Transcription of WESTERN PENNSYLVANIA ELECTRICAL …
1 BUS_EST:231695-4 WESTERN PENNSYLVANIA ELECTRICAL EMPLOYEES INSURANCE TRUST FUND BARGAINING EMPLOYEES summary plan DESCRIPTION AS IN EFFECT NOVEMBER 1, 2006 i TABLE OF CONTENTS PAGE SECTION 1 THE summary plan DESCRIPTION BOOKLET .. 1 SECTION 2 GENERAL ADMINISTRATIVE INFORMATION .. 2 2-1 NAME OF plan ..2 2-2 NAME AND ADDRESS OF plan SPONSOR ..2 2-3 SPONSOR S IDENTIFICATION NUMBER ..2 2-4 plan NUMBER ..2 2-5 TYPE OF plan ..2 2-6 plan ADMINISTRATOR ..3 2-7 THIRD PARTY ADMINISTRATORS ..3 2-8 SERVICE OR LEGAL SERVICE ..4 2-9 COLLECTIVE BARGAINING AGREEMENT ..4 2-10 2-11 FUNDING ..4 2-12 plan YEAR ..4 2-13 AMENDMENT OF THE plan ..4 2-14 TERMINATION OF THE plan ..4 SECTION 3 ELIGIBILITY 5 3-1 WHO IS ELIGIBLE ..5 3-2 YOU BECOME ELIGIBLE ..5 3-3 ROLLING-HOURS BANK ..5 3-4 ELIGIBILITY STATEMENT AND SELF-PAYMENT ..6 3-5 EFFECTIVE DATE OF YOUR COVERAGE.
2 7 3-6 TERMINATION OF YOUR COVERAGE ..7 3-7 JOB RELATED INJURY ..8 3-8 RECIPROCITY PROVISION ..9 3-9 MILITARY LEAVE ..9 3-10 DEPENDENT ELIGIBILITY .. 10 3-11 TERMINATION OF ELIGIBILITY FOR DEPENDENTS .. 10 3-12 CHANGE IN FAMILY STATUS .. 11 3-13 SPECIAL ENROLLMENT RIGHTS UNDER THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 ("HIPAA") .. 11 3-14 COVERAGE FOR SPOUSES AND ELIGIBLE DEPENDENT CHILDREN UPON DEATH OF PARTICIPANT .. 12 3-15 MEDICARE-ELIGIBLE ACTIVE PARTICIPANTS .. 12 3-16 MEDICARE-ELIGIBLE SPOUSES AND DEPENDENTS OF ACTIVE PARTICIPANTS .. 12 3-17 RETIRED PARTICIPANTS .. 12 3-18 SPOUSES AND DEPENDENT CHILDREN OF RETIRED PARTICIPANTS.. 13 3-19 TERMINATION OF COVERAGE .. 13 3-20 COBRA FOR GROUP HEALTH COVERAGES .. 14 3-21 HIGHMARK DIRECT-PAY PRIVATE HEALTH INSURANCE POLICIES .. 18 SECTION 4 INSURANCE TRUST FUND DEATH BENEFIT .. 19 4-1 DEATH BENEFIT .. 19 ii 4-2 BENEFICIARY.
3 19 4-3 FILING FOR DEATH BENEFITS .. 20 4-4 FACILITY OF PAYMENT .. 20 4-5 DECISION ON BENEFIT PAYMENT .. 20 4-6 IF PAYMENT IS DENIED .. 20 4-7 APPEAL OF ADVERSE BENEFIT DECISION .. 21 4-8 REVIEW OF APPEAL .. 21 4-9 DESIGNATION OF REPRESENTATIVE FOR CLAIMS AND APPEALS .. 22 SECTION 5 GENERAL PROVISIONS REGARDING THE FUND'S HEALTH PROGRAMS .. 23 5-1 APPLICATION FOR FUND COVERAGE .. 23 5-2 IDENTIFICATION CARDS .. 23 5-3 MEDICAL NECESSITY AND APPROPRIATENESS .. 23 5-4 RIGHTS UNDER THE WOMEN S HEALTH AND CANCER RIGHTS ACT.. 24 5-5 RIGHTS UNDER THE NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT.. 24 SECTION 6 HIGHMARK ADMINISTERED HOSPITALIZATION PROGRAM .. 25 6-1 PROVIDERS .. 25 6-2 HEALTHCARE MANAGEMENT .. 25 6-3 HOW TO FILE A CLAIM .. 30 6-4 HIGHMARK BLUE CROSS CLAIM REVIEW PROCEDURE .. 32 6-5 CUSTOMER SERVICE .. 34 6-6 OUT-OF-AREA CARE .. 34 6-7 HOSPITALIZATION PROGRAM BENEFITS.
4 35 (a) Providers of Service .. 35 (b) Payment of 35 (c) Benefit Period .. 36 (d) Inpatient Hospital Services .. 36 (e) Maternity Benefits .. 37 (f) Transplant Services .. 37 (g) Special Inpatient Limitations .. 37 (h) Inpatient Admissions and Outpatient Visits Oral Surgery .. 37 (i) Sterilization .. 37 (j) Benefits for Alcoholism and Drug Abuse .. 37 (k) Mammography Screening .. 38 (l) Outpatient Care .. 38 (m) Special Facilities and Services .. 40 (n) Chemotherapy Treatment .. 41 (o) Pediatric Immunization .. 41 (p) Routine Gynecological Examination and Pap Test .. 41 (q) Benefits After Termination of Coverage .. 41 6-8 EXPENSES NOT COVERED .. 42 6-9 TERMS YOU SHOULD KNOW .. 44 6-10 COORDINATION OF BENEFITS .. 46 SECTION 7 INSURANCE TRUST FUND MEDICAL/SURGICAL PROGRAM .. 49 7-1 PAYMENT OF BENEFITS .. 49 7-2 PROVIDERS OF SERVICE .. 49 7-3 SURGERY (IN OR OUT OF HOSPITAL).
5 49 7-4 OBSTETRICAL SERVICES (IN OR OUT OF HOSPITAL) .. 50 iii 7-5 NEWBORN CARE (IN-HOSPITAL) .. 50 7-6 ANESTHESIA (IN OR OUT OF HOSPITAL) .. 50 7-7 CHEMOTHERAPY (IN OR OUT OF HOSPITAL) .. 50 7-8 RADIATION THERAPY (IN OR OUT OF HOSPITAL) .. 50 7-9 DIAGNOSTIC SERVICES (IN OR OUT OF HOSPITAL) .. 50 7-10 ALLERGY TESTING (IN OR OUT OF HOSPITAL) .. 51 7-11 EMERGENCY ACCIDENT CARE .. 51 7-12 EMERGENCY MEDICAL CARE .. 51 7-13 TRANSPLANT SERVICES .. 51 7-14 IN-HOSPITAL MEDICAL .. 51 7-15 OUTPATIENT REHABILITATION .. 52 7-16 CONCURRENT CARE (IN-HOSPITAL) .. 52 7-17 CONSULTATION (IN-HOSPITAL) .. 52 7-18 OUTPATIENT MEDICAL VISITS .. 52 7-19 MAMMOGRAPHY SCREENING .. 52 7-20 ROUTINE GYNECOLOGICAL EXAM AND PAP SMEAR .. 53 7-21 OUTPATIENT SECOND OPINION CONSULTATION FOR SURGERY .. 53 7-22 CHILDHOOD IMMUNIZATIONS .. 53 7-23 CHIROPRACTIC VISITS .. 53 7-24 WELL-CARE CHILD VISITS .. 53 7-25 ROUTINE PHYSICAL EXAM.
6 53 7-26 IMPACTED TEETH (IN OR OUT OF HOSPITAL) .. 53 7-27 UNUSUAL TRAVEL .. 53 7-28 HEARING AIDS .. 54 7-29 DIABETIC EDUCATION .. 54 7-30 CARDIAC REHABILITATION .. 54 7-31 WORK BOOTS BENEFIT PROGRAM .. 55 7-32 EXPENSES NOT COVERED .. 55 7-33 CLAIMS AND APPEALS .. 57 SECTION 8 INSURANCE TRUST FUND MAJOR MEDICAL EXPENSE PROGRAM .. 58 8-1 CATASTROPHIC MAJOR MEDICAL EXPENSE PROGRAM .. 58 8-2 COVERED MAJOR MEDICAL EXPENSES .. 58 (a) Outpatient Mental Health Care .. 60 (b) Prescription Drugs .. 60 8-3 EXPENSES NOT COVERED .. 60 8-4 EXTENT OF PAYMENT .. 62 (a) Deductible .. 62 (b) Coinsurance .. 62 (c) Maximum Reimbursement .. 62 8-5 UNDERSTANDING THE TERMS .. 62 8-6 CLAIMS AND APPEALS .. 62 SECTION 9 HOW TO FILE A MEDICAL/SURGICAL AND MAJOR MEDICAL CLAIM .. 63 9-1 FILING OF MEDICAL CLAIMS .. 63 9-2 FILING OF PRIVATE DUTY NURSING CLAIMS .. 64 9-3 FILING OF PRESCRIPTION DRUGS AND MEDICINE CLAIMS.
7 64 9-4 PROCEDURES FOR PROCESSING CLAIMS AND FILING APPEALS .. 65 iv SECTION 10 DEVON PPO PROGRAM .. 66 10-1 DEVON PPO.. 66 10-2 CLAIM FILING .. 67 10-3 CLAIMS PROCESSING AND APPEAL PROCEDURE .. 67 10-4 DEVON PROVIDER NETWORK .. 67 SECTION 11 INSURANCE TRUST FUND DENTAL PROGRAM .. 68 11-1 LIMITATIONS AND BENEFITS .. 68 11-2 FILING A DENTAL CLAIM .. 68 11-3 PROCEDURES FOR PROCESSING CLAIMS AND FILING APPEALS .. 69 SECTION 12 INSURANCE TRUST FUND OPTICAL PROGRAM .. 70 12-1 LIMITATIONS AND BENEFITS .. 70 (a) Limitations .. 70 (b) Benefits .. 71 12-2 FILING AN OPTICAL CLAIM .. 71 12-3 REQUIRED INFORMATION FOR THE PROCESSING OF OPTICAL CLAIMS .. 72 12-4 PROCEDURES FOR PROCESSING CLAIMS AND FOR FILING APPEALS .. 72 SECTION 13 GIANT EAGLE HEALTHCARE RETAIL AND MAIL-SERVICE PRESCRIPTION DRUG PROGRAM .. 73 13-1 PRESCRIPTION DRUGS AT RETAIL PHARMACIES .. 73 13-2 PRESCRIPTION DRUGS AT MAIL-SERVICE PHARMACY.
8 74 13-3 ORDERING DRUGS .. 74 13-4 ORDERING DRUGS THROUGH THE MAIL-SERVICE OPTION .. 74 13-5 ORDERING REFILLS THROUGH MAIL-SERVICE .. 75 13-6 PAYING FOR YOUR ORDER .. 75 13-7 QUESTIONS .. 75 13-8 PROCEDURE FOR PROCESSING CLAIMS AND FILING APPEALS .. 75 SECTION 14 SUBROGATION AND REIMBURSEMENT RIGHTS .. 76 SECTION 15 COORDINATION OF 78 SECTION 16 MISCELLANEOUS .. 80 16-1 HIPAA CERTIFICATES OF CREDITABLE COVERAGE .. 80 16-2 QUALIFIED MEDICAL CHILD SUPPORT ORDERS .. 80 SECTION 17 HEALTH BENEFIT CLAIM PROCESSING AND APPEAL PROCEDURES .. 81 17-1 CLAIM PROCESSING .. 81 (a) Types of Claims .. 81 (1) Pre-Service Claim .. 81 (2) Urgent-Care Claim .. 81 (3) Post-service Claim .. 82 (b) Processing Pre-Service Claims (Non-Urgent).. 82 (c) Processing Urgent-Care Claims.. 83 (d) Processing Post-Service Claims.. 83 (e) Extension of Time by 84 (f) Approval of Claim .. 84 v (g) Denial of Claim.
9 84 (h) Improperly Filed Claims .. 85 17-2 APPEALS OF ADVERSE DECISIONS .. 85 (a) Right of Appeal .. 85 (1) In General.. 85 (2) Appeal of Urgent-Care Claim.. 85 (3) Appeal of Pre-Service (Non-Urgent) Claim or Post-Service Claim .. 85 17-3 APPEAL PROCESSING .. 86 (a) In General.. 86 (b) Processing Urgent-Care Claim Appeals.. 86 (c) Processing Pre-Service (Non-Urgent) Claim Appeals.. 86 (d) Processing Post-Service Claim Appeals.. 87 (e) Extension of Time by 87 (f) Notice of Denial of Appeal .. 87 (g) Final Decision .. 88 17-4 CONCURRENT CARE DECISIONS .. 88 (a) Reduction or Termination .. 88 (b) Requests for Extension of an Ongoing Course of Treatment .. 88 17-5 DESIGNATION OF 88 17-6 QUESTIONS .. 89 SECTION 18 ERISA RIGHTS .. 90 1 Section 1 - The summary plan Description Booklet This is the summary plan Description for the WESTERN PENNSYLVANIA ELECTRICAL Employees Insurance Trust Fund ( Fund ) for Bargaining Employees.
10 It summarizes the benefits available to you under the Fund as of November 1, 2006. The benefit programs offered under the Fund include the following: Death Benefit Hospitalization Program Medical/Surgical Program Major Medical Expense Program Devon PPO Dental Program Optical Program Retail and Mail-Service Prescription Drug Program 2 Section 2 - General Administrative Information 2-1 Name of plan WESTERN PENNSYLVANIA ELECTRICAL Employees Insurance Trust Fund (referred to herein as the "Fund") 2-2 Name and Address of plan Sponsor Board of Trustees WESTERN PENNSYLVANIA ELECTRICAL Employees Insurance Trust Fund Labor Trustees Management Trustees John Chalovich (Business Manager, Local Union #5) Michael R. Dunleavy (President, Local Union #5) Dennis E. Eicker (Vice-President, Local Union #5) Charles L. Fuellgraf, III (President, Fuellgraf Electric) James J.
