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Claims Filing Instructions
General Information
Most plans have a "timely filing" provision. Many require that claims be submitted within 90 days from the date services are provided. CHECK YOUR PLAN.If complete information is provided with your claim, most reimbursements are mailed within fourteen calendar days of receipt.
Be sure to read your explanation of benefits (EOB) carefully. Don't forget the "Comment" section. This will provide information about how the claim was paid and, more importantly, why something was not covered. This section will refer you to the page in your plan document that explains the reason for the denial.
Don't forget, your first claims of the year will have deductible applied. If you receive an EOB and no check, it may have all been applied to your calendar year deductible. CHECK THE COMMENTS SECTION OF YOUR EOB.
Our customer service staff is always available to help you with any questions you might have about your plan and the benefits payments.
Accident Claims
If you are submitting a claim for an injury or accident, be sure to fill out the "accident" portion of the claim form. Be precise and give complete information about the accident as follows:Did it happen at home, work, playground, school, etc.? Was someone else involved? Was it a motor vehicle accident? Were you on a snowmobile? ATV?
The bills from the provider don't always indicate how or where the accident occurred.
The claims examiner must be able to document that the accident was not work related, a motor vehicle accident, or the fault of another party, etc.
If you include a claim form with the bill that includes a complete explanation of the accident, the time it will take to make a determination and to issue a check can be reduced substantially.
Do You and Your Spouse Both Have Insurance?
If another insurance plan is primary on your spouse or children, wait until the primary insurance has completed processing the claim. Then send a copy of the itemized bill (HCFA form 1500 or UB-92) and a copy of the "explanation of benefits" (EOB) from the primary payer.Please do not submit "statements." The statement does not provide the information necessary to process the claim.
Note: If your spouse works and is covered under an employer sponsored health plan, that plan is always primary for her/him.
All benefit plans contain "rules" that determine which plan is primary for dependent children if they are covered under both plans.
Which plan pays first is not something that can be decided by you and/or your spouse.
Coverage for College Students
If you are filing a claim on a dependent child who is over 19 years of age, full-time student status must be established before a claim can be paid.Your dependent must be a full-time student at the time charges are incurred.
It is not uncommon for a student to drop a class after the semester begins, resulting in a change from "full-time" to "part-time" status.
Make sure your dependents understand the impact this change can have on their eligibility for benefits.
COBRA continuation is available if notice is given to your employer that your child is no longer an "eligible" dependent within 60 days of the "qualifying event" (drop from full-time to part-time student status, or graduation).
However, if this notice is not given within the 60 days, insurance will automatically terminate for the student.
New Enrollees
Most plans have a provision that excludes benefits for conditions that were present and/or treated prior to coverage. These are called "pre-existing conditions."
However, the Health Insurance Portability and Accountability Act (HIPAA) provides that previous coverage (Medicaid, Medicare, Blue Cross, CHAMPUS, etc.) can be credited toward the pre-existing time period in your new plan.
All plans are required to provide a "certificate of creditable coverage" to employees when they terminate employment. In order for this coverage to be credited, we must have a copy of the certificate.
PLEASE PROVIDE YOUR CERTIFICATE OF CREDITABLE COVERAGE UPON ENROLLMENT UNDER YOUR NEW PLAN.
This will enable us to process your claims promptly upon receipt, rather than going through the process of determining if a pre-existing condition exists.