Currentculinary health fundPolicy N/A

Subrogation and Repayment for Accident-related Benefits

Governs Culinary Health Fund's right to recover medical benefits paid when a third party may be responsible for injuries, and the process participants must follow to have claims processed and repay the Fund from any recovery. Affects participants and their covered dependents who received accident-related benefits and may pursue claims or settlements.

Policy Summary

Payerculinary health fund

PolicySubrogation and Repayment for Accident-related Benefits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Statement of Facts, signed Repayment Agreement and HIPAA Authorization (and requested supporting documents) before the Fund will process medical bills when a third party may be responsible.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

45response timeframe (days)

15processing time (days)

$500example payment

$2,000example settlement

Firstrepayment priority

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Repayment and Processing Criteria

inv-01: Repayment and Processing Criteria

Conditions under which the Fund will process and recover benefits:

Submit a completed Statement of Facts and Repayment Agreement (and HIPAA Authorization and any requested supporting documents) before the Fund will process medical bills when a third party may be responsible.

If you or your attorney intend to pursue a claim or lawsuit and want the Fund to process bills prior to settlement, the Repayment Agreement must be signed by the participant (and attorney, if applicable) and returned to the Fund.

Upon settlement, the participant must reimburse the Culinary Health Fund from the settlement proceeds; the Fund is reimbursed the lesser of: the total benefits paid to date or the total amount recovered.

The Trustees may, upon written request showing special circumstances (for example lost wages, disability, insufficient recovery or other relevant factors), reduce the amount the participant must pay the Fund.

The Fund has first lien and subrogation rights on recoveries related to the accident; the Fund may notify and file liens, intervene or pursue recovery (including in the participant's name), and require attorneys to pay the lien prior to disbursing recovery.

Participants must cooperate fully with the Fund, including providing requested information and documents and notifying the Fund immediately upon starting any claim, lawsuit, or settlement negotiations.

Any failure to comply with this Agreement or the Plan's rules may be grounds to deny benefits or to offset future benefits, even if unrelated to the accident.

Accident inquiry and processing timing: provide requested Accident Inquiry information within 45 days to avoid denial; if information is received within 45 days, the claim will be processed within 15 days.

inv-02: Authorization form requirements and processing

Information captured and required elements for processing an authorization form.

Participant information fields: Collect participant: Last Name; First Name; Middle Initial; Date of Birth; SS # or Participant ID #; Phone; Street; Apt #; City; State; Zip.

Dependent information fields: Collect dependent (when applicable): Last Name; First Name; Middle Initial; Date of Birth; SS # or Participant ID #; Phone; Street; Apt #; City; State; Zip; Relationship to Participant/Member.

Purpose and release: Member must indicate purpose (At my request or For a different purpose) and identify person/organization to receive information, phone number, and relationship.

Information to release (select one or more): Options include ANY and ALL information; Explanation of Benefits; Eligibility; Enrollment; Itemization of Lien; Appeal; Other.

Billing and Recovery Rules

Billing/Codingmixed

No specific billing or diagnosis codes provided in this portion of the document.

Recovery cap rule

Recovery cap ruleFund is reimbursed the lesser of: (1) total benefits paid to date or (2) the total amount recovered from the third party (the lesser of benefits paid or recovery).

Trustees' discretion to reduce recoveryTrustees may reduce the amount owed for special circumstances (e.g., lost wages, disability, insufficient recovery) upon written request.

Obligation at settlementUpon settlement, participant/attorney must reimburse the Culinary Health Fund from settlement proceeds up to the cap amount described above.

Required Provider Steps and Consequences

Prior Authorization

Pre-processing requirements and Repayment Agreement

The Fund requires a completed Statement of Facts, Repayment Agreement, and HIPAA Authorization (plus supporting documents such as the police/incident report, auto insurance declaration page, and exhausted MedPay log if applicable) before it will process medical bills when a third party may be responsible. If you or your attorney intend the Fund to process bills prior to settlement, the Repayment Agreement must be signed and returned.

Submit completed Statement of Facts and Repayment Agreement (signed by participant and attorney if applicable) before Fund processes bills.
Include HIPAA Authorization and requested supporting documents: Police/Incident Report, Auto Insurance Declaration Page, Exhausted MedPay Log (if applicable).

Denial Risk

Consequences for noncompliance

Any failure to comply with the Repayment Agreement or the Plan's Rules and Regulations may be grounds to deny benefits, including denial of benefits unrelated to the Accident and offsetting future benefit claims.

Key Terms

Lien / Recovery

DefinitionLien/Recovery: The Plan has a first lien and subrogation rights on amounts recovered from another person (including an insurer) because of the accident; the Lien equals the Benefits the Plan paid or, if less, the total Recovery.

Scope of LienApplies to recoveries from judgment, settlement, or otherwise; Plan may notify and file the Lien to protect its rights.

EnforcementPlan may intervene in suits, file suit in participant's name, or require attorneys to pay the Lien prior to disbursing recovery.

Participant/Member and Dependent

Participant/MemberThe person who receives insurance coverage through their job (checkbox option on the authorization form).

DependentA family member covered under the participant/member's plan (checkbox option on the authorization form).

Policy Summary

Payerculinary health fund

PolicySubrogation and Repayment for Accident-related Benefits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Expiration: Member must select expiration: Not until I revoke; On this date (specify); When the following event occurs (specify). If no box is checked, authorization expires in one year.

Signature and legal notices: Authorization must be signed and dated by the person authorizing release; form explains that Culinary Health Fund cannot control information after release, revocation must be in writing to the Privacy Officer and does not affect information already released, and signing is voluntary and does not affect treatment/payment/enrollment/eligibility.

Administrative tracking (office use): Office fields: Date Received; Received By; Copy Mailed On; Copy Given to Patient On.

Noncompliance can result in denial of benefits payable under the Plan, even if those benefits are unrelated to the accident.
The Fund may offset future benefit claims by you or your dependents for noncompliance.

Documentation Required

HIPAA Authorization submission requirements

Authorization forms must be fully completed (all numbered sections) and match Fund records; incomplete or non-matching forms will be returned. Submit the form by fax to 860-747-4880 or by mail to Culinary Health Fund, C/O NexClaim Recoveries, 75 Farmington Valley Drive, Plainville, CT 06062.

If required sections are missing or information does not match Fund records, the Authorization may be returned for completion.
Fax: 860-747-4880; Mail: Culinary Health Fund, C/O NexClaim Recoveries, 75 Farmington Valley Drive, Plainville, CT 06062.

Documentation Required

Member authorization to release health information

A member may authorize the Culinary Health Fund to discuss and/or release specified health information for themselves or a dependent to a named person or organization, selecting items such as ANY and ALL information, Explanation of Benefits, Eligibility, Enrollment, Itemization of Lien, Appeal, or Other. The authorization must be signed and dated; if no expiration box is checked, it expires in one year. The member may revoke the authorization in writing to the Privacy Officer, but revocation does not affect information already released.

Selectable release items include: ANY and ALL information; Explanation of Benefits; Eligibility; Enrollment; Itemization of Lien; Appeal; Other.
Expiration options: Not until revoked; On a specified date; When a specified event occurs; default is one year if no box checked.
Signing is voluntary and does not affect treatment, payment, enrollment or eligibility.

Selection required on formThe authorization form requires checking whether the signer is the participant/member or a dependent.

Authorization

DefinitionAuthorization: A signed form authorizing Culinary Health Fund to use or disclose specified health information, which may include reports, correspondence, test results, diagnoses, or medical procedures.

Scope optionsForm allows release of ANY and ALL information, Explanation of Benefits, Eligibility, Enrollment, Itemization of Lien, Appeal, or Other (checkbox selections).

Expiration optionsAuthorization may expire when revoked, on a specified date, or upon a specified event; if no box checked, it expires in one year.

Revocation

Revocation methodWritten cancellation by notifying Culinary Health Fund's Privacy Officer in writing to revoke the Authorization.

Effect on previously released informationRevocation does not affect information already released prior to the Fund receiving the revocation.

Post-revocationIf revoked, additional information will not be released except as permitted or required by law.