Claims Procedures – Medical Benefit Claims; Dental Claims; Prescription Drug Benefit Claims Sample Clauses

Claims Procedures – Medical Benefit Claims; Dental Claims; Prescription Drug Benefit Claims. The Fund does not administer medical benefit claims, dental claims or prescription drug benefit claims. The Trustees have delegated the responsibility of administration and processing of medical benefits claims, dental claims and prescription drug claims to Blue Cross Blue Shield of Massachusetts and or Express Scripts, Fallon Health Plan and Xxxxx Vision. Each of these organizations has sole and complete discretionary authority to determine claims and appeals in accordance with the terms of the documents or instruments governing the plan in which you are enrolled. The claims procedures utilized by these organizations must comply with all federal laws applicable to group health plans including but not limited to ERISA, the Patient Protection and Affordable Care Act of 2010, as amended and the applicable regulations promulgated there under. Each of these organizations has agreed to conduct internal appeals in accordance with all federal laws applicable to group health plans. However, only Blue Cross Blue Shield of Massachusetts and or Express Scripts have agreed to conduct external appeals in accordance to federal laws applicable to group health plans. For those organizations who do not conduct external appeals, the plan has retained three (3) Independent Review Organizations to administer external appeals for these claims. Attached hereto as Exhibit “B” is the procedures to be followed by the medical claims reviewers/administrators who are acting on behalf of the Fund.
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