Claims and Appeals Process for ValueOptions (VO)
Note: For information about claims and appeals regarding your eligibility to participate in The Pacific Gas and Electric Company Health Care Plan for Retirees and Surviving Dependents or to make election changes to your coverage under the Plan, see the Claims and Appeals Process and Health Care Participation sections.
Claims
Filing a Claim for Benefits
ValueOptions is the Claims Administrator for the Mental Health and Substance Abuse program. As the Claims Administrator, ValueOptions contracts with a network of providers and facilities and processes claims for services.
If you use a network provider or facility, the provider will send the claim directly to ValueOptions for payment. Claim forms are available by calling ValueOptions at 800-562-3588.
NAP and CAP members who receive care from non-network providers should submit claim forms to VO. All claims must be made within two years of the date on which services or supplies were received. Claim forms are available by calling VO at 800-562-3588 or the PG&E Benefits Service Center at 866-271-8144 (open weekdays from 7:30 a.m. to 5 p.m. Pacific time).
You should only direct claims for the treatment of mental health and substance abuse to VO. Claims for all other medical services should be submitted to Anthem Blue Cross if you are enrolled in one of the plans administered by Anthem Blue Cross, or to your Health Maintenance Organization (HMO) if you are enrolled in an HMO.
Inquiries, Benefit Certifications, and Claims
If you have a question, an issue or complaint regarding your Mental Health and Substance Abuse benefits, you should contact ValueOptions at 800-562-3588. Many problems, complaints or potential claim issues can be resolved informally.
Most requests for services and inquiries can be handled over the telephone. If you wish to find a network provider, you may call ValueOptions at 800-562-3588. If you would like to receive a benefits certification, which is a pre-approval of coverage for services, you or your provider should also call 800-562-3588. Generally, a determination of your benefit request will be made by the end of the telephone conversation and will be confirmed with a written notification from ValueOptions. If the benefit certification cannot be made at the time of the phone call, you will receive a written notification from ValueOptions of the decision. The type of benefit certification requested will determine the timeframe for the receipt of notification.
The processing timeframes for receipt of benefit certifications are as follows:
  • Urgent care — where a delay in treatment could jeopardize your life or health — within 72 hours of receipt of your request.
  • Non-urgent — a request for services that require pre-authorization-within fifteen calendar days of receipt of your request.
  • Concurrent care — a request for continuation of current treatment-within one day for urgent requests, fifteen calendar days for non-urgent requests.
For urgent care and urgent concurrent care certifications, notification by telephone will be made to your provider at the time of the determination, along with written notification to you and your provider.
If you have questions regarding a claim for non-network services, you should also call ValueOptions at its toll-free number. If you submit a claim for services received, ValueOptions will process your claim and notify you of its disposition within 30 days of receipt of the claim.
Appeals
Pre-Service Appeals — Non Urgent
If you are not satisfied with ValueOptions' initial determination or benefit certification resolution or you believe you have received some other type of adverse benefit determination that is preventing you from receiving the services you requested in the process of trying to obtain a benefits certification, you can appeal the benefit denial/determination within 180 days of receipt of the denial or adverse determination. Your appeal may be made in writing or by calling ValueOptions at 800-562-3588. If you submit your appeal in writing, you must include the following information: your name, member ID, phone number, the service for which benefit coverage has been denied, and any additional information that may be relevant to your appeal. The appeal should be sent to:
ValueOptions
Attention: Appeals
P.O. Box 6065
Cypress, CA 90630-0065
ValueOptions will mail you a decision notice within 15 calendar days of receipt of your appeal. The notice will include the specific reason(s) for the decision and the Plan provision(s) on which the decision was based. You have the right to receive, upon request only and at no charge, the information used by ValueOptions to review your appeal.
If you are not satisfied with ValueOptions' decision, you have 90 days from the date of your receipt of the decision notice to request a second level of appeal. To initiate a second level of appeal, you can submit the appeal in writing by sending it to the ValueOptions address or you can call ValueOptions at 800-562-3588. A professional committee composed of two or more members who were not involved in the initial decision will conduct the review. The decision regarding your request will be sent to you within 15 calendar days of its receipt. If at this point your appeal is denied, you can bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974 ("ERISA") or initiate PG&E's Voluntary Review Process.
Pre-Service Appeals — Urgent
If your appeal for coverage involves urgent care, you can request an expedited review by telephoning or writing to ValueOptions. You will be notified of the benefit determination within 72 hours of ValueOptions' receipt of the appeal. A Medical Department representative will contact your provider to schedule a time for a telephone review of your case. Your provider will be advised of the determination at the end of the telephone review. A written notification of the decision will be sent to you and your provider within three calendar days of the verbal notification. If you or your provider has additional information to be included in the appeal, you will need to provide the additional information within three days of the appeal request.
An urgent appeal is any claim for treatment with respect to which the application of the time periods for a non-urgent care determination could seriously jeopardize the life or health of the claimant or the claimant's ability to regain maximum function or, in the opinion of a physician with knowledge of the claimant's medical condition, could subject the claimant to severe pain that cannot be adequately managed.
If you receive an adverse benefit determination on your appeal, you have the right to further appeal the decision. You have 90 days to request a second level of appeal. A professional committee composed of two or more members, or a board-certified MD Peer Advisor, who were not involved in the initial decision, will conduct the review. A benefit determination will be sent to you and your provider within 15 calendar days of your request. You may submit the appeal in writing or by calling ValueOptions at 800-562-3588.
The appeal should be sent to:
ValueOptions
Attention: Appeals
P.O. Box 6065
Cypress, CA 90630-0065
If at this point your appeal is denied, you can bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974 ("ERISA") or initiate PG&E's Voluntary Review Process.
Post-Service Appeals
If you believe that your claims were processed or denied incorrectly, you can try to resolve the issue informally as described under "Inquiries, Benefit Certifications, and Claims" under "Claims and Appeals Process for ValueOptions (VO)." If this approach is unsatisfactory, you may appeal the initial claim determination. To initiate an appeal, you must write or telephone ValueOptions (800-562-3588) within 180 days of receipt of the claim processing determination. Your appeal must include the following information: your name, member ID, phone number, a copy of the denied or incorrectly processed claim and any additional information that may be relevant to your appeal. Written appeals should be sent to:
ValueOptions
Attention: Appeals
P.O. Box 6065
Cypress, CA 90630-0065
A decision notice will be mailed to you within 30 days of receipt of your appeal. The notice will include the specific reason(s) for the decision and a reference to the Plan provision(s) on which the decision was based. You also have the right to receive, only upon request and at no charge, the information that ValueOptions used to review your appeal. If the information you submit with your appeal is incomplete, you will be notified by letter of the additional information needed. If you do not send the information within 45 days of the date on which you received the letter, an administrative denial may be issued.
If at this point your appeal is denied, you can bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974 ("ERISA") or initiate PG&E's Voluntary Review Process.
PG&E's Voluntary Review Process
If you are not satisfied with the claims and appeals process completed with ValueOptions, you may elect to use either PG&E's Voluntary Review Process, or elect to bring a civil action. You have 90 days from the date of the receipt of the final decision from ValueOptions to elect this voluntary review. Initiation of the Voluntary Review Process does not restrict your ability to bring a civil action against the Plan.
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 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.
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.
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. 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).