Each type of benefit described in the Summary Guide to Benefits has special claims and appeals procedures. It is important that you understand the complaint/grievance, claims, and appeals processes in order to protect your right to benefits in a timely manner and to receive appropriate care on a timely basis.
Each benefit booklet describes the specific claim and appeal procedures for that benefit, such as medical, dental, vision, disability. The benefit booklets, found at www.hr.pitt.edu/benefits include the contact information, special requirements for claims and appeals and should be referenced for all claims and appeal purposes as such claim and appeal provisions control the adjudication of the benefits in question. Otherwise, the general Plan’s claims procedures is intended to reflect procedures regulations and, for certain medical benefits, the applicable requirements of regulations issued under federal health care reform law, and should be interpreted accordingly. If there is any conflict between this summary and those regulations, the regulations will control. In addition, any changes in applicable law will apply to the Plan automatically effective on the date of those changes. Again, each benefit booklet describes the specific claim and appeal procedures to be used for that particular benefit.
The applicable complaint/grievance, claims, and appeals procedures are described in the “Resolving Disputes with UPMC Health Plan” section of the certificate of coverage for the University of Pittsburgh Health and Welfare Plan (“Plan”). The Plan has a specific amount of time to evaluate and process claims for benefits, which commences on the date the claim is first filed. There are processes in place to address urgent health care claims for which application of nonurgent care time frames could seriously jeopardize the life or health of the covered patient. You also have a limited period in which to appeal any adverse claim determinations.
Please familiarize yourself with these special procedures and your responsibility to take appropriate and timely action. For UPMC Health Plan, you may call the Member/Provider Services Department at 1-888-499-6885 for more information about filing a health care claim including an urgent care claim and appealing an adverse determination.