When/Where to File Claims
Claims for benefits should be filed as soon as reasonably
possible in order that timely payment may be made.
Claims must have been filed prior to the end of the second
calendar year following the date the claim was incurred in
order to be eligible for consideration for payment under
the Plan. Failure to file claims within the time required
shall not invalidate or reduce any claim if it can be demonstrated
that it was not reasonably possible to file the claim
within such time.
You are generally not required to file a claim for
In-Network benefits. When you file a claim for Out-of-
Network benefits, submit a completed claim form to the
Claim Administrator responsible for the administration
of the benefits you are requesting. Your claim will be
considered to have been filed as soon as it is received by the
appropriate Claim Administrator. Claims should be filed
with the appropriate Claim Administrator at the address
shown in the sections that follow.
When you need to submit a claim:
- Obtain a claim form and complete the Member’s
portion of the claim form (including your name
and Social Security number, the patient’s name, the
patient’s date of birth);
- Have your physician either complete the Attending
Physician’s Statement section of the claim form
(including date of service, CPT-4 code [the procedure
code], ICD-9 [the diagnosis code], billed charge,
number of units [for anesthesia and certain other
claims], the provider’s federal taxpayer identification
number [TIN], billing name and address of the
provider and if treatment is due to an accident, the accident
details); or submit a completed Claim Administrator-
provided claim form (as an alternative, an
HCFA [Health Care Finance Administration] health
insurance form may be used) or a HIPAA-compliant
electronic claims submission; and
- Attach all itemized hospital and doctor’s bills and
any doctor’s statements that describe the services
rendered. (In most circumstances, the hospital will
submit these claims directly to the address listed in
this section for the payment of its bill.)
