Coastwise Indemnity Plan Appeal Process

The Coastwise Indemnity Plan has an appeal process in the event preauthorization or payment of your medical claim is denied or partly denied. The stages of this process are: Appealing the Denial of Preauthorization (if applicable), Full and Fair Review, Arbitration, Judicial Review.

​Below are descriptions of how to navigate each of these processes. 

Appealing the Denial of Preauthorization

When preauthorization of a procedure is denied by Innovative Care Management (ICM), there are steps you can take before requesting a Full and Fair Review:

• First, gather all medical documentation and provide it to ICM. It is possible you have new information that may change the outcome of their review.
• If preauthorization remains denied after you have ensured ICM has all documentation, your next option is a peer-to-peer review. You are allowed one peer-to-peer review per case and your treating provider must request a peer to peer review. ICM explains the process for a peer to peer when they make the denial notification (by phone or fax).In a peer-to-peer review, an ICM doctor contacts your provider to discuss the procedure.
• If preauthorization is still denied after following these steps, begin a Full and Fair Review as outlined below.

Full and Fair Review

Participants in the Coastwise Indemnity Plan who experience a claim denial or denial of preauthorization may be able to appeal the decision through a Full and Fair Review. Below is a brief description of how to navigate this process:

• To begin a Full and Fair Review:
  • Write a letter addressed to the Trustees of the ILWU-PMA Welfare Plan, c/o ILWU-PMA Benefit Plans, 1188 Franklin St, Ste. 101, San Francisco, CA 94109.
  • Be specific about what you are appealing. For a denied claim, include the date of service and provider(s). For a denial of preauthorization, include the procedure. The request to appeal must be made within 1 year of the denied medical claim, or within 180 days of the preauthorization denial.
  • Sign and date your letter.

 

• Once a Full and Fair Review is received in the Benefit Plans Office:
  • The Benefit Plans Office will contact all Coastwise Indemnity Plan vendors to obtain all documents related to the claims in question.
  • Your personal information is removed from the documents and they are referred to the Trustees along with a description of the denied claim(s).
  • When the Full and Fair Review file is sent to the Trustees for their review, you will receive a letter from the Benefit Plans Office. You will receive a second letter from the Benefit Plans Office letting you know the outcome of your appeal. It generally takes 60 days from the date of your request letter to provide a decision.
  • The Full and Fair Review will either be approved or denied:
    • If both the Union and Employer Trustees agree to approve, the appeal is approved.
    • Under any other circumstances, the appeal is denied.
      • If your Full and Fair Review is denied, your next option is arbitration. There is more information on that process below.​
• For further guidance or to ask about the status of your Full and Fair Review, please call the Benefit Plans Office at our  phone number (415) 673-8500 or (888) 372-4598.

Arbitration

If your appeal remains denied following a review by the Trustees, you may request Arbitration. Below is a description:

• If you are denied in the Full and Fair Review process, you may request Arbitration of the same issue. The request for arbitration must be made within 180 days of the Full and Fair Review denial letter.

• Beginning the Arbitration process requires a new letter:
  • Write a letter to the attention of the Trustees of the ILWU-PMA Welfare Plan.
  • Request Arbitration of your appeal. State whether you wish your Arbitration to be held in writing or a live hearing (see below for more detail on this option).
  • Sign and date your letter.
  • Mail your letter to ILWU-PMA Benefit Plans, 1188 Franklin St, Ste. 101, San Francisco, CA 94109.

• At the time you request Arbitration, you must decide if it will be held in writing or as a live hearing. Both methods take a minimum of several months to complete.
  • Arbitration held in writing generally has four stages. Each generally takes a minimum of a month:
    • 1) submission of your opening statement,
    • 2) submission of replying statements made on behalf of the Union and/or Employer Trustees,
    • 3) submission of your closing statement,
    • 4) the Arbitrator renders a binding decision.
  • Live Arbitration hearings are held in San Francisco. If you choose this option, you are responsible for your own travel to and lodging in San Francisco. It generally takes several months to coordinate the calendars of the Arbitrator and the Trustees or their representatives for a live hearing.

• Arbitration may result in complete approval, complete denial, or an in-between outcome depending on the order(s) of the Arbitrator.

• For further guidance or to ask about the status of your Arbitration, please call the Benefit Plans Office at our phone number (415) 673-8500 or (888) 372-4598.

Judicial Review

• A claimant has the right to file a suit in a court of law if a claim is denied or partly denied by the Coast Arbitrator. Plan provisions and applicable law require, however, that the claimant first exhaust all of his or her appeal rights under the Plan. This means that a claimant must obtain determinations by the Trustees and by the Coast Arbitrator before he or she may file a lawsuit for a benefit under the Plan.

For Your Information

Under paragraph 5.45 of the ILWU-PMA Welfare Plan, you are entitled to receive, upon request, all documents, records, and other information relevant to your claim free of charge.  You are also entitled to receive, upon request, an explanation of: (1) the scientific or clinical judgment that forms the basis of the Trustees’ determination; and (2) an explanation applying the terms of the Plan to your medical circumstances free of charge.  Please direct any request for this information to the Benefit Plans Office, located at:

ILWU-PMA Benefit Plans
1188 Franklin Street, Suite 101
San Francisco, CA  94109