PG&E's Voluntary Review Process
If you are not satisfied with the claims and appeals process completed with Anthem Blue Cross, you may elect to either use PG&E's Voluntary Review Process or elect to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974 ("ERISA"). You have 90 days from the date of receipt of the final decision from Anthem Blue Cross to elect this voluntary review. Initiation of the Voluntary Review Process does not restrict your ability to bring a civil action against the Plan. However, before you can initiate the Voluntary Review Process or take civil action, you must go through both levels of appeal provided through Anthem Blue Cross.
Step 1
The first step of the Voluntary Review Process is to write to the Benefits Department, requesting a review of your appeal. Your appeal should include all pertinent documentation. To expedite processing, you should also include a HIPAA AUTHORIZATION FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION form. You can access a copy online from the Human Resources Forms section of the PG&E@Work intranet or by calling the PG&E Benefits Service Center at 866-271-8144 (open weekdays from 7:30 a.m. to 5 p.m. Pacific time).
Send your appeal to:
Pacific Gas and Electric Company
Benefits Department
Appeals — Step One
1850 Gateway Blvd, 7th Floor
Concord, CA 94520
The PG&E Benefits Department will review your appeal and make a decision within 60 days of the date on which the appeal is received (non-receipt of the HIPAA Authorization form may delay your appeal). There may be special circumstances where an extension of up to 90 days may be required. You will be notified if such an issue occurs.
If your claim deals with specific medical issues, the Benefits Department may suggest that your claim be submitted to an External Review Program as part of the first step of the Voluntary Review Program. The External Review Program entails having an independent third party review the claim in question. This program only applies if the decision is based on either of the following:
  • clinical reasons such as previous denials for medical necessity, custodial care or cosmetic services; or
  • the exclusions for Experimental or Investigational Services.
The External Review Program is not available if the coverage determinations are based on explicit benefit exclusions or defined benefit limits. The External Review Program is optional, and its costs are paid by the Plan. If the External Review Program recommends that the claim be covered, the Benefits Department will instruct the Claims Administrator to abide by the recommendation of the External Review Program.
If the Benefits Department denies your claim, you will receive a written response that will include:
  • the reason(s) for the denial;
  • a reference to the Plan provision(s) that apply to the denial; and
  • an explanation of additional appeals procedures.
Step 2
The second step of the Voluntary Review Process is to submit your appeal to an independent neutral third party for review. The third-party reviewer will be selected from a predetermined panel of arbitrators familiar with benefits law. You have the option of submitting the same written appeal prepared for Step One or may choose to supplement the Step One write-up with additional written material. The neutral third party will issue a written decision within 45 days of receipt of the appeal documentation from PG&E. The neutral third party's decision shall be final and binding on the Plan, but not on you.
You have 60 days from receipt of a denied appeal in Step One to exercise your right to initiate the second step of the Voluntary Review Process. Send your written appeal with any additional information to:
Pacific Gas and Electric Company
Benefits Department
Appeals — Step Two
1850 Gateway Blvd., 7th Floor
Concord, CA 94520
If you are not satisfied with the decision resulting from Step Two of the Voluntary Review Process, you may bring a civil action under Section 502(a) of ERISA.
If you would like more information regarding the Voluntary Review Process, call the PG&E Benefits Service Center at 866-271-8144 (open weekdays from 7:30 a.m. to 5 p.m. Pacific time).
Requirement to File an Appeal Before Filing a Lawsuit
You must exhaust all mandatory Anthem Blue Cross appeals before you may bring a civil action under Section 502(a) of ERISA. You do not have to pursue the PG&E Voluntary Review Process.