FILING A CLAIM FOR BENEFITS

Aclaim for benefits is a request for benefits made in accordance with the Health Plan’s claims procedures. Simple inquiries about the Plan’s provisions that are unrelated to a specific claim are not treated as claims for benefits. Neither are requests for prior approval of benefits that do not require such an approval by the Plan. In addition, when you present a prescription to a pharmacy to be filled under the terms of the Plan, that request is not a claim under these procedures. However, if your prescription request is denied, in whole or in part, you may file an appeal of the denial by using the procedures outlined under “Claim Appeal Procedures” on page 78 .

Hospital and Medical Benefits
Claim forms may be obtained from any Plan Office, requested through the Automated Information Center or downloaded from the Plan’s Web site: www.sagph.org. All claims, except for California hospital claims, should be sent to the Plan Office for processing. California hospital claims should be sent to Blue Cross of California. All benefit checks, as well as your Explanation Of Benefits (EOB) will be issued by the Plan Office.

When you use network providers, the providers will file the claim for you.

The Plan will accept hospital expenses for up to 18 months after the date of service and major medical expenses for up to 15 months after the date of service. Hospital claims more than 18 months old and major medical expenses more than 15 months old will not be paid.

If you receive treatment outside of the United States, submit a detailed, translated hospital bill, which includes the number of days hospitalized, lab work done, drugs administered, diagnosis, and type of treatment given, to the Plan Office.

Before submitting a claim form, be sure it is filled out properly. To avoid delay in the processing of your claims, follow these steps:

1. Be sure to complete Part 1 of the Plan’s claim form in full. Attach your doctor’s itemized bill to the completed claim form.
2. You and the doctor should complete a separate form for each family member for each illness.
3. If you are seeing a doctor(s) for more than one illness or injury, you must submit a form for each illness or injury.
4. Please answer all questions completely.
5. Make sure you or your designated representative answer all questions about other insurance. Provide the name(s) of the other insurance, the address, identifying codes, and the name of the policyholder. Failure to supply information about other insurance and to answer questions truthfully may constitute fraud.
6. When you are covered under more than one plan, each plan will require a copy of all itemized bills with diagnosis and corresponding payment sheets. A copy of the operative and pathology reports are required for most surgical procedures. Please submit copies of the reports when you submit the surgeon’s bill.
7. Be sure to complete Part 3 of the claim form if you wish the Plan to make payment directly to the provider of services. An updated assignment of benefits is required every 12 months. Only the participant can assign payment of benefits. This cannot be done by any other person, including your eligible dependent(s). The Plan accepts “Signature on File” as a valid assignment of benefits.
8. If reimbursement for medical expenses and correspondence are to be handled by your business manager or accountant, please let us know in writing at the time you submit your first claim form. We cannot give information to a third party without your written permission. An Authorization to Release Medical Information is available from the Plan Office.
9. Don’t forget to sign the form. Your business manager or legal representative cannot sign for you unless he or she has
   power of attorney. If that is the case, please send a copy of the authorizing document.
10. If you have questions, call the Plan Office.

Prescription Drugs
If you use a non-participating retail pharmacy for your prescription drugs you need to file a claim with Medco. Claim forms may be obtained from any Plan Office, requested through the Automated Information Center or downloaded from the Plan’s Web site: www.sagph.org. Or you may call Medco at 1-800-903-4728. Non-participating retail pharmacy claims should be submitted to:

Medco
P.O. Box 14711
Lexington, KY 40512

You will be reimbursed the amount that would have been charged by a participating pharmacy less the required co-payment.

If your prescription drug coverage is provided under the major medical portion of the plan, submit your claims as described under “Hospital and Medical Claims”.

Dental Claims
Claim forms may be obtained from any Plan Office, requested through the Automated Information Center, downloaded from the Plan’s Web site: www.sagph.org, or from Delta’s Web site: www.deltadentalca.org/sagph. You or your dentist should submit claims directly to Delta Dental. DO NOT SEND CLAIM FORMS TO THE PLAN OFFICE.

Delta Dental of California
Claims Department
P.O. Box 997330
Sacramento, CA 95899-7330

Remember, when you use a network dentist, the dentist will file the claim for you.

Follow the instructions on the claim form carefully and answer all questions completely. This will expedite the processing of the claim. If you wish benefits to be paid directly to the dentist, be sure to sign the form in the space provided.

If your estimated charges are less than $300, the claim form serves as a statement of actual charges. You complete the employee section and your dentist completes the dentist’s section and sends the form to Delta Dental after services are performed.

If your estimated charges are $300 or more, the form may serve as a pre-treatment estimate of charges. You complete the employee section and your dentist completes the dentist’s section before treatment commences. The form should then be sent to Delta Dental. After review, a statement indicating the benefits payable under the Plan will be returned to you and your dentist. When the work is completed, your dentist should indicate on the statement the specific services performed, the date performed and the actual charges.

Once the claim has been processed, you will receive a check along with a benefits statement, unless benefits have been assigned to the dentist. If benefits have been assigned, the check will go directly to the dentist, but you will receive a copy of the benefits statement. If you have any questions about a dental claim payment, request an explanation directly from Delta Dental.

Vision Claims
If an Exam Plus eye exam is received through a non-VSP provider, you should request a copy of the bill showing the amount of the eye examination. Send the bill to:

Vision Service Plan
Attention: Non-Member Doctor Claims
P.O. Box 997100
Sacramento, CA 95899-7100

Be sure to include the participant’s name, mailing address and Social Security Number, and the patient’s name, relationship to participant and date of birth.

Life Insurance and Accidental Death and Dismemberment Benefits
Provide a certified copy of the death certificate, and, if appropriate, evidence of the accidental nature of death, to the Plan Office. In the event of dismemberment, notify the Plan Office promptly. A claim form will be sent to you. You may also request forms from the Automated Information Center or download them from the Plan’s Web site: www.sagph.org.

Authorized Representatives
An authorized representative may complete the claim form for you if you are unable to complete the form yourself and have previously designated the individual to act on your behalf. A form to designate an authorized representative can be obtained from the Plan Office or downloaded from the Plan’s Web site: www.sagph.org.

Types of Claims
A Pre-Service Claim is a claim for a benefit for which the Plan requires approval before medical care is obtained. For hospital and medical benefits, prior approval is required for organ transplants, eyelid, nasal and breast surgeries, outpatient private duty nursing and sleep studies. Certain prescription drugs also require prior approval from the Plan Office. For mental health and chemical dependency benefits, prior approval from ValueOptions is required for all care.

An Urgent Care Claim is any claim for medical care or treatment where the application of the time period for making a Pre-Service Claim determination:

• Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or
• In the opinion of a physician with knowledge of the claimant’s medical condition would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Whether your claim is an Urgent Care Claim is generally determined by the Health Plan. Alternatively, any claim that a physician with knowledge of your medical condition determines is an Urgent Care Claim within the meaning described above shall be treated as an Urgent Care Claim.

A Post-Service Claim is a claim submitted for payment after health treatment has been obtained.

Disability Claims are claims that require a finding of total disability as a condition of eligibility. Under the Health Plan, this would be a claim for waiver of the life insurance premium or coverage under the Total Disability Extension. The Plan reserves the right to have a physician examine you (at the Plan’s expense), as often as is reasonable while a Disability Claim is pending.

Initial Determination
When you submit a claim, the Plan has a certain amount of time to make a decision regarding payment of the claim. The time for response may be extended if necessary due to matters beyond the Plan’s control. For example, an extension may be available if the Plan needs additional information from you or your doctor to make its decision. You will be notified of the circumstances requiring the extension. The following table outlines these time periods and any available extensions.

Notice of Decision
For Pre-Service and Urgent Care Claims, you will receive written notice of the Plan’s decision. For Post-Service and Disability Claims, you will be provided with written notice for claim denials, including:

1. The specific reason(s) for the decision and reference to any specific Plan provision(s) on which the decision is based.
2. A description of any additional material or information necessary to perfect the claim and an explanation of why the
   material or information is necessary.
3. A description of the appeal procedures and applicable time limits.
4. A statement of your right to bring a civil action under ERISA Section 502(a) following an adverse benefit determination on review.
5. If an internal rule, guideline or protocol was relied upon in deciding your claim, a statement that a copy of the rule is available upon request at no charge.
6. If the decision was based on the absence of medical necessity, or because the treatment was experimental or investigational, a statement that an explanation of the scientific or clinical judgment for the decision is available upon request at no charge.
7. For Urgent Care Claims, the notice will describe the expedited review process applicable to Urgent Care Claims. Urgent Care decisions may be provided orally and followed with written notification.