Claiming Healthcare Benefits

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Claims should always be submitted to the primary plan first.

For Urgent Care Claims

If you file an urgent care claim, the Claims Administrator will make an initial benefit determination within 24 hours after they receive your properly completed claim form and all required documentation.

An urgent care claim is a claim filed before medical services are received and is for conditions in which receiving medical care quickly is a critical factor in:

  • assuring the patient’s life, health or ability to regain maximum function
  • in the opinion of a physician with knowledge of the patient’s medical condition, avoiding severe pain.

If you file an incomplete urgent care claim, the following steps show the procedure and timing. 

  • The Claims Administrator makes a final determination on the claim within 48 hours after:
  • You provide the requested information within the timeframe set by the Claims Administrator (but in no case less than 48 hours).
  • Within 24 hours after receiving your claim, the Claims Administrator will notify you that your claim is incomplete and tell you what information you need to provide.
    • you provide the requested information
    • the end of the time period you have to provide the requested information
      . . . whichever is earlier.

For Post Service Claims

If you file a post service claim, the Claims Administrator will send you written notification of their benefit determination within 30 days after receiving the claim. If matters beyond the control of the claims administrator require an extension of time, the Claims Administrator may extend the notification period by up to 15 days. If an extension is required, the Claims Administrator will notify you in writing before the end of the initial 30-day period. The notification will include the reasons the extension is required and the date by which the Claims Administrator expects to make its determination. If the extension is required because your claim was not complete, the notice of extension will describe the required information. You will have at least 45 days following receipt of the notice to provide the requested information.

A post service claim is a claim for benefits filed after the services are received.