How to File a Claim

Filing a Claim

To receive benefit payment under the Plan, you or your provider must properly file a claim within 180 days after services or supplies were provided.

Please note: For purposes of the Plan’s claims and appeals procedures, a claim does not include the following: (i) casual inquiries about benefits or the circumstances under which benefits might be paid under the terms of the Plan; or (ii) mere requests for advance information on the Plan’s possible coverage of items or services. 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

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 the claims administrator determines that additional time is necessary, 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.

Upon receipt of your claim, if the claims administrator determines that additional information is necessary in order for it to be a properly filed claim, the claims administrator will provide you with 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. The claims administrator will notify you of its benefit determination within 15 days following receipt of the additional information.

If a claim for benefits is denied, in whole or in part, you or your beneficiary(s) will receive written notice of the decision. The written notice will include the following:

• The specific reason(s) for the denial or decision
• 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 claim review procedure 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
• If an internal rule, guideline or protocol, or other similar criterion ("criterion") was relied upon in making the denial, either the:
  • Specific criterion used, or
  • A statement that such criterion 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 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.

Appeal Procedure

The Vision 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. 

Questions and Complaints

If you have a question or complaint, an initial attempt should be made to resolve the problem by directly communicating with Member Services. In most cases, Member Services 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 Level I Appeal process 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.

Level I - 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, you must request an appeal within 180 days from the date you received notice of the adverse benefit determination. A provider can also submit an appeal of an adverse benefit determination or preauthorization decision on your behalf.

  You must submit your request in writing to the following address:

  Alliance Coal, LLC
  Attn: Plan Administrator
  PO Box 1950
  Tulsa, OK 74101-1950

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

  As part of the appeal 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 Level I Appeal Process

  The claims administrator will review your appeal, provided that 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, investigational, or not medically necessary or appropriate, the claims administrator 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 claims administrator in connection with an adverse benefit determination.

• Timing for Decisions on Level I Appeals

  The claims administrator will provide you a written decision on your appeal no later than 60 days following the date your appeal is received.

• Adverse Decision on Level I 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
  • 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 any voluntary appeal procedures offered by the Plan and a statement of your right to bring a court action under section 502(a) of ERISA instead of using the voluntary appeal procedure
  • If an internal rule, guideline or protocol, or other similar criterion ("criterion") was relied upon in making the denial, either the:
    • Specific criterion used, or
    • A statement that such criterion 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 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

Level II - Voluntary Reconsideration Process

After exhaustion of the Level I appeal process outlined above, you may submit a benefit dispute to the Plan Administrator for reconsideration.

The Plan Administrator will not charge you any fees or costs as a part of the voluntary review process. If you elect to pursue your voluntary review rights, any statute of limitations or other defense based on timeliness will be tolled during the time that any voluntary review is pending.

The Plan Administrator cannot claim that you failed to exhaust the administrative remedies available to you for failing to submit the benefit dispute to the Plan Administrator's voluntary review process.

To request Level II reconsideration of your benefit determination, you should submit your request in writing within 180 days of the date your appeal was denied to the following address:

Alliance Coal, LLC
Attn: Plan Administrator
PO Box 1950
Tulsa, OK 74101-1950

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

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, investigational, or not medically necessary or appropriate, the Plan Administrator 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.

You have the right to receive, upon request, enough information relating to the voluntary level of appeal to allow you to decide whether to submit your benefit dispute to the voluntary level of appeal. The information you receive should include:

• A statement that your decision will have no effect on your rights to any other benefits under the Plan; and

• Details of the applicable rules, your right to representation, the process for selecting the decision-maker, and the circumstances, if any, that may affect the impartiality of the decision-maker (such as any financial or personal interests in the result or any past or present relationship with any party to the review process).

If your voluntary appeal is denied, you will receive a written explanation of the denial within 60 days following the date your appeal is received. The explanation will include the same type of information included in an internal appeal response (described above).

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 a Level I appeal of any complete or partial claim denial before seeking a review of your benefit claim in court. A decision on a Level I appeal of a claim denial (or a Level II appeal, if you file one) will be the final decision of the Plan. After the final decision is made by the Plan, you may seek 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 365 days after the date of the final decision on your appeal.