• SPD Table of Contents
  1. Introduction
  2. Plan A - Schedule of Benefits
  3. Plan B - Schedule of Benefits
  4. Plan C - Schedule of Benefits
  5. Plan 11 - Schedule of Benefits
  6. Plan 11-C - Schedule of Benefits
  7. Plan 14 - Schedule of Benefits
  8. Eligibility for Active Participants
  9. Eligibility for Retiree Coverage
  10. Insurance Coverage
  11. Medical Benefits
  12. Prescription Drug Program
  13. Weekly Time Loss
  14. Medicare Part D Prescription Drug Plan (PDP) for Retirees
  15. Member Assistance Program (MAP)
  16. Dental Benefit
  17. Vision Benefit
  18. Hearing Benefit
  19. Special Fund Program
  20. Union Wellness Centers
  21. General Plan Exclusions and Limitations
  22. Other Limitations on Your Benefits
  23. Definitions
  24. Claim and Appeal Procedures
  25. General Plan Provisions
  26. Information About the Plan
  27. Board of Trustees

Claim and Appeal Procedures

CLAIM FILING PROCEDURES

In order for the Plan to pay benefits, a claim must be filed with the Fund Office or the claims office designated for receiving claims in accordance with the procedures described below. A claim can be filed by the provider, you, your eligible dependent or by someone authorized to act on behalf of you or your eligible dependent.

1. A claim is considered to have been filed on the date it is received at the correct office, even if the claim is incomplete. Claims are received during regular business hours, Monday through Friday.
2. A "claim" is a request for Plan benefits, normally because the claimant has incurred a healthcare expense. A request for confirmation of Plan coverage is not a claim if you have not yet incurred the expense unless the Plan conditions payment on the receipt of prior approval. A general inquiry about eligibility or coverage when no expense has been incurred is not a claim, nor is presenting a prescription to a pharmacy.
3. Most claims must be filed before the end of the calendar year following the year in which the claim was incurred. Life and AD &D insurance claims must be filed within 90 days of the loss.
4. You may designate another person as your authorized representative for purposes of filing a claim. Except in the case of an urgent care claim, such designations must be in writing.
• Unless your authorization states otherwise, all notices regarding your claim will be sent to your authorized representative and not to you.
• A routine assignment of benefits so that the Plan will pay the provider directly is not a designation of the provider as your authorized representative. You have no right to assign any interest in your benefits or any right to recover benefits to any person, including a provider, and a provider is not a beneficiary under the Plan. All claims, internal or external appeals and judicial appeals must be brought in the name of the participant or beneficiary who incurred the claim.

WHERE TO SEND CLAIMS

Claims Offices

Medical (Hospital and Physician) Claims Most providers will automatically file their claims for you. If you use an out-of-network provider who will not submit claims to Blue Cross, send a paper claim on a standard claim form to the Fund Office.	Your local Blue Cross Blue Shield plan
When this Plan is the Secondary Payer to Another Plan Submit a copy of the other plan's explanation of benefits the Fund Office.	IBEW Local 701 Welfare Fund 28600 Bella Vista Parkway Suite 1110 Warrenville, IL 60555
Prescription Drug Claims In most cases you will not need to file prescription drug claims, but if you have a special situation, send your claim to Sav-Rx.	Sav-Rx OON Claims 224 North Park Avenue Fremont, NE 68025 Group / Plan No. IBEW701
Dental Claims Dentists can use standard dental claim forms.	Delta Dental of Illinois Attn: DDIL-Group Claims PO Box 5402 Lisle, IL 60532
Out-of-Network Vision Claims Submit itemized bills with a completed NVA claim form. Claim forms are available from NVA or the Fund Office website.	National Vision Administrators P.O. Box 2187 Clifton, NJ 07015 Plan No. 10900001
Special Fund (Program) Claims Submit itemized bills, explanations of benefits from all other plans (including this one), and a TASC claim form available from www.tasconline.com or the Fund Office.	TASC P.O. Box 7511 Madison, WI 53707
Hearing Claims Loss of Time (Disability) Benefits Life and AD &D Insurance Claims	IBEW Local 701 Welfare Fund 28600 Bella Vista Parkway Suite 1110 Warrenville, IL 60555

CLAIM PROCESSING TIME PERIODS

The amount of time the applicable Plan can take to process a claim depends on the type of claim. A claim can fall into one of the following categories:

1. A claim is "post-service" if you have already received the treatment or supply for which payment is now being requested. Most claims are post-service claims.
2. A "disability claim" is a claim for Weekly Loss of Time Benefits. It also include the retroactive termination of a disability benefit.
3. A "pre-service claim" is a request for pre-authorization of a type of treatment or supply that requires approval in advance of obtaining the care.
4. An "urgent care claim" is a pre-service claim where the application of the time periods for making non-urgent care determinations could seriously jeopardize your life, health, or ability to regain maximum function, or that could subject you to severe pain that cannot be adequately managed without the proposed treatment.
5. A "concurrent care claim" is also a type of pre-service claim. A claim is a concurrent care claim if a request is made to extend a course of treatment beyond the period of time or number of treatments previously approved.

If all the information needed to process your claim is provided to the claims office, your claim will be processed as soon as possible. However, the processing time needed will not exceed the time frames allowed by law, which are as follows:

• Post-service claims — 30 days.
• Disability claims — 45 days.
• Pre-service claims — 15 days.
6. Urgent care claims — 72 hours. Full-time supervision by at least one physician;
7. 24-hour nursing service by registered nurses;
8. Surgery or formal arrangements for available surgical facilities; and
• Therapeutic
• Concurrent care claims — 24 hours if the concurrent care is urgent and if the request for the extension if made within 24 hours prior to the end of the already authorized treatment. If the concurrent care is not urgent, then the pre-service time limits apply.

When Additional Information Is Needed (Claimant Extension)

If additional information is needed from you, your doctor or the provider, the necessary information or material will be requested in writing. If the request goes to your provider, you will receive a copy of the request. The request for additional information will be sent within the normal time limits shown above, except that the additional information needed to decide an urgent care claim will be requested within 24 hours.

It is your responsibility to see that the missing information is provided to the claims office. The normal processing period will be extended by the time it takes you to provide the information, and the time period will start to run once the claims office has received a response to its request. If you do not provide the missing information within 45 days (48 hours for an urgent care claim), the claims office will make a decision on your claim without it, and your claim could be denied as a result.

Plan Extension

The time periods above may be extended if the claims office determines that an extension is necessary due to matters beyond its control (but not including situations where it needs to request additional information from you or the provider). You will be notified prior to the expiration of the normal approval/denial time period if an extension is needed. If an extension is needed, it will not last more than:

• Post-service claims — 15 days.
• Disability claims — 30 days (a second 30-day extension may be needed in special circumstances).
• Pre-service claims — 15 days.

Claim Denials

If all or a part of your claim is denied after the claims office has received all other necessary information from you, you will be sent a written notice giving you the reasons for the denial. The notice will include reference to the Plan provisions on which the denial was based and an explanation of the claim appeal procedure. If applicable, it will give a description of any additional material or information necessary

for you to perfect the claim, and the reason such information is necessary. The notice will provide a description of the appeal procedures and the applicable time limits for following the procedures. It will also include a statement concerning your right to bring a civil action under section 502(a) of ERISA, the Plan's time limit for bringing such an action and, if applicable, the right to bring an external appeal. In cases where the Plan relied upon an internal rule, guideline, protocol or similar criterion to make its decision, the notice will state that the specific internal rule, guideline, protocol or criterion will be provided to you free of charge upon request. If the decision was based on medical necessity or if the treatment was deemed experimental, the notification will include either an explanation of the scientific or clinical judgment for the determination or a statement that such explanation will be provided free of charge upon request. For urgent claims, a description of the Plan's expedited review process will be provided.

Claim Denials for Disability Claims

In claim denials for disability claims certain additional and different items will be included in the written notice of denial. In addition to the items set forth in claim denials for non-disability claims the denial of a disability claim will include a statement regarding the rights of the claimant and an authorized representative to review pertinent documents, submit written comments and request an appearance before the Board of Trustees. Another additional item is an explanation of the basis for disagreeing with or not following the views presented by the claimant of (a) health care professionals treating the claimant and vocational professionals who evaluated the claimant, (b) the views of medical or vocational experts whose advice was obtained by the plan, without regard to whether the advice was relied upon in making the determination and (c) a Social Security disability determination presented by the claimant. With respect to a specific internal rule, guideline, protocol or criterion relied upon in making a claim, the notice shall include such items or a statement that there were no such items, rather than requiring a request for the item to be made by the claimant. With respect to decisions based on medical necessity, experimental treatment or a similar exclusion or limit, instead of the provisions applicable to other claims, 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 or a statement that such explanation will be provided free of charge upon request. The notice will be provided in a culturally and linguistically appropriate manner to the extent required under applicable law.

CLAIM APPEAL PROCEDURE

Internal Appeals

If your claim has been denied in whole or in part, you may request a full and fair review (also called an "appeal") by filing a written notice of appeal with the Plan.

1. A notice of appeal must be received at the applicable claims office not more than 180 days after you receive the written notice of denial of the claim. Your appeal is considered to have been filed on the date the written notice of appeal is received at the claims office.
2. For post-service claims and disability claims, the Review Committee will be the Board of Trustees or a committee of the Board of Trustees. Mail your written request for review to the Board of< Trustees, IBEW Local 701 Welfare Fund, Fund Office, 28600 Bella Vista Parkway, Suite 1110, Warrenville, IL 60555.
3. For all pre-service claims, the Review Committee will be the Plan's utilization review organization RhythmmAI. You may orally request a review of a denied urgent care claim by calling RhythmmAI at 1-800-991-6124, or you may submit your request to RhythmmAI at care@myrhythmm.com. RhythmmAI may notify you of its decision by telephone or facsimile. If you are not satisfied with the appeal decision made by RhythmmAI, you can request that the Board of Trustees conduct a second review of the claim.
4. The Review Committee will not include the person, or a subordinate of the person, who made the original claim denial.
5. If you wish, another person may represent you in connection with an appeal. If another person claims to be representing you in your appeal, the Review Committee has the right to require that you give the Plan a signed statement, advising the Review Committee that you have authorized that person to act on your behalf regarding your appeal. Any representation by another person will be at your own expense. You (and your authorized representative, if any) may request to appear in person before the Review Committee. If the Trustees grant your request, you and your representative's appearance must be at your own expense.
6. You or your authorized representative may review pertinent documents and may submit comments and relevant information in writing.
• Upon written request, the claims office will provide reasonable access to, and copies of, all documents, records or other information relevant to your claim.
• If the claims office obtained an opinion from a medical or vocational expert in connection with your claim, the claims office will, on written request, provide you with the name of that expert.
• The claims office will not charge you for copies of documents you request in connection with an appeal.
7. In deciding your appeal, the Review Committee will consider all comments and documents that you submit, regardless of whether that information was available at the time of the original claim denial. The review will not defer to the initial denial, and will take into account all comments, documents, records and other information submitted by you, without regard to whether such information was previously submitted or relied upon in the initial determination.
8. If an appeal involves a medical judgment, such as whether treatment is medically necessary, the Review Committee will consult with a medical professional who is qualified to offer an opinion on the issue. If a medical professional was consulted in connection with the original claim denial, the Review Committee will not consult with the same medical professional (or a subordinate of that person) for purposes of the appeal.

Additional and Different Procedures Applicable to Disability Internal Appeals

For disability internal appeals, in the event that new or additional evidence is considered, relied upon or generated by the Plan or Review Committee or the Review Committee decides that it will rely on a new or different rationale on appeal, the evidence or rationale will be provided to the claimant as soon as possible and sufficiently in advance of the required date for providing a determination on review in order to provide the claimant with a reasonable opportunity to respond to that evidence or rationale prior to that date.

Notification Following Internal Appeal

• If your appeal is for an urgent care claim, you will be notified of the decision about your appeal as soon as possible, taking into account the circumstances, but not later than 72 hours after receipt of your request for review. In the case of non-urgent pre-service claims, you will be notified no later than 30 days after receipt of your request for review.
• A review and determination for disability and post-service claims will be made no later than the date of the meeting of the Trustees that immediately follows the Plan's receipt of a request for review. The Review Committee meets on a monthly basis. However, if the request is filed within 30 days preceding the date of such meeting, a determination may be made by no later than the date of the second meeting.
• If special circumstances (such as the need to hold a hearing) require a further extension of time, a determination will be made not later than the third meeting of the Trustees. Before the start of the extension, you will be notified in writing of the extension, and that notice will include a description of the special circumstances and the date as of which the determination will be made.
• You will be informed of the Trustees' decision, normally within five calendar days of the review. The decision will be in writing unless the appeal was for an urgent care claim and you are advised by telephone or fax. When you receive the written decision, it will contain the reasons for the decision and specific references to the particular Plan provisions upon which the decision was based. It will also contain a statement explaining that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to you claim, a statement of your right to bring an action under section 502(a) of ERISA, the time limit for bringing such an action and, if applicable, the right to bring an external appeal. Additionally, if applicable, you will also be informed of your right to receive free of charge upon request the specific internal rule, guideline, protocol or similar criterion relied on to make the decision. If the decision was based on a medical judgment, you will receive an explanation of that determination or a statement that such explanation will be provided free of charge upon request.

Notification Following Internal Appeal of Disability Claims

The notification following internal appeals for disability will include certain additional and in the written notice of denial. In addition to the items set forth in notification following an internal appeal of a non-disability claim the notification following appeal of a disability claim will include an explanation of the basis for disagreeing with or not following the views presented by the claimant of (a) health care professionals treating the claimant and vocational professionals who evaluated the claimant, (b) the views of medical or vocational experts whose advice was obtained by the plan, without regard to whether the advice was relied upon in making the determination and (c) a Social Security disability determination presented by the claimant. With respect to a specific internal rule, guideline, protocol or criterion relied upon in making a claim, the notice shall include such items or a statement that there were no such items, rather than requiring a request for the item to be made by the claimant. With respect to decisions based on medical necessity, experimental treatment or a similar exclusion or limit, instead of the provisions applicable to other claims, 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 or a statement that such explanation will be provided free of charge upon request. The notice will be provided in a culturally and linguistically appropriate manner to the extent required under applicable law.

External Appeals

If you appeal to the Review Committee but the process still results in a denial of your claim, you may, in certain cases, request an additional review by an independent review organization (IRO). An independent external review is available for claims denied based on clinical or scientific judgments, such as decisions based on medical necessity. It is also available for matters addressed in the No Surprises provisions found in the Consolidated Appropriations Act of 2021 to ensure compliance with these provisions. It does not apply to claim denials related to a person's eligibility for coverage. You must apply for the external review within four months after the date of receipt of the written appeal decision you received from the Fund. To request an external review, call or write the Fund Office. Fund Office staff will provide you with the information you need to file your formal request for an external review and provide you with the information you need to complete the process. The appellant must pay a $25 administrative fee for each external review, which will be refunded if the appeal is granted.

You may apply for an expedited external review if the claim involves a medical condition for which the regular timeframe for completion of an appeal 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 (denial) 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. M.o<>

Judicial Review of Claims

If the Plan fails to make timely decisions or otherwise fail to comply with the applicable federal regulations, you may go to court to enforce your rights. A claimant may not file suit against the Plan until the claimant has exhausted all of the procedures described in these procedures. The time limit for filing suit is one year from the date a final decision was made or from the date a final decision was required to be provided if no final decision was made. In addition, judicial review of claims must comply with all terms of the Plan's General Plan Provisions regarding Legal Proceedings found at page 100.

Claim and Appeal Procedures for Life/AD &D Claims

Life/AD &D insurance claims should be filed with the Fund Office who will forward them to The Standard Life Insurance Company, the insurer of these benefits. Since the Fund is the holder of the insurance contract, notices from The Standard may be issued to the Fund instead of you.

The Standard will normally issue approval or denial of a life/AD &D claim within 90 days of the date it receives the claim. An extension of 90 days will be allowed if special circumstances are involved. The Fund Office will notify you in writing of any extension the insurer requires to review your claim, and the notice will state the special circumstances involved and the date by which it expects to reach a decision.

If The Standard denies your claim, the Fund Office will issue you a notice written in an understandable manner explaining the reasons for the denial. The notice will also include an explanation of the claim appeal procedures.

Review of claim denials and final decisions on appeal are The Standard's responsibility.

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