Blue Cross Blue Shield will notify you of a final decision within 60 days of receiving your written appeal. If more research is necessary to resolve your claim issue, Blue Cross Blue Shield will notify you of this fact and will make a decision within 120 days of receiving the appeal.

Filing an Appeal of a Utilization Review Determination

An "appeal of a utilization review determination" is an application made by you to request a reconsideration of a prospective, concurrent, or retrospective determination made by Blue Cross Blue Shield or any entity acting on its behalf, not to provide reimbursement coverage for a service requested by you, your doctor or other health care provider. If Blue Cross Blue Shield makes a utilization review determination not to provide coverage for a requested service, you will receive a denial in writing within one business day of Blue Cross Blue Shield's receipt of all information necessary to conduct its review or, for concurrent determinations, prior to the end of the certified period. Upon a denial, you will receive information on the appeal procedures available. You are entitled to the following levels of review when seeking an appeal:

First Level Appeal of a Utilization Review Determination

A first level appeal of a utilization review determination must be submitted in writing (except in a case of an expedited appeal) within 180 calendar days of the initial determination. You will receive written notification of a determination on a first level appeal within 15 business days following Blue Cross Blue Shield's receipt of all necessary medical information required to conduct a review. NOTE: You may request an expedited review of denied services if the circumstances are urgent or you are an inpatient by calling the Customer Relations Department.

Second Level Appeal of a Utilization Review Determination

If the denial of services was confirmed during the first level appeal process, you may submit a written request for a second level appeal within 180 calendar days of the receipt of the determination of the first level appeal. You will be given the opportunity to inspect the utilization review file and add information to the file. The process for inspecting your file is outlined in the confidentiality act. You will receive written notification of a determination on a second level appeal within 15 business days following receipt of all necessary medical documentation. If the service for which you are requesting a review was denied after you already obtained the service (retrospectively), you will receive written notification of a determination within 30 calendar days of receipt of all necessary documentation.

External Appeal

If you remain dissatisfied with the determinations of Blue Cross Blue Shield's internal review process after completion of a second level review appeal, you may request an external appeal by an objective appeal agency approved by the Department of Health. You will be responsible for 50% of the predetermined fee of the external appeal agency; Blue Cross Blue Shield will pay the remaining 50%. To request an external review, you must submit your request within 180 calendar days of receipt of your second level of appeal denial notification. The external appeal agency will complete its review and make a final determination within ten business days for all non-urgent appeals, and within two business days for expedited appeals. The external agency will notify you directly of its decision.

Judicial Review

If you are dissatisfied with the final decision of the external appeal agency, you are entitled to a judicial review in an appropriate court of law. If you choose to file suit, you cannot recover payment for a claim through legal actions unless you notify Blue Cross Blue Shield in writing that you intend to take such action.

Grievances Unrelated to Claims

Blue Cross Blue Shield encourages you to discuss any complaint that you may have about any aspect of your medical treatment with the health care provider that furnished the care. In most cases, issues can be more easily resolved when they are raised sooner. If, however, you are dissatisfied with a service or Blue Cross Blue Shield's administration of covered benefits, you may access any of Blue Cross Blue Shield's grievance procedures. In order to initiate a grievance, please call the Customer Relations Department at (401) 459-5000 or 1 (800) 639-2227.

The grievance procedures described in this section do not apply to utilization review determinations, claims appeals, claims of medical malpractice or to allegations that Blue Cross Blue Shield is liable for the professional negligence of any doctor, hospital, health care facility or other health care provider furnished covered services.

Weekly Accident and Sickness Claims

To submit a claim for the Weekly Accident and Sickness Benefit:

Notify and request the appropriate form from the Fund Office within six weeks from the date of the covered incident;
Have the required paperwork completed by Rhode Island TDI, if employed in Rhode Island;
Have the appropriate paperwork completed by your physician;
Return the appropriate forms to the Fund office before they expire (six weeks from the date sent). The expiration date is shown on the Accident and Sickness Claim Form;
If requested by the Fund, undergo a physical examination by the Fund's independent doctor at any time while you are seeking or receiving benefits.

Your claim will be voided automatically after the expiration date shown on the accident and sickness claim form, however, you may make an appeal to the Board of Trustees.

Life Insurance, Accidental Death and Dismemberment, and Personal Accident Coverage Claims

The Life Insurance benefit will be paid in full in accordance with the terms of the insurance certificate to the last named beneficiary on file at the Fund Office upon receipt of the Certified Death Certificate. Accidental Death and Dismemberment benefits will be paid to you, or in the event of your death, to your beneficiary.

Proof of Loss

Aetna must be given written proof of the loss for which claims is made under the coverage. This proof must cover the occurrence, character and extent of that loss. It must be furnished within 90 days after the date of loss or as soon as reasonable possible. Aetna, at its own expense, has the right to examine the person whose loss is the basis of claim.

Benefits are paid when Aetna received the written proof of the loss.

Legal Action

No action at law or in equity shall be brought to recover on the group contract earlier than 60 days after the written proof of loss is furnished and no later than three years after the end of the time within which the proof of loss is required.

Coordination of Benefits

Members of a family are often covered under more than one plan of group benefits. Because of this, there are many instances of duplication of coverage — two plans paying benefits for the same hospital and medical expenses. For this reason, the Plan will take into account any coverage an eligible person has under other benefit programs, including Medicare. Blue Cross Blue Shield determines which insurance pays first according to the rules summarized below. After that, benefits are provided only up to the amount which, when added to the benefits paid by the other group plan, may equal but not exceed 100% of reasonable charges for eligible health care expenses.

Who Pays First?

When duplicate coverage arises, and both plans contain a Coordination of Benefits provision, the plan that insures the person incurring the claim as an employee is the primary plan and the plan that insures the person as an active employee will pay before a plan that insures the person as a laid off or retired employee. If an individual is insured under two plans through two jobs, the plan that has insured the person for the longer time pays first. If a claim is filed for a child, the group plan that insures the parent whose birth date — month and day (not year) — occurs earliest in the calendar year is primary. When another plan does not contain a Coordination of Benefits provision, it will always be considered the primary plan. Payment under the secondary plan is made after the amount payable under the primary plan has been determined.

There are exceptions to this general rule:

When parents are separated or divorced and the parent with custody of a child is not remarried, the benefits of a plan that covered the child as a dependent of the parent with custody will be determined before the benefits of a plan that covers the child as a dependent of the parent without custody.
When the parents are divorced and the parent with custody of the child has remarried, the benefits of a plan that covers the child as a dependent of the parent with custody will be determined before the benefits of a plan that covers that child as a dependent of the step-parent, and the benefits of a plan that covers that child as a dependent of the step-parent will be determined before the benefits of a plan that covers that child as a dependent of the parent without custody.

If there is a court decree that would otherwise establish financial responsibility for the medical, dental or other health care expenses with respect to the child, the benefits of a plan that covers the child as a dependent of the parent with such financial responsibility shall be determined before the benefits of any other plan that covers the child as a dependent.

Coverage Under Two or More Blue Cross Blue Shield Contracts

If a member or dependent is covered under more than one basic Blue Cross Blue Shield contract he will be entitled to receive credit for the benefits of both contracts, up to but not to exceed the cost for hospital or physicians charges for covered services.

Coordination with Medicare

If you (or your covered spouse) become eligible for Social Security Retirement Benefits at age 65, you (or your spouse) are also eligible for Medicare. If you are covered by this Plan and by Medicare, then as long as you remain actively employed, this Plan pays first and Medicare pays second. This means that after the Plan pays benefits for your eligible expenses, you may submit a claim to Medicare for any unpaid balances for consideration. These rules also apply to your covered spouse who is age 65 or older whether or not you are also age 65 or older.

However, if you are under the age of 65 and become entitled to Medicare because of disability, you will no longer be considered actively employed and Medicare pays first and this Plan pays second with respect to all family members.

If any family member becomes entitled to Medicare because of end-stage renal disease (ESRD) and this Plan was primary at that time, this Plan pays first and Medicare pays second for a limited period of time.

Medicare imposes a three-month waiting period at the onset of end-stage renal disease before Medicare becomes effective. Medicare waives this waiting period if the patient enrolls in a self-dialysis training program within the first three months of the diagnosis of end-stage renal disease or receives a kidney transplant within the first three months of being hospitalized for the transplant. If there is a waiting period, this Plan continues to be the primary plan for the three-month waiting period. This Plan will then be the primary plan for the next 30 months. Medicare is the primary payor after the 30-month period.

Subrogation

If benefits are paid under this Plan by Blue Cross Blue Shield or directly by the Fund, and if you or your dependent has a claim against any other party, including your own insurance carrier who may be responsible or liable for the cost of the benefits paid by the Fund, the Fund must be repaid out of any proceeds you or your dependent receive from the other party. Whether the proceeds are paid by way of settlement of the claim or by way of judgment, the amount due the Fund must be repaid in full without any reduction for attorney's fees or costs. The Fund will have an equitable interest in any amount you or your dependent recovered or will recover. If necessary, the Fund will institute legal action against you or your dependent for failing to repay the Fund, you or your dependent will be liable for all costs of collection, including reasonable attorney's fees.

No payment for any benefit is due or payable unless you and/or your dependent sign a reimbursement agreement on a form approved by the Board of Trustees. In the event you or your dependent fail to reimburse the Fund from proceeds received from a third party, the Fund will have the right to withhold future benefits equal to the amount otherwise due the Fund, plus interest. Once settlement is reached, the Fund will not make any payments for future charges relating to the injury.