Health Summary Plan Description

Claim Appeal Procedures

As of January 1, 2016, ValueOptions is now Beacon Health Options. For more information, please see the Winter 2015 Take 2.

The Health Plan Trustees are authorized and empowered to construe the meaning of any doubtful or ambiguous provisions of the Health Plan, and any construction thereof adopted by the Health Plan Trustees in good faith shall be binding upon SAG-AFTRA, the Producers, the participants and all beneficiaries.

The Health Plan Trustees are authorized and empowered to decide on a participant's entitlement to or application for benefits under the Health Plan, and any such decision of the Health Plan Trustees shall be final and binding upon all affected parties, except where federal law allows for an external appeal to an Independent Review Organization (IRO).

The Health Plan Trustees are authorized and empowered generally to do all things, execute all such agreements, adopt and promulgate all such reasonable rules and regulations, take all such proceedings and exercise all such rights and privileges as are necessary in the establishment, maintenance and administration of the Health Plan.

Eligibility, Life Insurance and AD&D Appeals

If your claim for Health Plan eligibility or for life insurance or AD&D benefits is denied in whole or in part, you will be notified, in writing, within 90 days of receipt of your claim. In some instances, an additional 90 days may be required for study. If additional time or information is needed you will be notified in writing of the reasons. In no case will the extension exceed 180 days from the date your claim was received.

The notice of determination will contain specific reasons for the determination and a specific reference to the provisions of the Plan or policy on which the determination is based.

If you have not been notified of action taken on your claim within the 180-day period, you may treat the claim as having been denied and may make an appeal in the following ways:

  • Administrative Review of a Determination to Deny. If your claim was denied and you have additional medical or other information, you may request an administrative review. Your request must be submitted in writing to the Chief Executive Officer within 60 days of the denial of the claim, and accompanied by the additional medical or other information upon which you rely.
  • Appeal of a Determination to Deny. If you have no additional medical or other information or you feel the claim has been incorrectly denied, initially or after administrative review as outlined above, you may appeal to the Benefit Appeals Committee of the Board of Trustees. An appeal to the Benefit Appeals Committee must be submitted in writing to the Chief Executive Officer within 60 days of the initial denial of the claim or 60 days of the administrative review denial, whichever is later, and accompanied by a statement giving the reasons the denial is believed to be incorrect.

A determination by the Chief Executive Officer on an administrative review or by the Benefit Appeals Committee on an appeal shall be made within 60 days after the receipt of the request. An additional 60 days may be required for special study. However, the determination will be made no later than 120 days after your request is received. The notice of the determination will contain specific reasons for the determination and a specific reference to the provisions of the Health Plan on which the determination is based.

If you have not been notified of action taken on your appeal within the 120-day period, you may treat the appeal as having been denied and may initiate a lawsuit as described under the heading "Statement Of ERISA Rights" on pages 102 and 103.

Health, Disability and Retroactive Removal of Coverage Appeals

If your health claim or Disability Claim is denied in whole or in part, you may ask for a review. You may also request a review if the Plan has retroactively removed your health coverage. In accordance with federal law, the Plan provides both an internal and external appeals process; however, the external appeals process is only available in certain circumstances. Please see page 92 for additional information.

Under the internal process, your claim determination notice will tell you where to send an appeal. If your denied claim is for hospital or medical benefits, or for coverage under the Total Disability Extension, you may appeal one time to the Benefit Appeals Committee of the Board of Trustees. You may also appeal to the Benefit Appeals Committee if your health coverage
was retroactively removed.

If your denied claim is for another type of benefit there are two levels of internal appeal. The first is to the appropriate carrier listed below. If your claim is denied after the first review you may file a second appeal with the Benefit Appeals Committee.

Benefit Company
Dental Delta Dental
Hospital/Medical Utilization Management Review Anthem Blue Cross
Life Insurance Premium Waiver MetLife
Mental Health and Substance Abuse ValueOptions
Prescription Drug Express Scripts
Vision Vision Service Plan

Your initial request for review must be made in writing within 180 days after you receive notice of the denial. Specific information on how to file an appeal with these carriers is contained in their claim denial notices.

Appeals involving Urgent Care Claims may be made verbally by calling one of the following numbers:

Urgent Care Appeals
Benefit Company
Phone Number
Hospital Anthem Blue Cross (800) 274-7767
Mental Health and Substance Abuse ValueOptions (866) 277-5383
Prescription Drugs – Clinical Appeals Express Scripts (800) 864-1135
All Other Benefits Health Plan Office (818) 954-9400 or
(800) 777-4013

If your appeal is for a Concurrent Care Claim, the Plan will provide continued coverage for the course of treatment during the appeal process.

Internal Appeal Process

You have the right to review documents relevant to your claim and will be provided with any new material considered during the appeal.

Your appeal will be reviewed by someone other than the person who originally denied the claim. The determination will be made on the basis of the record, including any additional documents and comments submitted by you. If your claim was denied on the basis of a medical judgment, such as lack of medical necessity, a health care professional with appropriate training and experience in a relevant field of medicine will be consulted. Any such health care professional shall not be an individual who was consulted in connection with the claim denial, nor a subordinate of any such individual.

Notice of Determination on Internal Appeal

The table below outlines the timing for the internal appeal determination.

The Plan may waive the internal appeal process and proceed to the expedited external review procedures if your attending provider determines that your appeal is urgent because it involves a medical condition for which the time period for completion of the appeal would seriously jeopardize your life or health, or your ability to regain maximum function.

The determination on any review of your claim will be given to you in writing. If the internal appeal is denied, the notice will explain the reason for the determination as described in items 1, 4, 5 and 6 under "Notice of Determination" on pages 87 and 88. 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.

  Health Claims Disability Claims
Appeals Procedures for Denied Claims Pre-Service Urgent Care Post-Service (including Retroactive Removal of Coverage)  
How much time do I have to appeal? 180 days. 180 days. 180 days. 180 days.
How may I make the appeal? Anthem – Verbally or in writing.

All other – In writing.
Verbally or in writing. In writing. In writing.
How long does the Plan have to make a determination on my appeal? One level - 30 days.

Two levels - 15 days for each level.
One level only - 72 hours. One level - Usually appeals will be decided at the next Benefit Appeals Committee meeting.* You will be notified within 5 days of the determination.

Two levels - 30 days for each level.
One level - Usually appeals will be decided at the next Benefit Appeals Committee meeting.* You will be notified within 5 days of the determination.

Two levels - 30 days for each level.

* If your internal appeal is received within 30 days of the next regularly scheduled Benefit Appeals Committee meeting, it will be considered at the second regularly scheduled meeting following receipt of your request. In special circumstances a delay until the third regularly scheduled meeting following receipt of your internal appeal may be necessary.

External Review Process

Please note: External review is not available for every claim denial or internal appeal denial.

If your internal appeal is denied, you may file a request for external review with the Plan. As of July 1, 2013 the external review process is only available under the circumstances outlined below. The Plan will accept claims for external review in accordance with federal law.

  • The initial claim denial or internal appeal denial involved medical judgment. Examples include determinations of medical necessity, appropriateness, health care setting, level of care and experimental or investigational status.
  • Your health coverage was retroactively removed, unless this occurred because you did not meet the Health Plan's eligibility requirements. Retroactive removal of coverage due to eligibility reasons is not eligible for external review.

Preliminary Review. The Plan will complete a preliminary review of the request. In addition, to the requirements outlined above, all of the following factors must be met:

  1. For Pre-Service and Urgent Care Claims you were covered under the Plan at the time the health care item, service, or other benefit was requested. For Post-Service Claims, you were covered under the Plan at the time the health care item, service, or other benefit was provided.
  2. The initial claim denial or the internal appeal denial do not relate to the failure to meet the Plan's eligibility requirements.
  3. You have exhausted the Plan's internal appeal process unless not required to do so under federal law or in accordance with a request for an expedited external review.
  4. You have submitted a completed External Appeals Form.

Notice of Preliminary Review. The Plan will issue a written notice after completion of the preliminary review. If your internal appeal denial is not eligible for external review, the notice will include the reasons for its ineligibility and contact information for the Employee Benefits Security Administration. If your request for external review is not complete, the notice will describe the information or materials needed to make it complete.

The table below outlines the timing for the preliminary external review steps.

External Review Step Responsible Party Time to Complete
Request external review Patient* 4 months after receipt of internal appeal denial.
Preliminary review Plan 5 business days after receipt of request.
Notice of preliminary review decision Plan 1 business day after making decision.
Provide additional information for external review request Patient* The later of:
  • The end of the 4-month filing period; or
  • 48 hours following receipt of notice of preliminary review decision.

* The patient's authorized representative may complete these steps.

Assignment to IRO. In accordance with federal law, the Plan will assign an accredited IRO to conduct the external review. The IRO will notify you, in writing when they receive the external review request. This notice will include a statement that you may submit additional information in writing for the IRO to consider. The information should be submitted within 10 business days of receiving the notice. The IRO may accept and consider additional information submitted after 10 business days but it is not required to do so.

The Plan will provide the IRO any documents and information used in denying the claim or denying the internal appeal within five business days after the external review is assigned to the IRO. If the Plan fails to do so, the IRO may terminate the external review and make a decision to reverse the denial. Within one business day after making such decision, the IRO must notify you and the Plan.

Upon receipt of any information submitted by you in connection to the external review, the IRO will forward it to the Plan within one business day. Upon receipt, the Plan may reconsider its claim denial or internal appeal denial. The Plan will provide written notice to you and the IRO if it reverses its previous decision within one business day of such reversal. Thereafter the IRO will terminate the external review proceedings.

External Review Decision. The IRO will review all information and documents timely received and use experts where appropriate to make coverage determinations under the Plan. The IRO is not bound by any decisions or conclusions reached during the initial benefit denial or the internal appeal. In addition to the documents and information provided, the IRO will consider the following, as it determines appropriate, when making its decision:

  • Your medical records.
  • The attending health care professional's recommendation.
  • Reports from appropriate health care professionals and other documents submitted by the Plan, you or your treating provider(s).
  • The terms of the Plan (unless contrary to applicable law).
  • Appropriate medical practice guidelines, including evidence-based standards.
  • Any applicable clinical review criteria developed and used by the Plan (unless contrary to the Plan or applicable law).
  • The opinion of the IRO's clinical reviewer.

The IRO will provide written notice of the final external review decision to you and the Plan within 45 days after the IRO receives the external review request. Such notice will include: (i) an explanation of the primary reason(s) for the IRO's decision, (ii) references to the evidence or documentation considered in reaching the decision, including the rationale for the decision and any evidence-based standards that were relied on in making the decision, (iii) the binding effect of the decision with a statement that judicial review may be available to you, and (iv) current contact information for any applicable office of health insurance consumer assistance or ombudsman.

Expedited External Review. Expedited external review is available for the following cases:

  • You or your dependent has a medical condition for which the time period for completion of the standard external review would seriously jeopardize your or your dependent's life, health or ability to regain maximum function, as determined by your attending provider; or
  • The internal appeal denial concerns an admission, availability of care, continued stay, or health care item, service, or other benefit for which you or your dependent received emergency services, but have not been discharged from a provider's facility.

You must file a request for expedited external review. The request should be filed with the following vendors:

Expedited External Review
Benefit Company Phone Number
Hospital Anthem Blue Cross (800) 274-7767
Mental Health and Substance Abuse ValueOptions (866) 277-5383
Prescription Drugs Express Scripts (800) 864-1135
All Other Benefits Health Plan Office (818) 954-9400 or
(800) 777-4013

Upon receipt of the request the preliminary review will be performed as soon as possible without regard to the five business days. A notice of determination will be sent as soon as the preliminary review is completed.

If the request is eligible for expedited external review, the Plan or its designee shall assign an IRO in accordance with the external review procedures and transmit or provide all required documents and information electronically or by telephone or facsimile or by any other available expeditious method.

The IRO must provide its final external review decision in accordance with the external review standards described previously and provide notice of such decision as expeditiously as you or your dependent's medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request.

Reversal of Denial. In the event the claim denial or the internal appeal denial is reversed by the Plan, its designee or the IRO, the Plan will provide coverage or payment for the claim in accordance with applicable law and regulations, but reserves the right to pursue judicial review or other remedies available or that may become available to the Plan under applicable law and regulations.

90 Day Limitation on When a Lawsuit May Be Filed

You may file a lawsuit to obtain benefits after you have exhausted the internal review process and the external review process if applicable, and a final decision has been reached. You may also file a lawsuit if the Plan or IRO does not reach a decision, or notify you that an extension is necessary within the appropriate time periods described previously.

A lawsuit may not be filed more than 90 days after the earlier of: (i) the date you receive the Plan's or IRO's written decision on your appeal, or (ii) the end of the appeals and extension time periods described previously.