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Medical Benefits

The Plans

If you are a regular, active member, your medical plan is determined by the contribution paid by your employer as required by your collective bargaining agreement. Your medical benefits are provided under the:

Building Trades Plan (also known as the Comprehensive Major Medical Plan), or
The Flexible Choice Plan

If you are a member of the CW/CE classification, your medical plan is the Flexible Choice Plan.

The medical plans are administered by the Fund under a network agreement with Highmark Blue Cross and Blue Shield which provides discounts for services received from PPO providers. However, the calendar year deductible, coinsurance and other coverage amounts differ by plan.

When you receive care from a PPO network provider, both you and the Fund save money.

The PPO Network

When you need care, you have the option to go in- or out-of-network. The medical plans use the Highmark Blue Cross and Blue Shield Preferred Provider Organization (PPO) network.

When you use a PPO provider, you receive the highest level of benefits because the providers have agreed to charge negotiated, discounted rates. Pre-negotiated rates offer savings for you and the Fund. Plus, when you use PPO providers, the calendar year deductible is lower.

You have the option to visit providers outside the PPO network. However, when you do, your deductible and copayment (out-of pocket expenses) are higher because non-PPO providers do not offer negotiated rates.

Is your provider in the Highmark Blue Cross and Blue Shield PPO Network?

How to Find a PPO Provider

Call 1-800-810-2583 or visit highmarkbcbswv.com/home/

PPO Network cost-savings example.

Using PPO providers can save you money. The example below compares what Jason would pay for hospital expenses at a PPO network hospital and a non-PPO hospital. It assumes Jason is enrolled in the Building Trades Plan, he is participating in the Healthy Life Program, and has not satisfied his calendar year deductible.

	PPO Hospital	Non-PPO Hospital
Hospital Charge	$4,381	$4,381
PPO Network Discount	$1,593	$0
Net Covered Charges	$2,788	$4,381
Deductible (paid by Jason)	$350	$700
Expenses Subject to Reimbursement	$2,438	$3,681
Plan pays	$1,950.40 (80% of $2,438)	$2,208.60 (60% of $3,681)
Jason Pays	$837.60 (20% of $2,438 + deductible)	$2,172.40 (40% of $3,681+ deductible)

Jason saves $1,334.80 using a PPO-network hospital. This example reflects actual savings from a network PPO provider. Your actual savings may vary, depending on your plan and the specifics of your hospital confinement.

Pre-certification Requirements

Lyra Health Hospital Pre-Admission Certification Program

Either you or your provider must call Lyra Health at 877-363-0489 to precertify an inpatient hospital admission for mental health and/or substance abuse treatment.

Inpatient treatment for mental health and substance abuse

Either you or your provider must call Lyra Health at 1-877-363-0489 to pre-certify inpatient hospital treatment for mental health and substance abuse. In an emergency, seek care immediately, then call your primary care doctor as soon as possible for further assistance and directions on follow-up care.

Once you or your physician contacts Lyra Health, they will determine the appropriateness of your hospitalization as soon as possible, and within 15 days. If additional information is needed from you or your physician to make the decision, you will be notified as to what information must be submitted. You and/or your physician will have at least 45 days to submit the additional information. Once Lyra Health receives the information from you or your physician, you will be notified of the decision on the claims, generally within 10 days.

In the event that Lyra Health does not approve the admission as requested, a denial or “Adverse Benefit Determination” will apply and you will receive a Notice of the Adverse Benefit Determination that includes:
- The specific reasons for the adverse benefit determination;
- The specific reference to the Plan and/or Summary Plan Description provisions on which the adverse benefit determination was based;
- A description of any additional materials or information necessary for you to perfect your claim and an explanation of why such material or information is necessary;
- The notice of any internal guidelines or protocols used in making the decision, if applicable, and your right to receive a copy;
- A notice of your right to a written explanation of any exclusion which affects your claim; and
- A description of Lyra Health’s appeals procedure.
Learn more about the Plan’s Hospital Pre-Admission Certification Program for treatment of mental health and substance abuse.

Filing Medical Claims

When you use a PPO network provider, you do not need to file a claim. In most cases, the provider will submit all necessary claim information to the Fund’s Claims Administrator on your behalf. Any reimbursements are sent directly to the provider.

Regardless of whether the provider participates in the PPO network or not, when you receive health care services you should:

Show your identification card to the provider of service; and
Ask the provider to file a claim for you.

How to submit a medical claim.

In some cases, for instance if you receive your care from a non-PPO provider, you may have to submit a claim for benefits directly to the Fund’s Claims Administrator. If you must submit a claim for health care services received, you should:

Obtain an itemized bill from the hospital, doctor, or medical facility. An itemized bill generally includes all of the following:
- Patient’s name and address
- Date of Service
- Type of Service and diagnosis
- Itemized charges
- Provider’s complete name, address, and tax identification number
Download a claim form.
Complete the claim form and attach the itemized bill to the form.
Send the claim form and bill to the address on the claim form.

Payment for eligible benefits will be made to the health care vendor unless your claim includes a paid receipt. If a receipt is submitted with your claim, payment will be sent to you.

A claim is not considered filed until it is received by the Fund’s Administrative Office. The Fund’s Administrative Office will process your claim within 30 days of the date it is filed, unless special circumstances require additional processing time. If additional information is needed to process your claim, the Fund may request additional information from you or the provider. You and/or your physician will have at least 45 days to submit the additional information.

When certain expenses are not eligible under the Plan, you will be notified by the Fund’s Administrative Office that the claim is denied, with an explanation of the reasons for the denial. You will receive a Notice of the Adverse Benefit Determination in writing which contains the following:

The specific reasons for the adverse benefit determination;
The specific reference to the Plan and/or Summary Plan Description provisions on which the adverse benefit determination was based;
A description of any additional materials or information necessary for you to perfect your claim and an explanation of why such material or information is necessary;
The notice of any internal guidelines or protocols used in making the decision, if applicable, and your right to receive a copy;
A notice of your right to a written explanation of any exclusion which affects your claim; and
A description of this Plan’s Appeals Procedure (see the next section).

Internal and external appeal review process.

For internal appeal reviews, the following standards apply:

An adverse benefit determination includes rescissions of coverage, pre- and post-service claim determinations, exclusions, limitations, and eligibility determinations;
Benefit determinations relating to urgent care claims generally must be made to claimants within 24 hours of receipt of the claim;
Claimants must be provided, free of charge, with any new or additional evidence considered, relied upon or generated by the Plan in connection with the claim;
Notices must be provided in a culturally and linguistically appropriate manner;
All claims and appeals must be handled in a way that is designed to ensure impartiality;
Notices to claimants must provide additional content such as identifying information on the claim, denial codes, description of available appeals processes and contact information for health insurance consumer assistance.

For external appeal reviews, the following standards apply:

Request For External Review: Claimants will be allowed to file a request for an external review, provided that the request is filed within four months of the date of the notice of adverse benefit determination (denial).
Preliminary Review: Within five business days of receipt of the request for an external review, the plan will complete a preliminary review of the request to determine whether the claimant was a participant in the plan at the time of the service, whether the participant had exhausted all of the plan’s internal appeal processes and whether the claimant has provided all information and forms necessary to proceed with an external review.
Within one business day after the completion of the preliminary review, the plan will issue a notification in writing to the participant identifying any deficiencies with regard to the ability to proceed to the external review process. The participant will then be entitled to supply information and materials needed to make the request complete. Note that for an urgent care issue, the preliminary review must be done immediately and the claimant must be then immediately notified.
Referral to Independent Review Organization (IRO): The Plan must contract with at least three (3) IROs. Within five (5) business days after assignment to an IRO, the Plan must provide all documents and information considered in denying the appeal to the IRO; for an urgent care issue, the information must be sent electronically, by fax or other expeditious means). The IRO must provide written notice of its decision within 45 days of assignment; for urgent care issues, the IRO must provide notice of its decision as soon as possible but in no event more than 72 hours after receipt of the request for expedited external review.
Implementation of Reversal: Upon receipt of notice of final external review decision reversing an adverse benefit determination, the Plan must immediately provide coverage or payment (including immediately authorizing or immediately paying benefits for claim).

Before receiving outpatient mental health and substance abuse treatment, you must contact Lyra Health for a referral at 1-877-363-0489

Benefit Summary: Flexible Choice Plan

Vision Benefits