The Claims Manager shall process all claims for benefits in accordance with the terms of the Fund’s Plan Documents. This includes:
- Verifying the participant’s eligibility and enrollment.
- Making an initial determination whether the claim is covered by the Plan.
- Arranging for medical reviews of submitted claims, where appropriate.
- Preparing and distributing payments for covered claims
- When appropriate the Claims Manager shall make its best efforts to coordinate with physicians, hospitals and other providers or facilities in order to obtain discounts.
- Preparing and sending explanations of benefits and/or claims denial notices.
The Claims Manager shall:
- Maintain files for all level 2 appeals of denied claims for benefits, but only if the Fund specifically delegates the responsibility to perform such services to the Claims Manager.
- If the Fund specifically delegates this responsibility to the Claims Manager the Claims Manager shall determine any initial appeals of denied benefits according to the procedure provided in the Plan and Summary Plan Description.
- The Claims Manager shall assist in the investigations of disputed claims and provide all documentation to the Fund Trustees that they require to decide the final internal appeals of denied participant benefit claims in accordance with the Plan document and 29 CFR 2560.503-1.
- Notify participants of Trustee decisions within the time required by federal law.
- Assist the Fund and the Fund’s counsel at hearings or other legal proceedings regarding denied claims.
In order to assist the Fund in providing valuable customer service to Plan Participants, the Claims Manager shall:
- Maintain hours of operation reasonably consistent with Fund practices.
- Maintain staff levels sufficient to perform all services described in this Agreement and process participant claims in advance of statutory and regulatory deadlines.
- If the Fund specifically delegates this responsibility to the Claims Manager the Claims Manager shall handle provider and participant inquiries concerning coverage that are sent by phone, mail, fax, and by e-mail.
- Respond to appropriate participant requests for Fund documents that are related to claims and the claim appeals process, which are required to be furnished to participants within certain statutory time limitations, in accordance with Federal law.
- Maintain the ability to communicate with participants in Spanish.
The Claims Manager shall:
- Maintain files documenting the eligibility and claim history of each Fund participant.
- Maintain files for all pending subrogation and reimbursement claims identified by the Trust Fund and in accordance with its subrogation policies and procedures.
- Report, on a monthly basis a list of all: (a) claims processed (b) payments issued; and (c) claim settlements based on participant and/or dependent coverage.
- Report, on a quarterly basis, the Fund’s utilization rate. This report shall be prepared in cooperation with the providers of service for the Fund.
- Produce: (a) 1099 Statements at year end; (b) information necessary for the filing of Form 5500 or other governmental filings; and (c) Utilization reports as requested by the Trustees, provided that the Claims Manager may, in unusual circumstances, need to consult with the Fund Trustees and Fund counsel regarding these tax forms.