If your claim has been denied, in whole or in part, you have a right to request a review of the adverse determination. Such a request must be made in writing within 180 days of receipt of your Explanation of Benefits (EOB) and be sent to UMWA Health and Retirement Funds, Attention: Appeals Department, PO Box 292167, Nashville, TN 37229. All requests for review must state the basis for your request and include your name and Funds’ beneficiary number beginning with UM0, and any additional documentation or information you would like the Funds to consider. The Funds will gather any necessary medical information. You may have someone else, such as a relative, file an appeal on your behalf. We will send the necessary information to you so you may give your written and dated permission for someone to act on your behalf.
On review, you will receive a full and fair review of your claim by someone other than the person who initially made the adverse benefit determination or that person’s subordinate. If denial of your claim is based, in whole or in part, on a medical judgment, a health care professional with appropriate training and experience will be consulted. You will be notified of the Funds’ appeal decision not later than 30 days after receipt of your request for review. You have the right to request copies of all documents, records, and other information we used in evaluating your claim, at no cost to you. If an internal rule, guideline or other similar criterion was relied upon in making the adverse benefit determination, we will provide you with a copy of the rule, guideline or criterion free of charge, upon request. If an adverse benefit determination was made based on a lack of medical necessity or due to an experimental treatment or other similar exclusion or limit, we will provide an explanation of the scientific or clinical judgment for the adverse benefit determination free of charge, upon request. We will also disclose the name of medical professionals or vocational experts whose advice we obtained, whether or not we relied on that advice in reaching our benefits determination.
You will be notified of the Funds’ decision on appeal not later than 30 days after receipt of your initial request for review. If you disagree with the Funds’ decision on review, you have a right to a second appeal. On a second level review, we will make a determination within 15 days of the receipt of the second level pre-service appeal request and within 30 days of the receipt of the second level post-service appeal request. You may bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974, following a final adverse decision. If you need help with your appeal, you can contact the Funds’ Call Center at 1-800-291-1425, the Area Agency on Aging, the Insurance Counseling and Assistance Program or the Medicare Rights Center toll-free at 1-888-466-9050.
