Health & Security Retiree Health Plan > SPD > How to File a Claim

Summary Plan Description

How to File a Claim

Most health care providers bill the Trust Office directly. The Trust Office processes the claim and then provides an Explanation of Benefits (EOB) describing what this plan paid, the PPO discount, if applicable, and what is owed as part of the annual deductible, copayment, coinsurance, and noncovered expenses.

If services or supplies are received from a provider that does not bill the Trust Office directly, or if you have another health care plan that is primary, the following guidelines should be followed:

  • Submit the provider's itemized bill to the Trust Office. The address is on the back cover of this booklet.
  • If the patient is covered under another health care plan or Medicare, and the other plan or Medicare is the "primary" plan (please see "Coordination of Benefits With Other Plans and Medicare" on pages 108- 113), include the primary plan's Explanation of Benefits (EOB) with the provider's itemized bill. The Explanation of Benefits (EOB) and the provider's itemized bill must correspond. Inaccurate or incomplete information can create unnecessary paperwork and delay processing.
  • If the primary plan has prescription drug coverage, submit the claim to the primary plan first. Then submit the primary plan's Explanation of Benefits or the prescription drug copayment receipt to the Trust Office for additional reimbursement.
  • Claims for services received outside the U.S. are converted to U.S. currency based upon the conversion rate at the time of service and then paid directly to the retiree. Itemized bills must be translated into English before being submitted to the Trust Office.

Medicare Note

Medicare crossover refers to an agreement between Medicare and other health care plans that permits Medicare to directly provide claim information to other plans to expedite the processing of claims. When Medicare processes a claim, that claim is forwarded directly to this plan for processing. In this way, you no longer need to submit Medicare claims to the Trust Office. Crossover is currently being used with Medicare Part A and Medicare Part B services.

If prescription drugs are purchased from a nonparticipating pharmacy, complete a Prescription Drug Reimbursement Form. These forms are available from Medco Health.