How to File a Claim

Claims are filed automatically on your behalf when you use an In-Network pharmacy, the EnvisionMail mail-order pharmacy, and the EnvisionSpecialty pharmacy.

If you use an Out-of-Network pharmacy, you pay in full when you obtain the drugs. You then file a claim to be reimbursed for the amount the Plan would have paid to an In-Network pharmacy. To file a claim, send a completed claim form and your receipt(s) to the claims administrator at:

EnvisionRxOptions
2181 East Aurora Road
Suite 201
Twinsburg, OH 44087

You or your provider must properly file a claim within 12 months after services were provided in order to receive reimbursement under the Plan.

Please note: For purposes of the Plan’s claims and appeals procedures, a claim does not include the following:

  • Casual inquiries about benefits or the circumstances under which benefits might be paid under the terms of the Plan;
  • Mere requests for advance information on the Plan’s possible coverage of items or services or advance approval of covered items or services that do not require preauthorization; and
  • The submission of a prescription to a pharmacy or a pharmacist.

A determination of eligibility under the Plan (including a request or application for such determination) will not be treated as a claim under the Plan and will be determined by the Plan Administrator in accordance with a procedure established by the Plan Administrator. However, if an individual files a request for benefits in accordance with the Plan’s procedure for filing claims, and that claim is denied because the individual is not eligible for coverage under the Plan, the coverage determination will be considered to be part of a claim.

Benefit Determinations

Prior-Authorization Requests Involving Urgently Needed Care

When you request prior-authorization involving urgently needed care, the claims administrator (EnvisionRxOptions) will provide a response to your prior-authorization request within 72 hours, unless additional time is needed. If additional time is needed, the claims administrator will notify you within the first 24 hours that additional time is necessary. If the claims administrator requests additional information from you, you will have a minimum of 48 hours to provide the information. The claims administrator will provide a response within 48 hours of whichever of the following events occurs first:

  • Receipt of the additional information, or
  • The end of the time period you were given to provide additional information.

The claims administrator’s responses may be issued orally, in which case a written response will also be provided within three days of the oral notification.

Prior-Authorization Requests Involving Non-urgent Care

When you request prior-authorization for non-urgent care, the claims administrator will provide a written response to your prior-authorization request within 15 days, unless additional time is needed. If additional time is needed, the claims administrator will notify you within the original 15 days that additional time is necessary. If the claims administrator requests additional information from you, you will have 45 days to provide the information. The claims administrator will provide a written response within 15 days of receiving the additional information.

Post-Service Claims

Once the claims administrator receives a properly filed claim from you or your provider, a benefit determination will be made within 30 days. This period may be extended one time for up to 15 additional days, if the claims administrator determines that additional time is necessary.

If additional time is necessary to process your claim, you will be notified, in writing, prior to the expiration of the original 30-day period, that the extension is necessary, along with an explanation of the circumstances requiring the extension of time and the date by which the claims administrator expects to make the determination.

If additional information is necessary in order for your claim to be a properly filed claim, you will receive written notice of the specific information needed prior to the expiration of the initial 30-day period. You will have 45 days from receipt of the notice to provide the additional information. You will receive notification of the benefit determination within 15 days following receipt of the additional information.

Written Notice of Denials

If a claim for benefits (including a prior-authorization request) is denied, in whole or in part, you or your beneficiary(s) will receive written notice of the decision (normally included in the Explanation of Benefits). The written notice will include the following:

  • The specific reason(s) for the denial or decision, including the denial code and its corresponding meaning, and the standard, if any, that was used in denying the claim
  • Information sufficient to identify the claim involved (including the date of service, the health care provider, the claim amount (if applicable), and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning)
  • Specific reference to the Plan provision(s) on which the denial or decision was based
  • A description of any additional material or information necessary to perfect the claim and an explanation of why it is necessary
  • An explanation of the Plan's internal procedures and the time limits applicable to such procedures, including a statement that you may bring a civil action under section 502(a) of ERISA only after a benefit denial on review of your appeal(s)
  • A description of the Plan's external appeal process
  • If an internal rule, guideline, protocol, or other similar criterion ("criterion"), or any new or additional information, was relied upon in making the denial, either the:

    • Specific criterion and new or additional information used, or
    • A statement that such criterion or information was relied upon in making the benefit denial and that a copy of such criterion or information will be provided free of charge upon request.

  • If the benefit denial is based on medical necessity or experimental or investigational treatment limitation, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the person's special medical circumstances, or a statement that such explanation will be provided free of charge upon request
  • Information about the availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman established under the Public Health Services Act to assist individuals with the internal claims and appeals and external review processes

Claim Appeals Procedure

The Plan has established the following process to review any dissatisfactions, complaints, and appeals. If you have designated an authorized representative, that person may act on your behalf in the appeal process. Please note: designation of an authorized representative does not constitute a waiver of the Health Care Program’s anti-assignment provisions.

Questions and Complaints

If you have a question or complaint, an initial attempt should be made to resolve the problem by directly communicating with EnvisionRxOptions Customer Service at (800) 361-4542 (toll free). In most cases, a Customer Service Representative will be able to provide you with a satisfactory solution to your problem. However, if a resolution cannot be reached in an informal exchange, you may request an administrative review of the problem through the appeal process described below. You must use the internal appeal and external appeal processes below before seeking a review of your claim in court.

You may request to review information used to make any adverse determination. Copies will be provided free of charge.

If you have a question or complaint about on-site Health Center services, you should first discuss it with the Health Center staff. If your concern cannot be resolved, you may request an administrative review of your concern using the internal appeal and external appeal processes described below.

Level 1 - Internal Appeal

  • How and When to File an Appeal
  • If you are not satisfied with the initial attempt to resolve your problem, or if you wish to request a review of a benefit determination, prior-authorization decision, or a certain type of retroactive termination of coverage (a "rescission"), you must request an appeal within 180 days from the date you received notice of the adverse benefit determination or prior-authorization notice. A provider can also submit an appeal of an adverse benefit determination or preauthorization decision on your behalf, but not as an assignee of benefits. Please note that the Plan’s communication with such provider with respect to the appeal does not constitute a waiver of the Plan’s anti-assignment provisions.

    • How to File an Appeal Involving Urgently Needed Care
    • If you wish to appeal a denial or prior-authorization decision involving urgently needed care, you may appeal by calling the claims administrator (EnvisionRxOptions) at (800) 361-4542. You may also submit such an appeal in writing to the EnvironRxOptions address described above for the submission of claims.

    • How to File an Appeal Involving Non-Urgent Care or the Denial of a Claim
    • If you wish to appeal a prior-authorization decision involving non-urgent care, or to appeal any claim denial, you must submit your request in writing to the following address:

      Alliance Coal, LLC
      Attention: Plan Administrator
      PO Box 22027
      Tulsa, OK 74121-2027

      The written request should include your name and identification number, the patient's name, the nature of the complaint, the facts upon which the complaint is based, and the resolution you are seeking. Necessary facts are: dates and places of services, names of providers of services, place of hospitalization, and types of services or procedures received (if applicable). You should include any documentation, including records, that you want to become a part of the review file. The Plan Administrator may request further information if necessary.

    As part of the appeals process, you have the right to be provided, upon request and free of charge, reasonable access to or copies of all documents, records, and other information relevant to the claim. The appeal process will take into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

  • The Internal Appeal Process

    For appeals involving urgently needed care that are initiated by calling the claims administrator, staff members of the claims administrator who did not participate in the initial claim denial will review your appeal. For other appeals, the Plan Administrator will review your appeal. When the claims administrator or Plan Administrator reviews your appeal, the appeal will be conducted by a person or committee who is not subordinate to (does not "report to") the previous decision-maker for the initial claim. In deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental or investigational, or not medically necessary or appropriate, the party that is responsible for reviewing the appeal will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. You have the right to know the identity of any medical or vocational experts whose advice was obtained on behalf of the Plan Administrator in connection with an adverse benefit determination.

    If the party responsible for reviewing your appeal (i) considers, relies upon, or generates any new or additional evidence in connection with the claim, or (ii) intends to issue a final appeal decision based on a new or additional rationale, such evidence or rationale, as applicable, must be provided to you as soon as possible and sufficiently in advance of the date on which a final appeal decision is required to be made, to give you a reasonable opportunity to respond prior to that date. It may happen that  new or additional evidence is received by the Plan Administrator so late that it would be impossible to provide it to you in time for you to have a reasonable opportunity to respond. If that occurs, the period for providing a notice of the final appeal decision will be extended until you have had a reasonable opportunity to respond. After you respond or have had a reasonable opportunity to do so, the Plan Administrator will notify you of the appeal determination as soon as reasonably possible under the circumstances.

  • Timing for Decisions on Internal Appeals

    You will receive a written decision on your appeal as follows:

    • Urgently needed prior-authorization request: In the case of an appeal of a prior-authorization request involving urgently needed care, the claims administrator will respond to you no later than 72 hours after receipt of your appeal request.
    • Non-urgent prior-authorization request: In the case of an appeal involving a non-urgent prior-authorization request, the Plan Administrator will provide a written response to you no later than 30 days following the date that your appeal is received.
    • All other appeals: In the case of other appeals that are initiated by writing to the Plan Administrator, the Plan Administrator will provide you a written decision on your appeal no later than 60 days following the date your appeal is received.

  • Adverse Decisions on Internal Appeals

    If your appeal is denied, then you will generally receive the following information about the denial of the appeal:

    • The specific reason(s) for the denial or decision, including the denial code and its corresponding meaning, the standard, if any, that was used in denying the claim, and a discussion of how that standard was applied to any appeal denial
    • Information sufficient to identify the claim involved (including the date of service, the health care provider, the claim amount (if applicable), and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning)
    • Specific reference to the Plan provision(s) on which the denial or decision was based
    • A statement that you may have access to or copies of all documents or records that are relevant to your claim (without charge)
    • A description of the external appeal procedures offered by the Plan and a statement of your right to bring a court action under section 502(a) of ERISA
    • If an internal rule, guideline, protocol, or other similar criterion ("criterion"), or any new or additional information, was relied upon in making the denial, either the:

      • Specific criterion and new or additional information used, or
      • A statement that such criterion or information was relied upon in making the benefit denial and that a copy of such criterion will be provided free of charge upon request.

    • If the benefit denial is based on medical necessity or experimental or investigational treatment limitation, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the person's special medical circumstances, or a statement that such explanation will be provided free of charge upon request
    • Information about the availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman established under the Public Health Services Act to assist individuals with the internal claims and appeals and external review processes

Level 2 - External Appeal Process

The Medical Plan and the Prescription Drug Plan also provide an opportunity to request an external appeal of certain claim denials that have been upheld during the internal appeal process. The external appeal is performed by an independent review organization (IRO). You must exhaust the internal claim and appeal process before starting an external appeal (except as provided in the section of the Medical Plan titled “Expedited External Appeal”).

Currently, external appeal is only available for:

  • A claim denial that involves medical judgment, which includes, but not limited to those based on one or more of the following (as determined by the external reviewer):

    • The Medical Plan or Prescription Drug Plan’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit
    • The determination that a treatment is experimental or investigational
    • The determination whether a participant or beneficiary is entitled to a reasonable alternative standard for a reward under a wellness program (if applicable)
    • The determination of whether the Plan is complying with the nonquantitative treatment limitation provisions of the federal mental health parity rules

  • Rescission (retroactive termination) of coverage (whether or not the rescission has any effect on any particular benefit at that time)

This means that an external appeal will not be available for all types of claims. For example, an external appeal is not available for review of a denial, reduction, or termination. It is also not available for review of a failure to provide payment for a benefit, if it is determined that a claimant has failed to meet the requirements for eligibility under the terms of the Medical Plan or the Prescription Drug Plan.

For a description of the external appeal process that applies to both the Medical Plan and the Prescription Drug Plan, see "External Appeal Process" in the Medical Plan section of this benefits handbook.

Effect of Appeal Decision

Decisions on appeals will be made at the sole discretion of the claims administrator and the Plan Administrator, in their respective roles, and will be final and binding on all persons.

You must properly file a claim for benefits and request an internal appeal of any complete or partial claim denial before seeking a review of your benefit claim in court. A court may require you to complete the external appeal process before hearing your claim. A decision on an internal appeal of a claim denial will be the final decision of the Plan. After the final decision is made by the Plan, you may seek an external appeal or judicial remedies in accordance with your rights under section 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA).

Any claim in court for benefits must be filed no later than 12 months after the date of the final decision on your appeal under the Plan, or the date of an external appeal decision, if later.

Conflicts of Interest

Each stage of claim decisions and appeals will be decided by a person or committee who is not subordinate to (does not "report to") the previous decision-maker. The employment terms, including compensation, of a person involved in a claim decision may not be based on the likelihood that a denial will be supported.

Additional Assistance

You may also contact the Employee Benefit Security Administration at (866) 444-3272 for assistance.