FREQUENTLY ASKED QUESTIONS

• Go in to your local Union Hall and fill out a change of address form and have them fax or mail it to us.
• Send a notarized statement, signed by the employee with the new address listed
• Send in copy of the employee’s driver’s license if the new address is printed on it.
• Change your address on your Annual Update Form (AUF) which is mailed out at the beginning of each year.

WHERE SHOULD CLAIMS BE SUBMITTED?
All claims for Medical, Dental, Vision and Short Term Disability should be submitted to:
GROUP BENEFIT ADMINISTRATORS
PO BOX 30749
SALT LAKE CITY, UT 84130

HOW CAN I REQUEST NEW OR ADDITIONAL ID CARDS?
You can request new or additional cards by calling our Customer Service Department at 801-972-1177 or 800-657-5377.

HOW CAN I REQUEST A NEW PLAN BOOKLET?
You can request a new plan booklet by calling our Customer Service Department at 801-972-1177 or 800-657-5377.

WHAT IS A PREFERRED PROVIDER?
A preferred provider is a doctor or facility that has signed a contract or agreement with a network.

HOW CAN I FIND OUT IF MY DOCTOR IS A PREFERRED PROVIDER?
You can find out if your doctor is a preferred provider by contacting the preferred provider network or by contacting your doctor’s billing department. click here

HOW CAN I FIND A PREFERRED PROVIDER IN MY AREA?
You can locate a preferred provider in your area by calling the preferred provider network or by visiting their website.

WHY CAN’T YOU TALK TO ME ABOUT MY DEPENDENT’S OR SPOUSE’S CLAIMS? click here for PHI release
Because of HIPAA we can only discuss Protected Health Information (PHI) with the patient or an authorized representative. PHI includes claim status and the payment of claims. The patient must complete and submit a PHI release form if they would like us to be able to discuss PHI with a spouse, parent or other person. The Natural or Custodial parent of a dependent under age 18 is considered to be an authorized representative. The Natural or Custodial parents of dependent children who are age 18 or older will not be able to call on claims for those children unless there is a PHI release on file. Eligibility and benefits are not considered PHI.

WHAT IS HIPAA?
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) required the Department of Health and Human Services (HHS) to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addressed the security and privacy of health data. As the industry adopts these standards for the efficiency and effectiveness of the nation's health care system will improve the use of electronic data interchange.

HOW CAN I GET A CERTIFICATE OF CREDITABLE COVERAGE?
A Certificate of Creditable Coverage is automatically mailed out when coverage ends. Additional Certificates may be requested by calling our Customer Service Department at 801-972-1177 or 800-657-5377.

WHAT CAN I DO IF I AM UNHAPPY WITH THE WAY A CLAIM WAS PROCESSED, OR IF A CLAIM WAS DENIED?
You have a right to appeal the decision to deny benefits or pay at less than 100% to the Board of Trustees following the appeal procedures described below. If you appeal you will receive a full and fair review of your claim and this decision.

1. You must file your appeal in writing within 180 days of the date you received the Notice of Benefit Determination, and your appeal must set forth the reasons of your appeal.
2. You may submit written comments, documents, records and other information relating to the claim, all of which should be submitted with your appeal in order to be considered.
3. Upon request, and at no charge, you may obtain reasonable access to, and copies of, all documents, records and information relevant to your claim for benefits.
4. The review will take into account all comments, documents, records and other information submitted that relates to the claim.
   This would include comments, documents, records and other information that either were or were not submitted previously or were or were not considered in the initial benefit decision. The Board of Trustees was not involved in the initial decision, and its members are not subordinates to the person or persons involved in the initial decision.
5. If your benefit denial or payment at less than 100% was based in whole or in part on a medical judgment, the Board of Trustees will consult with a health care professional with training and experience in the relevant medical field. This health care professional was not involved in the initial decision, and is not a subordinate of any health care professional who was involved in the initial decision. If the plan has obtained or will obtain medical experts in connection with your claim, they will be identified, regardless of whether the plan relies on their advice in making any benefit determinations.

Time Period for Appeal Decision
If you appeal, you will be notified of the decision following the review as soon as possible, but no later than five days after the Board of Trustees makes its decision. The Board of Trustees will make its decision at its next regularly scheduled meeting following the receipt of your appeal. However, if you file your appeal within the 30-day period prior to that meeting, your appeal may not be decided until the second quarterly Board of Trustees’ meeting following receipt of the appeal. If special circumstances require additional time for investigation of the facts, you will be notified in writing in advance, of the extension, the special circumstances, any additional information required from you, and the date on which your appeal will be decided. The extended date for this decision will not be later than the third quarterly Board of Trustees’ meeting following receipt of your appeal, unless such date is suspended based upon your failure to provide information requested in the notice of extension. You have the right to bring a civil action under ERISA §502(a) if you file an appeal and your request for benefits is denied or paid at less than 100% following review. Please carefully review the above information. If you decide to appeal this decision by requesting a review as described above, your appeal must be sent within 180 days to:

TRUSTEE APPEALS
P.O. Box 25117
Salt Lake City, UT 84125
Phone: (801) 972-1177 or Toll Free: (800) 657-5377 or FAX (801) 972-3364

If you fail to appeal within 180 days after receipt of the Notice of Benefit Determination, you waive your right to a plan review of this benefit determination.

WHAT IS THE DIFFERENCE BETWEEN “PRE-DETERMINATION”, “PRE-CERTIFICATION” AND “PRE-AUTHORIZATION”?

Pre-determination:
Usually done for dental procedures. Recommended for all dental services over
$200.Not a guarantee of payment, only an estimate of benefits payable and patient
responsibility.

Pre-certification:
Required for all inpatient hospital admissions. Failure to pre-certify an inpatient
hospital admission will result in a reduction in benefits. Determines the medical
necessity of an inpatient hospital stay and the number of days that the patient will be allowed to stay. Pre-certification is not a guarantee of eligibility, benefits or payment.
Some procedures will require a “Pre-authorization” in addition to the inpatient “Pre-
certification”.

Pre-authorization:
Usually done for medical procedures. Required for certain medical procedures.
Determines whether or not service(s) being requested are considered to be a covered benefit by the plan. May give a description of benefits. Actual payment will be based
on eligibility and services actually rendered.