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Health Fund

Filing Claims In General

How claims are processed depends on the type of claim. Who processes the claim also depends on the type of claim. Certain claims must be submitted to the applicable third-party claims administrator. All other claims must be submitted to the Administrative Office. Each third-party administrator, as well as the Administrative Office, is referred to as a "Claims Administrator." This chart illustrates the Claims Administrator for each plan:

Generally, if you receive services from a network provider, the provider will submit the claim to the applicable Claims Administrator directly. If you receive services from a non-network provider, you or your provider will submit the claim to the applicable Claims Administrator. For "Claim Submission" details, see pages 49-50.

You may designate an authorized representative for assistance with respect to your claim for benefits. For more information, contact the Claims Administrator.

Claim Type Submit/Refer To
Medical, Vision, Wellness, Mental Health and Chemical Dependency claims
Administrative Office /Blue Cross/ Blue Card (see claim submission section)
Dental claims
Delta Dental (PPOAn acronym for Preferred Provider Organization.) or DeltaCare USA (DHMO)
Outpatient Prescription Drug claims
Express Scripts
Life and AD&D claims
Administrative Office
Vision claims
Davis Vision

Initial Claim Determinations

The Claims Administrator has full discretion to deny or grant a claim in whole or in part. Such decisions will be made in accordance with the governing Fund documents, and where appropriate, Fund provisions will be applied consistently with respect to similarly situated claimants in similar circumstances.

How and when claims are processed depends on the type of claim. Most claims under the Fund that are required to be submitted to the Administrative Office are post-service health care claims. Most other claims under the Fund will also be post-service health care claims.

Post-Service Health Care Claims
  • A post-service claim is a claim for benefits after services or treatment have been provided.
  • The Claims Administrator will notify the claimant of a denial within a reasonable period of time but not later than 30 days after receipt of the claim, unless an extension of 15 days is necessary due to circumstances beyond the Fund's control. If the reason for the extension is because the Claims Administrator doesn't have enough information to decide the claim, the notice will describe the required information, and the claimant will have 45 days from the date he/she receives the notice to provide the necessary information.
  • After the claimant responds to this request for information (or at the end of the 45-day period, whichever comes first), the Fund will make a decision on your claim and notify you of the determination within 15 days. If the requested information is not provided within the time allowed, your claim will be considered denied.