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Administration > Health Care Plans
Health Care Plans
Administrative and claims services for the health care plans are provided by:
Medical Plan
UnitedHealthcare Insurance Company
450 Columbus Boulevard
Hartford, CT 06115
1-860-702-5000
Prescription Drug Program
Express-Scripts
225 Summit Avenue
Montvale, NJ 07645
1-800-711-0917
Dental Plan
Delta Dental Plan of New Jersey
P.O. Box 222
Parsippany, NJ 07054
1-877-738-3384
These administrators do not insure your benefits. The above plans are self-insured by the Company. This means that the Company funds benefits for these plans from its general assets.
No contracts of insurance exist with respect to benefits under these plans, and no insurance company insures your benefits.
Request for Review of Health Care Claims
If you wish to request a review of a medical, prescription, or dental claim, send your written request for review, including the reasons you believe you are entitled to benefits, together with all supporting documents to the Claims Administrator at:
Medical Claims
UnitedHealthcare Appeals
P.O. Box 740816
Atlanta, GA 30374-0816
Prescription Claims
Express-Scripts
225 Summit Avenue
Montvale, NJ 07645
1-800-711-0917
Dental Claims
Delta Dental of NJ
1639 Rte 10
Parsippany, NJ 07054
The Claims Administrator will notify you as follows:
Urgent Care Claim
Urgent care means any claim for medical care or treatment where denial of such care could seriously jeopardize your life or health or your ability to regain maximum function; or in the opinion of a physician, with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. Your treating physician can designate a claim for urgent care.
A claim will be considered to be an urgent care claim if an individual acting on behalf of the plan, applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine, determines the claim to be an urgent care claim. Also, any claim that a physician with knowledge of the claimant's medical condition determines is an urgent care claim within the meaning of this section shall be treated as a claim involving urgent care for the purposes of this section.
You will be notified of any determination on your claim (whether favorable or unfavorable) as soon as possible, but not later than 72 hours after your claim is received. However, if you do not provide sufficient information to determine whether benefits are payable under the plan, the Claims Administrator will notify you as soon as possible, but no later than 24 hours after receipt of the claim. You will have at least 48 hours to provide the necessary information. The Claims Administrator will notify you of its determination (whether favorable or unfavorable) as soon as possible, but no later than 48 hours after the Claims Administrator receives the additional information required (or, if earlier, the date by which the Claims Administrator required you to submit the additional information). If your claim is being denied, you will receive notice of the denial as described below. The initial notice of denial of your urgent care claim may be provided orally, provided that written notification is provided to you within three days after the oral notification.
Concurrent Care Decisions
This section applies if you have already received approval for an ongoing course of treatment to be provided over a period of time or a specified number of treatments.
  • Reduction/Termination in Course of Treatment: Any decision to reduce or terminate a previously approved course of treatment (unless the Plan is being terminated altogether) will be considered a denial of a claim for benefits. You will receive sufficient advance written notice of the reduction or termination to allow you to obtain a review of the decision before the course of treatment is reduced or eliminated. The notice will be provided as described below.
  • Requesting an Extension of a Course of Treatment: If you wish to request an extension of a course of treatment beyond the initial period of time or number of treatments for which you previously received approval, and if the request involves urgent care, you must make such request at least 24 hours prior to the expiration of the previously-approved course of treatment. You will be notified in writing of the decision whether to extend your course of treatment as soon as possible, but no later than 24 hours after receipt of your request. If your request does not involve urgent care, your claim will be treated as a regular pre-service claim. If your request is being denied, you will receive notice as described below.
Pre- and Post-Service Claims
A Pre-Service Claim is a claim for a benefit under a group health plan that requires prior approval from the plan in order to ensure full benefit coverage.
A Post-Service Claim is a claim for a benefit under a group health plan that does not require pre-approval before receiving care.
If your claim under the plan is totally or partially denied, you will be notified of the decision, after the Claims Administrator's receipt of your claim within the time limit shown below for the type of claim submitted:
Initial Notification Period by Type of Claim
Urgent Care
Pre-Service
Post-Service
72 hours
15 days
30 days
A decision regarding your request for the Plan to approve an on-going course of treatment will be made far enough in advance of the proposed reduction or termination of treatment to allow you to appeal before the benefit is reduced or terminated.
Under special circumstances, the notification period may be extended for the time period shown below for the type of claim submitted:
Extension of Initial Notification Period by Type of Claim
Urgent Care
Pre-Service
Post-Service
24 hours
15 days
15 days
If an extension is required, you will be notified of the special circumstances involved and the date by which the Claims Administrator expects to render a final decision. If the extension of time is required because you failed to provide information necessary to decide the claim, the notice of extension will describe the additional required information and you will be notified of the deadline for providing the specified information.
If your claim is denied, the Claims Administrator will provide you with a written or electronic notification of an adverse benefit determination. The notice will:
  • Provide the specific reason(s) for the denial
  • Refer to the specific plan provisions on which the denial is based
  • Describe any additional information necessary for you to complete your claim and explain why such information is necessary
  • Describe the plan's review procedure and the time limits that apply to your right to appeal, including your right to bring a civil action under federal law following an adverse benefit determination on review
  • If the plan relied on a specific internal rule or guideline to make the adverse determination, provide (1) an explanation of the rule or guideline, or (2) a statement that a specific rule or guideline was relied upon and that a copy of the rule will be provided to you free of charge upon request
  • If the adverse determination is based on medical necessity, experimental treatment, or similar exclusion or limit, provide either an explanation of the clinical judgment for the determination or a statement that such an explanation will be provided free of charge upon request
  • In the case of an adverse determination for urgent care, describe the expedited review process applicable to such claims.
In the case of an adverse benefit determination involving a claim for urgent care, the information described above may be provided to you orally within the permitted time frame provided that written or electronic notification is furnished to you no later than three days after such oral notification.
 
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