The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 FILING CLAIM DISPUTES This section describes the claim-and-review procedures for all the health care options (except the Kaiser, Medica and UnitedHealthcare plan options.) These claims and appeals procedures are effective January 1, 2012.* U.S. Bank has delegated authority and discretion to decide internal claims and appeals relating to ERISA claims for benefits to the Claims Administrators responsible for the benefit in question. If you are enrolled in the Kaiser Colorado option or the Medica or UnitedHealthcare plan options, you will receive separate materials from that Claims Administrator explaining the claimand-review procedures for your option. You must follow the claim-and-review procedures contained in the separate materials in order to ensure the highest level of benefits. Each Kaiser, Medica and UnitedHealthcare plan is fully insured. Each insurer has the sole authority, discretion and responsibility to interpret and construe the terms of the benefit plan it insures, and determine all factual and legal questions under such benefit plan, including but not limited to eligibility to participate, the entitlement of benefits and the amount of benefits to be paid, if any. U.S. Bank has no authority to make determinations with respect to any Kaiser, Medica or UnitedHealthcare plan. Your only source of recovery is from the applicable insurer. * These procedures include provisions provided by federal health reform law, regulation and subregulatory guidance. Some of these provisions may be eliminated or changed in subsequent guidance, and to the extent this occurs, the Plan will be administered in accordance with such eliminations or changes. The Plan reserves the right to delay compliance to the latest date permitted under current or future regulations. Eligibility and Enrollment Claims for All Options All claims or disputes regarding eligibility and enrollment must be submitted in writing to: U.S. Bank Benefit Claim Subcommittee EP-MN-R2BN 4000 West Broadway Robbinsdale, MN 55422-2299 Fax 763-971-1285 Within 60 days after your claim is received, you will receive a written notice of the decision. If your claim is denied, in whole or in part, the Claim Reviewer will further notify you of your right to additional review of your denied claim. If your request for review is denied in whole or in part and you still disagree with the decision, within 60 days of the date you receive written notice, you must deliver to the U.S. Bank Benefit Claim Subcommittee a written request for a final claims determination at the above address. Your request for a final claims determination should include any documentation supporting your claim. Release of Medical Records and Medical Reviews Generally, your health or pharmacy information may be used without obtaining your authorization or consent for purposes of claims payment and other health care or pharmacy operations required by the Program. However, in some circumstances, an authorization for the 110
Retiree Health Care SPD Effective January 1, 2012 release of medical records may be required. If this is required, you may be asked to sign an authorization permitting the disclosure of your medical records for this purpose. Internal ERISA Claims Procedures Initial Claim Determination Under ERISA’s claims procedures there are three types of claims: • Post-Service Claims – any claim for payment filed after medical services or supplies have been received and any other claim that is neither a Pre-Service nor an Urgent Claim. • Pre-Service Claims – any claim for a benefit that, under the terms of the Program, requires notification or approval prior to receiving medical treatment or supplies (e.g., prior authorization or preadmission notification); and • Urgent Claims – a Pre-Service claim (as defined above), where, in the opinion of the claimant's health care provider, a delay in providing medical treatment or supplies might jeopardize the life or health of the claimant, or jeopardize the ability to regain maximum function or subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. The time period for deciding each type of claim and notifying you of such decision differs based upon the nature of claim. The chart in this section provides the time periods for notifying you of the initial claims decision, any possible extensions and the time periods for you to provide additional information, if needed. Within the timeframes indicated in the chart, you will receive either a: • Written notice of the decision; or • For Post-Service Claims, notice describing the need for additional time to reach a decision due to reasons beyond the control of the Claims Administrator; • For Pre-Service Claims, notice that your claim was incorrectly filed and information about how to correctly file a claim or notice describing the need for additional time to reach a decision due to reasons beyond the control of the Claims Administrator; or • For Urgent Claims, notice that the claim is incomplete. If additional time is needed, the notice will describe the reason(s) for the extension and the date by which you can expect a decision. If the claim is incomplete or additional information is needed, the notice will specifically describe the additional information needed to complete the claim. You will then have the time period indicated in the fourth column of the chart to provide the specified additional information. The time between the date the notice is sent and the date the requested information is received from you shall not count against the time period for deciding your claim. If you fail to follow the procedures for submitting a Pre-Service claim, you will be notified of the correct process for submitting a Pre-Service claim within five days after the incorrect claim is received. This notice may be provided orally, unless you request written notification. 111
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