Contracts & Agreements_211-2002 - Laserfiche WebLink

Home Browse Search

Effective January 1, 2003 the Plan Document for CITY OF REDLANDS Group Dental Plan is amended to reflect the following changes: Delete the CLAIMS PROCEDURES section in its entirety and replace it with: It is the intent of the Plan Administrator that the following claims procedures comply with the United States Department of Labor ("DOL") regulation , 29 CFR § 2560.503-1, and the Employee Retirement Income Security Act of 1974, as amended ("ERISA"). Where any provision is in conflict with the DOL's claims procedure regulations, ERISA, or any or any other applicable law, such law shall control. SUBMITTING A CLAIM A claim is a request for benefit determination made, in accordance with the Plan's procedures, by a Claimant or his authorized representative. A claim must be received by the person or organizational unit customarily responsible for handling benefit matters on behalf of the Plan so that the claim review and benefit determination process can begin. A claim must name the Plan, a specific Claimant, a specific health condition or symptom or diagnostic code, and a specific treatment, service or supply (or procedure/ revenue codes) for which a benefit or benefit determination is requested, the date of service, the amount of charges, the address (location) where services are received, and provider name, address, phone number and tax identification number. For purposes of the Plan, the Plan Administrator, at its discretion, may contract with other entities to handle claims communications and benefit determinations for the Plan. Such other entities may include an insurance company, a '-third party claims payer, a managed care organization, or a pharmacy benefit manager. Contact information for such entities is provided below. There are two types of claims: (1) Pre -Service Claims, and (2) Post -Service Claims: 1). A Pre -Service Claim is a written or oral request for benefit determination where the terms of the Plan condition benefits, in whole or in part, on prior approval of the proposed care (e.g., a dental pre-treatment review requirement), Important: A benefit determination for a Pre -Service Claim shall only be for the purposes of assessing the Medical Necessity and appropriateness of care and delivery setting. A benefit determination for a Pre -Service Claim is not a guarantee of benefits from the Plan. Plan benefit payments are subject to review upon submission of a claim to the Plan after dental services have been received, and are subject to all related Plan provisions, including exclusions and limitations. Further, where the Plan does not require prior approval, a request for advance information on the Plan's possible coverage of an item • service, or advance approval of a covered item or service, does not constitute a Pre - Service Claim. Citv of Redlands