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Medical and Dental Claims

For details about claims and appeals, refer to your separate medical and dental Summary Plan Descriptions (SPDs). You can find your SPDs, or information about where to obtain them, in the Medical and Dental sections of this site.

Vision Claims

If you are enrolled for vision coverage, all claims and appeals are handled by VSP. Contact VSP or refer to the VSP materials in the Vision section of this site for more information.

Flexible Spending Account Claims

DallasNews Corporation has delegated the administration authority for the health care (both Regular and Limited-Purpose) and dependent care flexible spending accounts to TaxSaver Plan. As the claims administrator, TaxSaver is responsible for reviewing the initial benefit determinations.

The DallasNews Corporation Benefits Administrative Committee is the claims administrator for all appeals.

Health Care Claims

If you participte in the PPO, are not eligible for a Health Savings Account (HSA) or do not elect medical coverage, you may use your Regular Health Care FSA to pay for unreimbursed medical, dental, vision and hearing expenses. If you participate in the CDHP and are eligible for an HSA, you may use your Limited-Purpose Health Care FSA to pay for eligible unreimbursed dental and vision expenses.

When you have health care expenses that are eligible for reimbursement, complete a claim form and attach a receipt for the expense. The receipt must include the following information:

Name of the person who received the health care service or supply

Name of the health care provider (physician, hospital or pharmacy)

Provider’s tax ID number

Date the care was provided (incurred)

Itemized costs for the care

Type of service rendered

A canceled check or a credit card receipt is not acceptable documentation of eligible expenses. If the expense is partially covered under a health care plan, submit the bill to the health care plan first. You will receive an Explanation of Benefits (EOB) from the plan. Use this EOB as proof of your expense to submit a flexible spending account claim for the unpaid portion of the bill.

If you have used your Flex Debit card for health care expenses, you may be required to submit supporting documentation to TaxSaver Plan.

Dependent Care Claims

Pay your dependent care expense and submit a claim form with proof of the expense to the claims administrator. Proof of expense is an itemized bill from the provider showing:

The dates of service

The names of the dependents who received the service

Itemized costs for the care

Payment of Spending Account Claims

After your claim is approved, you will receive reimbursement by either a check or direct deposit. Claims are processed weekly and paid as soon as possible.

If you do not have enough money in your account to cover the full amount of the expense:

Your Regular or Limited-Purpose Health Care Flexible Spending Account reimbursement will be for the full amount of the expense, up to the amount you elected to contribute to your account for the year, less any amounts already paid for other claims.

Your Dependent Care Flexible Spending Account reimbursement will be for the amount in your account. As you contribute more to your account through payroll deductions, you will receive additional reimbursements.

If you submit a claim for an expense that is not eligible for reimbursement under either flexible spending account, you will receive a letter explaining why it is not eligible. If it is determined that an ineligible health care claim was submitted using your Flex Debit card, you will be required to repay the amount.

You must postmark your claims by April 30 of the following year to receive reimbursement. The health care and dependent care flexible spending accounts operate on a plan year that begins each January 1 and ends December 31, with a 2½-month grace period ending on March 15 of the next calendar year. You may only file claims for expenses you incur during the plan year or grace period while you are a participant in the accounts. You have until April 30 of the calendar year following the plan year to postmark your claims for expenses you incurred during the plan year. The laws that govern the accounts require that you forfeit any money you have not claimed by April 30 (postmark date) for eligible expenses you incurred between January 1 of the prior plan year and the end of the grace period on March 15.

Eligibility Claims

If there is a question as to whether you or your dependents are eligible for coverage under any benefit option provided by the plans, that question will be decided by the plan administrator. If the eligibility question is not accompanied by a claim for benefits, the decision of the plan administrator will be final and will not be subject to review. However, if the eligibility question is being decided in connection with a claim for benefits, you may appeal the decision of the plan administrator.

Denied Claims

If your claim is denied (in whole or in part) by the claims administrator, you will receive written notice from the claims administrator. The time for notifying you of a denied claim and the deadline for requesting an appeal will depend on the type of claim you have submitted.

Medical, Dental, Vision and Health Care Flexible Spending Account Claims

Post-Service Claims. If a post-service claim for benefits is denied, the claims administrator will notify you no later than 30 days after the receipt of the claim. This 30-day period may be extended for an additional 15 days if the claims administrator determines the extension is necessary due to matters beyond the control of the plan and notifies you of the extension before the end of the initial 30-day period. If you have not furnished information that is necessary for determining your claim, the claims administrator will notify you and describe the information that is needed. You will be given a reasonable period of time, but not less than 45 days, in which to supply the missing information. While the claims administrator is waiting for the missing information, the deadline for responding to your claim will automatically be extended until 15 days after you furnish the missing information or, if you do not furnish the missing information, until 15 days after the date for furnishing such information.

If a post-service claim is denied by the claims administrator, you will have 180 days to file an appeal of the denial.

Pre-Service Claims. The claims administrator will notify you of its determination with respect to a pre-service claim, whether adverse or not, no later than 15 days after the receipt of the claim. This 15-day period may be extended for an additional 15 days if the claims administrator determines the extension is necessary due to matters beyond the control of the plan and notifies you of the extension before the end of the initial 15-day period. If you have not furnished information that is necessary for determining your claim, the claims administrator will notify you no later than five days after receiving your claim and will describe the information that is needed. You will be given a reasonable period of time, but not less than 45 days, in which to supply the missing information. While the claims administrator is waiting for the missing information, the deadline for responding to your claim will automatically be extended until 15 days after you furnish the missing information or, if you do not furnish the missing information, until 15 days after the date for furnishing such information.

If a pre-service claim is denied by the claims administrator, you will have 180 days to file an appeal of the denial.

Urgent Care Claims. The claims administrator will notify you with respect to an urgent care claim, whether adverse or not, as soon as possible, but no later than 72 hours after the receipt of the claim. If you have not furnished information that is necessary for determining your claim, the claims administrator will notify you within 24 hours of receiving your claim and will describe the information that is needed. You will be given a reasonable period of time, but not less than 48 hours, in which to supply the missing information. While the claims administrator is waiting for the missing information, the deadline for responding to your claim will automatically be extended until 48 hours after you furnish the missing information or, if you do not furnish the missing information, until 48 hours after the time for furnishing such information has expired.

If an urgent care claim is denied by the claims administrator, you will have 180 days to file an appeal of the denial.

Concurrent Care Claim. If the plan has approved a course of treatment to be provided over a period of time or a number of treatments and reduces or terminates the course of treatment before the expiration of the period of time or number of treatments that was approved, such reduction or termination will be treated as the denial of a concurrent care claim. The claims administrator will notify you of the denial of the concurrent care claim in sufficient time before the reduction or termination of treatment to allow you to appeal the denial. If you are receiving an ongoing course of treatment, you may proceed with an expedited external review at the same time the internal appeals process is in progress.

In addition, if you request the claims administrator to extend a course of treatment beyond the approved period of time or course of treatment, and your claim involves urgent care (as defined above), the claims administrator will notify you of its decision within 24 hours of receiving your claim, provided you made your claim at least 24 hours before the course of treatment was scheduled to terminate. If your claim involves urgent care and is made less than 24 hours before the course of treatment was scheduled to terminate, your claim will be treated as an urgent care claim.

Notice of Denied Claim

If a claim for benefits is denied, you will be notified in writing, and the written notice will contain the following information:

Information sufficient to identify the claim involved (including, to the extent applicable, the date of service, the health care provider and the claim amount)

The specific reasons for the benefit denial, including the denial code (if any) and its corresponding meaning and the plan’s standard (if any) that was used in denying the claim

Reference to the plan provisions on which the denial is based

A description of any additional material or information necessary to perfect your claim and an explanation of why such information is necessary

A statement describing the availability, upon request, of the diagnosis code and the treatment code (if applicable) and their corresponding meanings

A description of the plan’s appeal process and applicable time limits (including the expedited process applicable to urgent care claims) and a statement of your right to bring a civil action under ERISA following an adverse determination on appeal

A description of the availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman established to assist you with the claims and appeals and external review processes

If an internal rule, guideline, protocol or other similar criterion was relied on in denying your benefit claim, a statement to that effect (also, a copy of the applicable rule, guideline, protocol or other similar criterion will be provided to you, upon request, free of charge)

If the benefit denial was based on medical necessity or experimental treatment or a similar exclusion or limit, an explanation of such scientific or clinical judgment and its application to your medical circumstances

If your claim for benefits is denied, you may not bring a lawsuit to recover the denied benefits until you have exercised all of your appeal rights and your appeal has been denied in whole or part. The plan administrator is granted the discretion to determine all claims for eligibility for all fully insured benefits, and for all self-insured benefits, the discretion to determine all claims for eligibility, benefits and all rights under this plan in its sole discretion.

Appeal of Denied Claims

If you wish to appeal the denial of a claim for benefits (including a retroactive termination of coverage) under the plan, you or your authorized representative must file written notice of the appeal before the time for filing the appeal expires. Your appeal must be filed with the appropriate appeals administrator. The appeals administrator is:

The claims administrator, if the appeal relates to a denied dental PPO, dental HMO or VSP claim, or a denied claim for life insurance, personal accident insurance, long-term disability or business travel accident claims, or a first-level (initial) appeal related to a denied claim under the DallasNews Corporation self-insured PPO or CDHP Medical Plan.

The plan administrator, if the appeal relates to a second-level appeal of a denied claim under the DallasNews Corporation self-insured PPO or CDHP Medical Plan or a first-level (initial) appeal of a denied claim under the flexible spending accounts.

Your written notice should state in reasonable detail all of the grounds upon which your appeal is based, including references to applicable plan provisions, and any issues or comments you feel are relevant to your claim. You should supply any documents, records or other information relating to your claim. You may also request copies of documents, records and other information relevant to your claim that are in the possession of the plan, which will be provided to you free of charge. In addition, you shall receive, free of charge, any new or additional evidence considered, relied upon or generated by the plan in connection with your claim or any new or additional rationale upon which the decision of your claim is based, as soon as possible and sufficiently in advance of the date on which the final appeals decision is required to be provided to you so as to give you a reasonable opportunity to respond prior to that date.

The appeals administrator will review the denial of your claim without deference to the decision of the claims administrator. If the denial of your claim was based, in whole or in part, on a medical judgment, the appeals administrator will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who did not participate in the denial of your claim (and is not the subordinate of a health care professional who did participate in the claim denial).

The appeals administrator will also identify the medical or vocational experts whose advice was obtained on behalf of the plan in denying your claim, without regard to whether the plan relied on such advice. Finally, if the claim that was denied was an urgent care claim, the appeals administrator will permit an expedited appeal in which the appeal may be made orally and all necessary information, including the appeals administrator decision on appeal, may be transmitted between you and the plan by telephone, facsimile or other similar expeditious method.

The applicable time limits to file an appeal of a benefit denial are set forth below:

Post-Service Claims: 180 days after the benefit denial (including a retroactive termination of coverage); the appeals administrator will issue a decision with 30 days after receiving the first level appeal and, if a second level appeal is filed, within 30 days of receiving the second level appeal. A second level appeal must be filed no later than 180 days after receiving a denial of the first level appeal.

Pre-Service Claims: 180 days after the benefit denial; the appeals administrator will issue a decision with 15 days after receiving the first level appeal and, if a second level appeal is filed, within 15 days of receiving the second level appeal. A second level appeal must be filed no later than 180 days after receiving a denial of the first level appeal.

Urgent Care Claims: 180 days after the benefit denial; the appeals administrator will issue a decision as soon as possible, but within 72 hours, after receiving the appeal.

Concurrent Care Claims: In sufficient time to permit an appeal and determination on appeal before benefits terminate; the appeals administrator will issue a decision before benefits terminate.

Notice of Appeal Decision

If your appeal is denied, you will be notified in writing, and the written notice will contain the following information:

Information sufficient to identify the claim involved (including, to the extent applicable, the date of service, the health care provider and the claim amount)

The specific reasons for the benefit denial, including the denial code (if any) and its corresponding meaning and the plan’s standard (if any) that was used in denying the claim

Reference to the plan provisions on which the denial is based

A statement that you are entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records and other information relevant to your claim for benefits

A statement describing the availability, upon request, of the diagnosis code and the treatment code (if applicable) and their corresponding meanings

A statement that you and the plan may have other voluntary alternative dispute resolution options, such as mediation, and that you should contact your local U. S. Department of Labor Office and your State Insurance regulatory agency to find out what options may be available to you

Other Legal Information About Claims

Consistency of Treatment

The plan administrator will take such action from time to time as may be necessary to assure that all claims for benefits under the plan are determined in accordance with the applicable plan documents and that the provisions of the applicable plan documents are applied consistently to similarly situated plan participants and their dependents.

Coordination of Benefits

If you or your covered dependents have medical or dental coverage through another plan, your DallasNews Corporation plan will coordinate benefit payments with payments from the other plan. This means your benefit payments from all plans will not be more than the amount your DallasNews Corporation plan would have paid for eligible expenses if you had no other coverage.

The plan that pays first (as explained below) determines the amount of benefits you receive without considering other health care benefits you have under another plan. When the DallasNews Corporation plan pays benefits after another plan, DallasNews Corporation’s plan will reimburse you for the balance of allowable expenses not paid by the other plan, up to the amount that would have been paid if you had no other coverage.

How Coordination of Benefits Works

Let’s say your children are covered under both your spouse’s plan, which pays 70% of covered expenses, and DallasNews Corporation’s CDHP Medical Plan. You submit a $100 claim for your child’s outpatient lab services to your spouse’s plan. You would be reimbursed for $70 (70% of $100) from your spouse’s plan. You could then submit a claim for the remaining balance to Blue Cross and Blue Shield (BCBS). BCBS would pay $10 (assuming you already met your deductible, the lab services were provided in-network and the full expense was considered an allowable amount) so your total reimbursement from both plans is 80% of the cost of the service ($10 + $70 = $80) — the amount the CDHP would normally pay if you had no other coverage.

Your DallasNews Corporation plan coordinates benefits with the following other plans:

Group insurance plans

HMOs, group practices and other prepaid plans

Union welfare and employer plans

Government plans required by law, including Medicare and TRICARE

Plans for students enrolled at an educational institution.

Which Plan Pays First

A plan without a coordination of benefits provision is always the plan that pays first. If all the plans have a coordination of benefits provision, the plans pay according to the following rules:

1. The plan covering the person as an employee, rather than a dependent, pays first and the other pays second.

2. The plan covering a person as an active employee, (or that person’s dependent), pays before a plan covering a person who is laid off or retired (or that person’s dependent).

3. If a child is covered under both parents’ plans, the plan of the parent whose birthday (month and date regardless of year) falls earlier in the year pays first. However, if the other plan has a different provision for this situation, the provision of the other plan determines which plan pays first.

4. If a child is covered under both parents’ plans and the parents are separated or divorced with a court decree to establish financial responsibility for the child’s health care expenses, the plans pay benefits according to the court decree.

5. If a child is covered under both parents’ plans, the parents are divorced or separated, and there is no court decree to determine financial responsibility, their plans pay in this order:

First, the plan of the natural parent with physical custody,

Second, the plan of the spouse, if any, of the natural parent with physical custody, and

Last, the plan of the natural parent without physical custody.

If none of these rules apply, the plan that has covered the person the longest is the primary plan.

Medicare or TRICARE and Your Company Plan

If you work past age 65, you will be eligible for DallasNews Corporation medical coverage and Medicare. As long as you continue to work, the company’s medical plan is the primary plan. In calculating your benefits, Medicare benefits are coordinated (see Coordination of Benefits above) with those from this plan. Contact the Social Security Administration for more information about enrolling for Medicare. If you or a family member is or has been in uniformed military services you may be eligible for A.H. Belo medical coverage and TRICARE coverage. As long as you continue to work, the company’s medical plan is the primary plan. In calculating your benefits, TRICARE benefits are coordinated (see Coordination of Benefits above) with those from this plan. Contact the Defense Health Administration for more information about enrolling for TRICARE or go to www.tricare.mil which is the official website of the Defense Health Agency (DHA) a component of the Military Health System, DHA Address: 7700 Arlington Boulevard, Suite 5101, Falls Church, VA 22042-5101.

Liability for Payment

Neither DallasNews Corporation nor any DallasNews Corporation company will have any obligation to make a benefit payment to you or your dependents under a plan or program that is fully insured. The insurer is solely responsible to make such benefit payments, and DallasNews Corporation and the DallasNews Corporation companies will have no liability to you or your dependents if the insurer fails to make any payments required under any insured plan or program.

The plans and programs that are fully insured are the following:

Dental PPO and Dental HMO Plan

Vision Plan

EAP

Recovery of Overpayments

The amount of your plan benefits will be adjusted if:

You have misstated any information in your application for plan coverage (including any statement of health)

You do not report required information while receiving company-provided benefits

Any error is made in calculating your benefits

If a benefit is overpaid or benefits are duplicated, you are expected to repay the plan within 60 days. If you do not, the plan may reduce, refuse or offset future benefits until the overpayment is repaid. The plan may also take additional action allowed by law.

No interest will be charged on the amount of any overpayment or duplication of benefits and, unless required by law, no interest will be paid on any underpayment of benefits or on any benefit payments that have been delayed for any reason.