting information is to get it from the Fund Office. You
should not ask a Union Business Agent to interpret the Rules and
Regulations of the Plans because he is not a representative of the Fund and is
not expected to be familiar with Fund operations.
IMPORTANT:
Questions about Union dues, withdrawal, the burial fund, and the apprentice
training program must be directed to the offices of I.U.O.E., Local 12. The
Trust Fund does not handle these matters and cannot answer your questions
about them.
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