Claims
Submitting a Claim for Benefits
To file a claim under this Plan, follow these steps:
Obtain a claim form from your union or the Plan’s Administrative Office.
Complete your portion of the form and have the person providing services complete the rest of the form.
On completion of the form, attach itemized bills or statements and send it to:
Bay Area Automotive Group Welfare Fund
4160 Dublin Blvd., #400
Dublin, CA 94568
1 (800) 267-3232
Send any further bills or statements for any services covered by the Plan to the Administrative Office as soon as you receive them.
Claims for benefits including supporting documentation must be submitted as soon as possible after you first receive medical attention but in no event later than one year after the date services were rendered (except in the event of legal incapacity).
The Fund may, at its own expense, examine the person for whom the claim is made when and as often as it may reasonably require while a claim is pending and, in the case of death, may make an autopsy where not forbidden by law.
For Kaiser coverage, see your HMO materials for information on how to file a claim if necessary. If you participate in a dental HMO (DMO), your DMO materials will have information on filing any claims that may be required.
Time Allowed for Plan Response to Filed Claim
To file claims for any of the Plan’s health care benefits, follow the procedures as described in this section. The claims procedure you follow will depend on whether your claim for benefits is a claim involving urgent care, a pre-service claim, or a post-service claim.
A pre-service claim is any claim for services not yet performed, which are not for urgent care. An urgent care claim is a claim for medical care or treatment if delays could seriously jeopardize your life or health or your ability to regain maximum function, or would, in the opinion of your physician, subject you to severe pain that can only be effectively managed through the requested course of treatment. Any claim for health care benefits under the Plan that is not an urgent care claim, a pre-service claim, or a concurrent care claim (see below) is considered a post-service claim.
Pre-Service Claims
The Plan Administrator will issue a decision within 15 days after receipt of the claim. If an extension is necessary, then a decision will be issued within 30 days of receipt of the claim. You will receive written notice of the extension before the end of the initial 15-day period, which will state the reason(s) for the extension and the date you can expect a decision. If an extension is necessary because you failed to submit the necessary information, the notice will describe the required information, and you will have 45 days to provide the requested information. The time in which a decision will be issued is delayed from the date the extension was sent until the date you respond. If you do not provide the requested information within the 45-day period, your claim will be denied.
Urgent Care Claims
The Plan Administrator will issue a decision as soon as possible and within 72 hours after receipt of the claim. If more information is required to determine the claim, you will be notified as soon as possible but within 24 hours, and you will be given at least 48 hours to provide the requested information. If you do not provide the requested information within the 48-hour period, your claim will be denied.
Post-Service Claim
The Plan Administrator will issue a decision within 30 days after receipt of the claim, unless an extension is necessary, in which case a decision will be issued within 45 days. Written notice of the extension will be provided to you before the end of the initial 30-day period and will state the reason(s) for the extension and the date you can expect a decision. If an extension is necessary because you failed to submit the necessary information, the notice will describe the required information, and you will have 45 days to provide the requested information. The time period in which a decision will be issued is delayed from the date the extension was sent out until you respond. If you do not provide the requested information within the 45-day period, your claim will be denied.
Concurrent Care Claims
In the case of a concurrent care claim, where health care treatment is reduced or terminated before the end of the approved period of time or number of treatments, the Plan Administrator will notify you sufficiently in advance of the reduction or termination to allow you to appeal the decision if you choose to do so and have the appeal decided before the benefit is reduced or terminated.
If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and you request to extend treatment in a non-urgent circumstance, your request will be considered a new claim and decided according to post-service or pre-service time frames, whichever applies. If the request involves urgent care, any claim to extend a course of treatment will be decided as soon as possible but within 24 hours, provided the claim is submitted at least 24 hours prior to the prescribed end of the course of treatments.
Filing Claims for Disability Benefits
The Plan Administrator will issue a decision within 45 days after receipt of the claim. This period may be extended twice, up to 30 days for each extension. Written notice of the extension will be provided to you before the end of the initial 45-day period and will state the reason(s) for the extension and the date you can expect a decision. If an extension is necessary because you failed to submit the necessary information, the notice will describe the required information, and you will have 45 days to provide the requested information. The time period in which a decision will be issued is delayed from the date the request is made until you respond. If you do not provide the requested information within the 45-day period, your claim will be denied.
Filing Claims for Life Insurance and AD&D Insurance Benefits
Prudential will issue a decision within 90 days after receipt of the claim, unless an extension is necessary, in which case a decision will be issued within 180 days. Written notice of the extension will be provided to you before the end of the initial 90-day period and will state the reason(s) for the extension and the date you can expect a decision.