Appeal of Adverse Benefit Determinations
Full and Fair Review of All Claims
In cases where a claim for benefits is denied, in whole or in part, and the Claimant believes the claim has been denied wrongly, the Claimant may appeal the denial and review pertinent documents. The claims procedures of this Plan provide a Claimant with a reasonable opportunity for a full and fair review of a claim and Adverse Benefit Determination. More specifically, the Plan provides:
- A 180 day timeframe following receipt of a notification of an initial Adverse Benefit Determination within which to appeal the determination. The Plan will not accept appeals filed after a 180 day timeframe.
- The opportunity to submit written comments, documents, records, and other information relating to the claim for benefits.
- The opportunity to review the Claim file and to present evidence and testimony as part of the internal claims and appeals process.
- A review that does not afford deference to the previous Adverse Benefit Determination and that is conducted by an appropriate named fiduciary of the Plan, who shall be neither the individual who made the Adverse Benefit Determination that is the subject of the appeal, nor the subordinate of such individual.
- A review that takes into account all comments, documents, records, and other information submitted by the Claimant relating to the claim, without regard to whether such information was submitted or considered in the prior benefit determination.
- That, in deciding an appeal of any Adverse Benefit Determination that is based in whole or in part upon a medical judgment, the Plan fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment, who is neither an individual who was consulted in connection with the Adverse Benefit Determination that is the subject of the appeal, nor the subordinate of any such individual.
- Upon request, the identity of medical or vocational experts whose advice was obtained on behalf of the Plan in connection with a claim, even if the Plan did not rely upon their advice.
- That a Claimant will be provided, free of charge: (a) reasonable access to, and copies of, all documents, records, and other information relevant to the Claimant’s claim in possession of the Plan Administrator or Third Party Administrator; (b) information regarding any voluntary appeals procedures offered by the Plan; (c) information regarding the Claimant’s right to an external review process; (d) any internal rule, guideline, protocol or other similar criterion relied upon, considered or generated in making the adverse determination; and (e) an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the Claimant’s medical circumstances.
- That a Claimant will be provided, free of charge, and sufficiently in advance of the date that the notice of Final Internal Adverse Benefit Determination is required, with new or additional evidence considered, relied upon, or generated by the Plan in connection with the Claim, as well as any new or additional rationale for a denial at the internal appeals stage, and a reasonable opportunity for the Claimant to respond to such new evidence or rationale.
Requirements for First Level Appeal
The Claimant must file the appeal in writing (although oral appeals are permitted for pre service urgent care claims) within 180 days following receipt of the notice of an Adverse Benefit Determination.
For Pre-service Claims. Oral appeals should be submitted in writing as soon as possible after it has been initiated. To file any appeal in writing, the Claimant’s appeal must be addressed as follows:
Hines & Associates
115 East Highland Avenue Elgin, IL 60120
For Post-service Claims. To file any appeal in writing, the Claimant’s appeal must be addressed as follows:
2828 North Monroe Street Decatur, IL 62526
It shall be the responsibility of the Claimant or authorized representative to submit an appeal under the provisions of the Plan. Any appeal must include:
- The name of the Employee/Claimant.
- The Employee/Claimant’s social security number.
- The group name or identification number.
- All facts and theories supporting the claim for benefits.
- A statement in clear and concise terms of the reason or reasons for disagreement with the handling
of the claim.
- Any material or information that the Claimant has which indicates that the Claimant is entitled to
benefits under the Plan.
If the Claimant provides all of the required information, it may be that the expenses will be eligible for payment under the Plan.
Timing of Notification of Benefit Determination on Review
The Plan Administrator shall notify the Claimant of the Plan’s benefit determination on review within the following timeframes:
- Pre-service Urgent Care Claims: As soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the appeal.
- Pre-service Non-urgent Care Claims: Within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days after receipt of the appeal.
- Concurrent Claims: The response will be made in the appropriate time period based upon the type of claim: Pre-service Urgent, Pre-service Non-urgent or Post-service.
- Post-service Claims: Within a reasonable period of time, but not later than 30 days per internal appeal.
Calculating Time Periods
The period of time within which the Plan’s determination is required to be made shall begin at the time an appeal is filed in accordance with the procedures of this Plan, without regard to whether all information necessary to make the determination accompanies the filing.
Manner and Content of Notification of Adverse Benefit Determination on Review
The Plan Administrator shall provide a Claimant with notification, with respect to Pre-service urgent care claims, by telephone, facsimile or similar method, and with respect to all other types of claims, in writing or electronically, of a Plan’s Adverse Benefit Determination on review, setting forth:
- Information sufficient to allow the Claimant to identify the claim involved (including date of service, the health care Provider, the claim amount, if applicable, and a statement describing the availability, upon request, of the Diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning).
- Specific reason(s) for a denial, including the denial code and its corresponding meaning, and a description of the Plan’s standard, if any, that was used in denying the claim, and a discussion of the decision.
- A reference to the specific portion(s) of the summary plan description on which the denial is based.
- The identity of any medical or vocational experts consulted in connection with a claim, even if the Plan did not rely upon their advice (or a statement that the identity of the expert will be provided,
- A statement that 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 the Claimant’s
claim for benefits.
- Any rule, guideline, protocol or similar criterion that was relied upon, considered, or generated in
making the determination will be provided free of charge. If this is not practical, a statement will be included that such a rule, guideline, protocol or similar criterion was relied upon in making the determination and a copy will be provided to the Claimant, free of charge, upon request.
- A description of any additional information necessary for the Claimant to perfect the claim and an explanation of why such information is necessary.
- A description of available internal appeals and external review processes, including information regarding how to initiate an appeal.
- A description of the Plan’s review procedures and the time limits applicable to the procedures.
- In the case of denials based upon a medical judgment (such as whether the treatment is Medically Necessary or Experimental), either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the Claimant’s medical circumstances, will be provided. If this is not practical, a statement will be included that such explanation will be provided
to the Claimant, free of charge, upon request.
- Information about the availability of, and contact information for, an applicable office of health
insurance consumer assistance or ombudsman established under applicable federal law to assist
Participants with the internal claims and appeals and external review processes.
- The following statement: “You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your
local U.S. Department of Labor Office and your State insurance regulatory agency.
Furnishing Documents in the Event of an Adverse Determination
In the case of an Adverse Benefit Determination on review, the Plan Administrator shall provide such access to, and copies of, documents, records, and other information described in the provision relating to “Manner and Content of Notification of Adverse Benefit Determination on Review” as appropriate.
Decision on Review
The decision by the Plan Administrator or other appropriate named fiduciary of the Plan on review will be final, binding and conclusive and will be afforded the maximum deference permitted by law. All claim review procedures provided for in the Plan must be exhausted before any legal action is brought.
Requirements for Second Level Appeal
The Claimant must file an appeal regarding a Post-service claim and applicable Adverse Benefit Determination, in writing within 60 days following receipt of the notice of the first level Adverse Benefit Determination.
Two Levels of Appeal
This Plan requires two levels of appeal by a Claimant before the Plan’s internal appeals are exhausted. For each level of appeal, the Claimant and the Plan are subject to the same procedures, rights, and responsibilities as stated within this Plan. Each level of appeal is subject to the same submission and response guidelines.
Once a Claimant receives an Adverse Benefit Determination in response to an initial claim for benefits, the Claimant may appeal that Adverse Benefit Determination, which will constitute the initial appeal. If the Claimant receives an Adverse Benefit Determination in response to that initial appeal, the Claimant may appeal that Adverse Benefit Determination as well, which will constitute the final internal appeal. If the Claimant receives an Adverse Benefit Determination in response to the Claimant’s second appeal, such Adverse Benefit Determination will constitute the Final Internal Adverse Benefit Determination, and the Plan’s internal appeals procedures will have been exhausted.
Deemed Exhaustion of Internal Claims Procedures and De Minimis
Exception to the Deemed Exhaustion Rule
A Claimant will not be required to exhaust the internal claims and appeals procedures described above if the Plan fails to adhere to the claims procedures requirements. In such an instance, a Claimant may proceed immediately to make a claim in court. However, the internal claim and appeals procedures will not be deemed exhausted (meaning the Claimant must adhere to them before bringing a claim in court) in the event of a de minimis violation that does not cause, and is not likely to cause, prejudice or harm to the Claimant as long as the Plan Administrator demonstrates that the violation was for good cause or due to matters beyond the control of the Plan, the violation occurred in the context of an ongoing, good faith exchange of information between the Plan and the Claimant, and the violation is not reflective of a pattern or practice of non- compliance.
If a Claimant believes the Plan Administrator has engaged in a violation of the claims procedures and would like to pursue an immediate review, the Claimant may request that the Plan provide a written explanation of the violation, including a description of the Plan’s basis for asserting that the violation should not result in a “deemed exhaustion” of the claims procedures. The Plan will respond to this request within ten days. If a court rejects a request for immediate review because the Plan has met the requirements for the “de minimis” exception described above, the Plan will provide the Claimant with notice of an opportunity to resubmit and pursue an internal appeal of the claim.
Final Internal Appeal Procedure
A final internal appeal may be made by an employee enrolled in the Illinois Central College Group Health Care Plan when there is an alleged misinterpretation or misapplication of the specific benefits provided by the Plan which cannot be resolved satisfactorily through regular claim channels.
Insurance Appeal Advisory Committee Purpose and Structure
A five-member Insurance Appeal Advisory Committee shall be designated to review complaints regarding claim denials and to make recommendations regarding the disposition of disputed claims alleging misinterpretation or misapplication of the specific benefits provided by the Illinois Central College Group Health Care Plan.
The Chairperson of the Committee shall be an administrator appointed annually by the President of the College. The four other members shall be selected from the current Insurance Committee membership and shall represent each of the following full-time employee categories: Faculty, Professional and Support Staff, Classified Staff and Service Staff.
If a Committee member feels he/she cannot perform impartially because of a conflict of interest, or the appearance thereof, in a particular case, he/she may ask to be replaced during the specific case. If the claimant feels a Committee member cannot serve impartially, he/she may request that such a member be excused from the Committee and a replacement be designated from the Insurance Committee membership.
Adequate time for completion of the activities prescribed within each step of this procedure is provided. However, the process should proceed as expeditiously as possible.
If a complaint is not filed within the time limits set forth, the claimant shall forfeit the right to challenge the insurance settlement in question; and the complaint shall not be processed further through the appeal procedure.
Time limits for each step in the procedure may be extended by mutual written agreement of the parties involved. The term “working days” shall mean the days Monday through Friday, inclusive, exclusive of holidays.
Informal Complaint Resolution
Step 1: Questions and complaints regarding the initial settlement of an insurance claim shall be directed to Consociate, Inc., or the College’s designated third-party claim administrator, which will attempt to resolve misunderstandings or misapplication problems to the mutual satisfaction of all parties.
Step 2: If informal discussions with the Consociate, Inc. representative do not resolve the problem, the claimant shall contact the College’s designated insurance administrator who, in turn, shall attempt to resolve the case. If the complaint is not resolved, the claimant may proceed to the formal appeal process.
Formal Complaint Resolution
Step 1: Within sixty (60) days after receipt of Consociate, Inc.’s explanation of benefits worksheet
summarizing the disposition of the insurance claim in question, the Plan enrollee, spouse or estate executor shall submit a completed copy of the Insurance Claim Complaint Form (Attachment A) to the College’s designated insurance administrator. The form shall contain:
- The name of the claimant;
- A concise statement describing the nature of the complaint;
- A general explanation of the relevant facts which form the basis for the complaint, including copies of itemized bills, benefit explanations on which claims were denied and reasons the claimant feels there has been a misinterpretation or misapplication of specific benefits described in the Plan Description;
- A statement about the resolution sought;
- An account of any attempts made to resolve the problem through regular claim channels;
- The signature of the claimant; and
- The date on which the Complaint Form was submitted to the College’s insurance administrator.
Step 2: Within five (5) working days of receipt of the Complaint Form, the insurance administrator shall notify the Chairperson of the Insurance Appeal Advisory Committee about the complaint. The insurance administrator shall submit to the Committee Chairperson a copy of the claimant’s completed Complaint Form and supporting documentation together with a written rationale for the original disposition of the insurance claim.
Within five (5) working days, the Committee Chairperson shall distribute copies of these documents to Committee members for review. The Committee may request from either party further information which is deemed necessary, proper and/or relevant to the complaint.
Step 3: Within ten (10) working days of receipt of all related documentation, the Committee shall be convened and shall conduct other meetings as necessary in order to reach a decision, making every effort to complete its hearings within five (5) working days from the time it was convened. The Committee shall review the facts and issues presented to it in relation to specific benefits described in the College’s Health Care Plan Description and shall make a recommendation in writing to the President of the College regarding disposition of the complaint.
The Chairperson of the Committee shall submit the Committee’s findings and recommendations to the President within five (5) working days after completion of the Committee’s hearings of the complaint.
Step 4: Within fifteen (15) calendar days of receipt of the Committee’s recommendation, the President (or his/her designee), who may elect to endorse, reject or modify the recommendation, shall prepare and send a written explanation of the decision on the matter to the claimant, to the insurance administrator and to the Chairperson of the Insurance Appeal Advisory Committee. The decision of the President (or his/her designee) shall be final.
External Review Process
The Federal external review process does not apply to a denial, reduction, termination, or a failure to provide payment for a benefit based on a determination that a Claimant or beneficiary fails to meet the requirements for eligibility under the terms of a group health plan.
The Federal external review process, in accordance with the current Affordable Care Act regulations, applies only to:
- Any eligible Adverse Benefit Determination (including a Final Internal Adverse Benefit Determination) by a plan or issuer that involves medical judgment (including, but not limited to, those based on the plan’s or issuer’s requirements for Medical Necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit; or its determination that a treatment is Experimental or Investigational), as determined by the external reviewer.
- A rescission of coverage (whether or not the rescission has any effect on any particular benefit at that time).
Standard external review
Standard external review is an external review that is not considered expedited (as described in the “expedited external review” paragraph in this section).
- Request for external review: The Plan will allow a Claimant to file a request for an external review with the Plan if the request is filed within four months after the date of receipt of a notice of an Adverse Benefit Determination or Final Internal Adverse Benefit Determination. If there is no corresponding date four months after the date of receipt of such a notice, then the request must be filed by the first day of the fifth month following the receipt of the notice. For example, if the date of receipt of the notice is October 30, because there is no February 30, the request must be filed by March 1. If the last filing date would fall on a Saturday, Sunday, or Federal holiday, the last filing date is extended to the next day that is not a Saturday, Sunday, or Federal holiday.
- Preliminary review: Within five business days following the date of receipt of the external review request, the Plan will complete a preliminary review of the request to determine whether:
- The Claimant is or was covered under the Plan at the time the health care item or service was requested or, in the case of a retrospective review, was covered under the Plan at the time the health care item or service was provided.
- The Adverse Benefit Determination or the Final Internal Adverse Benefit Determination does not relate to the Claimant’s failure to meet the requirements for eligibility under the terms of the Plan (e.g., worker classification or similar determination).
- The Claimant has exhausted the Plan’s internal appeal process unless the Claimant is not required to exhaust the internal appeals process under the final regulations.
- The Claimant has provided all the information and forms required to process an external review. Within one business day after completion of the preliminary review, the Plan will issue a notification in writing to the Claimant. If the request is complete but not eligible for external review, such notification will include the reasons for its ineligibility and contact information for the Employee Benefits Security Administration (toll-free number 866-444- EBSA (3272)). If the request is not complete, such notification will describe the information or materials needed to make the request complete and the Plan will allow a Claimant to perfect the request for external review within the four-month filing period or within the 48 hour period following the receipt of the notification, whichever is later.
- Referral to Independent Review Organization: The Plan will assign an independent review organization (IRO) that is accredited by URAC or by a similar nationally-recognized accrediting organization to conduct the external review. Moreover, the Plan will take action against bias and to ensure independence. Accordingly, the Plan will contract with (or direct the Third Party Administrator to contract with, on its behalf) at least three IROs for assignments under the Plan and rotate claims assignments among them (or incorporate other independent unbiased methods for selection of IROs, such as random selection). In addition, the IRO may not be eligible for any financial incentives based on the likelihood that the IRO will support the denial of benefits.
- Reversal of Plan’s decision: Upon receipt of a notice of a final external review decision reversing the Adverse Benefit Determination or Final Internal Adverse Benefit Determination, the Plan will provide coverage or payment for the claim without delay, regardless of whether the plan intends to seek judicial review of the external review decision and unless or until there is a judicial decision otherwise.
Expedited external review
- Request for expedited external review: The Plan will allow a Claimant to make a request for an expedited external review with the Plan at the time the Claimant receives:
- An Adverse Benefit Determination if the Adverse Benefit Determination involves a medical condition of the Claimant for which the timeframe for completion of a standard internal appeal under the final regulations would seriously jeopardize the life or health of the Claimant or would jeopardize the Claimant’s ability to regain maximum function and the Claimant has filed a request for an expedited internal appeal.
- A Final Internal Adverse Benefit Determination, if the Claimant has a medical condition where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the Claimant or would jeopardize the Claimant’s ability to regain maximum function, or if the Final Internal Adverse Benefit Determination concerns an admission, availability of care, continued stay, or health care item or service for which the Claimant received Emergency Services, but has not been discharged from a facility.
- Preliminary review: Immediately upon receipt of the request for expedited external review, the Plan will determine whether the request meets the reviewability requirements set forth above for standard external review. The Plan will immediately send a notice that meets the requirements set forth above for standard external review to the Claimant of its eligibility determination.
- Referral to Independent Review Organization: Upon a determination that a request is eligible for external review following the preliminary review, the Plan will assign an IRO pursuant to the requirements set forth above for standard review. The Plan will provide or transmit all necessary documents and information considered in making the Adverse Benefit Determination or Final Internal Adverse Benefit Determination to the assigned IRO electronically or by telephone or facsimile or any other available expeditious method. The assigned IRO, to the extent the information or documents are available and the IRO considers them appropriate, will consider the information or documents described above under the procedures for standard review. In reaching a decision, the assigned IRO will review the claim de novo and is not bound by any decisions or conclusions reached during the Plan’s internal claims and appeals process.
- Notice of final external review decision: The Plan’s (or Third Party Administrator’s) contract with the assigned IRO will require the IRO to provide notice of the final external review decision, in accordance with the requirements set forth above, as expeditiously as the Claimant’s medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request for an expedited external review. If the notice is not in writing, within 48 hours after the date of providing that notice, the assigned IRO will provide written confirmation of the decision to the Claimant and the Plan.
Appointment of Authorized Representative
A Claimant may designate another individual to be an authorized representative and act on his or her behalf and communicate with the Plan with respect to a specific benefit claim or appeal of a denial. This authorization must be in writing, signed and dated by the Claimant, and include all the information required in the authorized representative form. The appropriate form can be obtained from the Plan Administrator or the Third Party Administrator.
The Plan will permit, in a medically urgent situation, such as a claim involving Urgent Care, a Claimant’s treating health care practitioner to act as the Claimant’s authorized representative without completion of the authorized representative form.
Should a Claimant designate an authorized representative, all future communications from the Plan will be conducted with the authorized representative instead of the Claimant, unless the Plan Administrator is otherwise notified in writing by the Claimant. A Claimant can revoke the authorized representative at any time. A Claimant may authorize only one person as an authorized representative at a time.
Recognition as an authorized representative is completely separate from a Provider accepting an assignment of benefits, requiring a release of information, or requesting completion a similar form. An assignment of benefits by a Claimant shall not be recognized as a designation of the Provider as an authorized representative. Assignment and its limitations under this Plan are described below.
Upon receipt of a claim for a deceased Claimant for any condition, Sickness, or Injury is the basis of such claim, the Plan maintains the right to request an autopsy be performed upon said Claimant. The request for an autopsy may be exercised only where not prohibited by any applicable law.
Payment of Benefits
Where benefit payments are allowable in accordance with the terms of this Plan, payment shall be made in U.S. Dollars (unless otherwise agreed upon by the Plan Administrator). Payment shall be made, in the Plan Administrator’s discretion, to an assignee of an assignment of benefits, but in any instance may alternatively be made to the Claimant, on whose behalf payment is made and who is the recipient of the services for which payment is being made. Should the Claimant be deceased, payment shall be made to the Claimant’s heir, assign, agent or estate (in accordance with written instructions), or, if there is no such arrangement and in the Plan Administrator’s discretion, the institute and/or Provider who provided the care and/or supplies for which payment is to be made – regardless of whether an assignment of benefits occurred.
For this purpose, the term “Assignment of Benefits” (or “AOB”) is defined as an arrangement whereby a Participant of the Plan, at the discretion of the Plan Administrator, assigns its right to seek and receive payment of eligible Plan benefits, less Deductible, Copayments and Coinsurance amounts, to a medical Provider. If a Provider accepts said arrangement, the Provider’s rights to receive Plan benefits are equal to those of the Participant, and are limited by the terms of this Plan Document. A Provider that accepts this arrangement indicates acceptance of an AOB and Deductibles, Copayments, and Coinsurance amounts, as consideration in full for treatment rendered.
The Plan Administrator may revoke an AOB at its discretion and treat the Participant of the Plan as the sole beneficiary. Benefits for medical expenses covered under this Plan may be assigned by a Participant to the Provider as consideration in full for services rendered; however, if those benefits are paid directly to the Participant, the Plan will be deemed to have fulfilled its obligations with respect to such benefits. The Plan will not be responsible for determining whether any such assignment is valid. Payment of benefits which have been assigned may be made directly to the assignee unless a written request not to honor the assignment, signed by the Participant, has been received before the proof of loss is submitted, or the Plan Administrator – at its discretion – revokes the assignment.
No Participant shall at any time, either during the time in which he or she is a Participant in the Plan, or following his or her termination as a Participant, in any manner, have any right to assign his or her right to sue to recover benefits under the Plan, to enforce rights due under the Plan or to any other causes of action which he or she may have against the Plan or its fiduciaries. A medical Provider which accepts an AOB does as consideration in full for services rendered and is bound by the rules and provisions set forth within the terms of this document.
Non U.S. Providers
A Provider of medical care, supplies, or services, whose primary facility, principal place of business or address for payment is located outside the United States shall be deemed to be a “Non U.S. Provider.” Claims for medical care, supplies, or services provided by a Non U.S. Provider and/or that are rendered outside the United States of America, may be deemed to be payable under the Plan by the Plan Administrator, subject to all Plan Exclusions, limitations, maximums and other provisions. Assignment of benefits to a Non U.S. Provider is prohibited absent an explicit written waiver executed by the Plan Administrator. If assignment of benefits is not authorized, the Claimant is responsible for making all payments to Non U.S. Providers, and is solely responsible for subsequent submission of proof of payment to the Plan. Only upon receipt of such proof of payment, and any other documentation needed by the Plan Administrator to process the claims in accordance with the terms of the Plan, shall reimbursement by the Plan to the Claimant be made. If payment was made by the Claimant in U.S. currency (American dollars), the maximum reimbursable amount by the Plan to the Claimant shall be that amount. If payment was made by the Claimant using any currency other than U.S. currency (American dollars), the Plan shall utilize an exchange rate in effect on the Incurred date as established by a recognized and licensed entity authorized to so establish said exchange rates. The Non U.S. Provider shall be subject to, and shall act in compliance with, all U.S. and other applicable licensing requirements; and claims for benefits must be submitted to the Plan in English.
Recovery of Payments
Occasionally, benefits are paid more than once, are paid based upon improper billing or a misstatement in a proof of loss or enrollment information, are not paid according to the Plan’s terms, conditions, limitations or Exclusions, or should otherwise not have been paid by the Plan. As such this Plan may pay benefits that are later found to be greater than the Maximum Allowable Charge. In this case, this Plan may recover the amount of the overpayment from the source to which it was paid, primary payers, or from the party on whose behalf the charge(s) were paid. As such, whenever the Plan pays benefits exceeding the amount of benefits payable under the terms of the Plan, the Plan Administrator has the right to recover any such erroneous payment directly from the person or entity who received such payment and/or from other payers and/or the Claimant or Dependent on whose behalf such payment was made.
A Claimant, Dependent, Provider, another benefit plan, insurer, or any other person or entity who receives a payment exceeding the amount of benefits payable under the terms of the Plan or on whose behalf such payment was made, shall return or refund the amount of such erroneous payment to the Plan within 30 days of discovery or demand. The Plan Administrator shall have no obligation to secure payment for the expense for which the erroneous payment was made or to which it was applied.
The person or entity receiving an erroneous payment may not apply such payment to another expense. The Plan Administrator shall have the sole discretion to choose who will repay the Plan for an erroneous payment and whether such payment shall be reimbursed in a lump sum. When a Claimant or other entity does not comply with the provisions of this section, the Plan Administrator shall have the authority, in its sole discretion, to deny payment of any claims for benefits by the Claimant and to deny or reduce future benefits payable (including payment of future benefits for other injuries or Illnesses) under the Plan by the amount due as reimbursement to the Plan. The Plan Administrator may also, in its sole discretion, deny or reduce future benefits (including future benefits for other injuries or Illnesses) under any other group benefits plan maintained by the Plan Sponsor. The reductions will equal the amount of the required reimbursement.
Providers and any other person or entity accepting payment from the Plan or to whom a right to benefits has been assigned, in consideration of services rendered, payments and/or rights, agrees to be bound by the terms of this Plan and agree to submit claims for reimbursement in strict accordance with their State’s health care practice acts, ICD or CPT standards, Medicare guidelines, HCPCS standards, or other standards approved by the Plan Administrator or insurer. Any payments made on claims for reimbursement not in accordance with the above provisions shall be repaid to the Plan within 30 days of discovery or demand or incur prejudgment interest of 1.5% per month. If the Plan must bring an action against a Claimant, Provider or other person or entity to enforce the provisions of this section, then that Claimant, Provider or other person or entity agrees to pay the Plan’s attorneys’ fees and costs, regardless of the action’s outcome.
Further, Claimant and/or their Dependents, beneficiaries, estate, heirs, guardian, personal representative, or assigns (Claimants) shall assign or be deemed to have assigned to the Plan their right to recover said payments made by the Plan, from any other party and/or recovery for which the Claimant(s) are entitled, for or in relation to facility-acquired condition(s), Provider error(s), or damages arising from another party’s act or omission for which the Plan has not already been refunded.
The Plan reserves the right to deduct from any benefits properly payable under this Plan the amount of any payment which has been made for any of the following circumstances:
- In error.
- Pursuant to a misstatement contained in a proof of loss or a fraudulent act.
- Pursuant to a misstatement made to obtain coverage under this Plan within two years after the date
such coverage commences.
- With respect to an ineligible person.
- In anticipation of obtaining a recovery if a Claimant fails to comply with the Plan’s Third Party
Recovery, Subrogation and Reimbursement provisions.
- Pursuant to a claim for which benefits are recoverable under any policy or act of law providing for
coverage for occupational injury or disease to the extent that such benefits are recovered. This provision (6) shall not be deemed to require the Plan to pay benefits under this Plan in any such instance.
The deduction may be made against any claim for benefits under this Plan by a Claimant or by any of his covered Dependents if such payment is made with respect to the Claimant or any person covered or asserting coverage as a Dependent of the Claimant.
If the Plan seeks to recoup funds from a Provider, due to a claim being made in error, a claim being fraudulent on the part of the Provider, and/or the claim that is the result of the Provider’s misstatement, said Provider shall, as part of its assignment to benefits from the Plan, abstain from billing the Claimant for any outstanding amount(s).
A Claimant’s eligibility for any State Medicaid benefits will not be taken into account in determining or making any payments for benefits to or on behalf of such Claimant. Any such benefit payments will be subject to the State’s right to reimbursement for benefits it has paid on behalf of the Claimant, as required by the State Medicaid program; and the Plan will honor any Subrogation rights the State may have with respect to benefits which are payable under the Plan.
Limitation of Action
A Claimant cannot bring any legal action against the Plan for a claim of benefits until 90 days after all appeal processes have been exhausted. After 90 days, if the Claimant wants to bring a legal action against the Plan, he or she must do so within three years of the date he or she is notified of the final decision on the final appeal or he or she will lose any rights to bring such an action against the Plan.