All Health Plan participants are entitled to know why a claim has been denied payment or partially paid.

If the denial is due to a medical or surgical decision by one of the Plan’s Managed Care Vendors, or due to a question of Medical Necessity or Experimental Treatment, follow the procedures outlined in Section 10.

All other claim or eligibility denials must be appealed to the Plan using the following procedure:

Step 1:
When you receive a claim denial or a partial payment for a claim that you believe should have been paid differently, you should do the following:

  • a. Review the appropriate Plan booklet;
  • b. Call the Claims Administrator using the toll-free number in Appendix A;
  • c. Discuss the paragraphs from our Plan booklet pertaining to the coverage denied with the claims processing representative.

Step 2:
If the inquiry fails to resolve your claim problems, you may begin the appeal process. Your Local School District Health Plan representative will act as your ombudsman during the appeal process. If your claim to be appealed is private (or of a medically confidential nature) you may perform all the following steps yourself, privately.

To do so, please request that your Local School District representative provide you with an appeal form and the name, address and phone number of the Plan’s Appeal Committee Chairperson and follow each step of the appeals procedure.

  • a. Request that your Local School District Health Plan representative review the claims with you. (At your option.)
  • b. Be prepared to submit in writing ALL evidence that supports your claim – a copy of the doctor or hospital bill and supporting receipt, copy of denial letter, or other correspondence on the claim.
  • c. You or your Local School District Health Plan Representative may contact the Plan’s Claims Administrator to find out reasons for the claim denial, and you may contact the Plan Administrator for additional clarification, if necessary.
  • d. Most denied or partially paid claims are resolved to the Employee’s satisfaction by reviewing the Plan provisions and the facts of the claim.

If the claim still cannot be resolved:

Step 3:

  • a. The Employee may request that the Local School District Health Plan Representative submit the matter to the Appeals Committee for review. This Appeal must be presented within 60 days from the claim denial (or final written action by the Claims Administrator which is the cause of the appeal), or within 60 days of receipt of the response from review by your Local Health Plan Representative as detailed above.*
  • b. The Local School District Health Plan Representative will present a written request to the Health Plan Administrator requesting that the Appeals Committee review the matter. The Local Health Plan Representative must provide sufficient documentation of the matter to reasonably allow determination by the Appeals Committee.*
  • c. Your Local School District Health Plan Representative may present your Appeal to the Health Plan Appeals Committee. The Appeals Committee will perform a review of the denial. The Committee will make every effort to provide the claimant with a written response within 60 days from when they received the appeal. If the Appeals Committee
    is unable to complete the review process within 60 days, the Local School District Health Plan Representative will notify the claimant within the 60-day period. The Appeals Committee will attempt to provide a written response within 120 days.*

* Steps 3 a, b, and c can be performed personally if the member requests and files completed appeal forms with the Plan Administrator.
The Appeals Committee’s written response shall cite the reasons for their decision and the specific Plan provisions upon which their review decision is based.

If you are not satisfied with the Appeals Committee resolution:
Step 4:

  • a. You are entitled to a hearing before the Appeals Committee. Your request for a hearing must be made in writing to your Local School District Health Plan Representative within 60 days from receipt of the response to your appeal.
  • b. The Appeals Committee will set a hearing date.
  • c. Your appeal may be presented to the committee, during the hearing, by your Local School District Health Plan, you and/or your Personnel Representative.
  • d. The Appeals Committee will review all materials submitted through the hearing process and will make every effort to respond to the claimant within 60 days of the hearing date.

The Appeals Committee is the appointed Plan Representative body to review member appeals. As the designated representative of the Health Plan, the Appeals Committee has the full power and authority in their absolute discretion to determine all questions of eligibility for benefits for all claimants and to interpret and construe the terms of the Plan. Such determinations, upon proper and adequate review, shall be conclusive and binding upon all interested parties.