Claims Appeal Procedure

PURPOSE: This rule sets forth the procedures to be followed in the event a person wishes to appeal a claim payment decision. (1) If a fund participant or beneficiary disagrees with a payment decision, he or she must send or deliver the objection(s) or reason(s) for the disagreement in writing to the party designated by the board to process claims within one hundred eighty (180) days of the date the check or the claim denial is issued. (2) The board’s agent or staff responsible for processing claims must then review the appeal and respond in writing to the fund participant or beneficiary within thirty (30) days of receipt of the appeal. (3) If the fund participant or beneficiary still disagrees with the administrator’s decision, he or she may request further review by sending a written request within sixty (60) days of receipt of the administrator’s decision to the board’s executive director. (4) The executive director will then review the claim file and the previous decisions, and will respond in writing to the fund participant or beneficiary within thirty (30) days of receipt of the request. The executive director must— (A) Affirm the decision previously made; (B) Refer the appeal to the board of trustees; or (C) Specify additional information or clarification which is needed. In this case, the executive director must then take one (1) of the two (2) steps listed above within thirty (30) days of receipt of the additional information or clarification, or, if no response is received, may terminate the appeal. (5) If the executive director affirms the previous decision, and the fund participant or beneficiary is still dissatisfied, he or she may request review by the board by sending a written request within sixty (60) days of receipt of the executive director’s decision to the board’s mailing address. (6) If this occurs, or if the executive director refers the appeal to the board, the board will consider the appeal at one (1) of its two (2) next regularly-scheduled meetings. Board deliberations will be in a “non-contested hearing” format; the fund participant or beneficiary will have opportunity to present information to the board in open session, and the board may also hear a presentation from its staff or third-party administrator. The board may limit the time allowed for such presentations. The board may deliberate and make its decision in closed session in accordance with section 610.021, RSMo. The board’s decision will be communicated in writing to the fund participant or beneficiary within fourteen (14) days after the board meeting at which a decision is made. (7) While the board may, at its sole discretion, choose to consider an appeal which is not submitted according to the deadlines imposed by sections (1), (3) or (5) of this rule, it is under no obligation to consider or take action on such requests, and may deny a claim based upon the failure to timely comply with the deadlines stated in this section. AUTHORITY: section 319.129, RSMo Supp. 1998.* Original rule filed April 1, 1999, effective Nov. 30, 1999. *Original authority: 319.129, RSMo 1989, amended 1991, 1996, 1998.