Health Summary Plan Description

Filing A Claim For Benefits

A claim 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 "Health, Disability and Retroactive Removal of Coverage Appeals" on pages 90 through 94.

Hospital and Medical Benefits

When you use network providers, the providers will file the claim for you. For non-network claims, claim forms may be obtained from any Plan Office, requested through the Automated Information Center or downloaded from the Plan's website: www.sagph.org. All claims from California providers and facilities should be sent to:

Anthem Blue Cross
P.O. Box 60007
Los Angeles, CA 90060-0007

Claims from providers and facilities in states outside California should be sent to the local Blue Cross Blue Shield Plan.

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

If you receive treatment outside of the United States, submit a detailed, translated bill to the Plan Office. The bill should include the date services were provided, a description of each service, the charge for each service and the reason treatment was provided. Be sure to also include the type of currency that was used when you paid for these services.

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 for Release of Health Information is available from the Plan Office or on the Plan's website: www.sagph.org.
  9. Do not 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, contact the Plan Office:

    (818) 954-9400
    (800) 777-4013
    email us

Mental Health and Substance Abuse

When you use network providers, they will file the claim for you. When you use a non-network provider, you or your provider should submit claims directly to ValueOptions. DO NOT SEND CLAIM FORMS TO THE PLAN OFFICE.

ValueOptions, Inc.
Latham Claims
P.O. Box 1290
Latham, NY 12110

Claim forms may be downloaded from the Plan's website: www.sagph.org or obtained from the Plan Office.

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 provider, be sure to sign the form in the space provided.

Prescription Drugs

If you use a non-participating retail pharmacy for your prescription drugs you need to file a claim with Express Scripts. Claim forms may be obtained from the Plan Office or downloaded from the Plan's website: www.sagph.org. Or you may call Express Scripts at (800) 903-4728.

Non-participating retail pharmacy claims should be submitted to:

Express Scripts, Inc.
P.O. Box 2187
Lee's Summit, MO 64063-2187

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

If your prescription drug coverage is provided under the medical benefits, submit your claims to the Plan Office. A prescription drug claim should include a claim form, copy of the prescription and the original receipt.

Dental Claims

When you use a network dentist, the dentist will file the claim for you. When you use a non-network dentist, 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

Claim forms may be downloaded from the Plan's website: www.sagph.org, or from Delta's website: www.deltadentalins.com/sagph, or obtained from the Plan Office.

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 pretreatment 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.

Vision Claims

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

VSP
Attention: Non-Member Doctor Claims
P.O. Box 997105
Sacramento, CA 95899-7105

Be sure to include the participant's name, mailing address and ID 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. You should also contact the Plan Office if you are applying for an accelerated life insurance payment. A claim form will be sent to you.

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 website: 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, bariatric surgery, eyelid, nasal and certain breast surgeries, outpatient private duty nursing, psychological testing and sleep studies. Certain prescription drugs also require prior authorization.

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 Concurrent Care Claim is a claim involving an approved ongoing course of treatment either for a specific period of time or for a specific number of treatments. If the claim involves urgent care it will be treated as an Urgent Care Claim. Otherwise it will be subject to the time periods for Pre-Service Claims as outlined on the following page.

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 the 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 determination regarding payment of the claim. The time to make a determination 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 determination. You will be notified of the circumstances requiring the extension. The table on the following page outlines these time periods and any available extensions.

Notice of Determination

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

  1. The specific reason(s) for the determination and reference to any specific Plan provision(s) on which the determination 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 making the determination, a statement that a copy of the rule is available upon request at no charge.
  6. If the determination 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 determination 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 determinations may be provided orally and followed with written notification.
  Health Claims Disability Claims
Claims Procedures Pre-Service Urgent Care Post-Service  
How long does the Plan have to make a determination when you file a claim? 15 days. 72 hours. 30 days. 45 days.
Are there any extensions available? Yes, one 15-day extension. No. Yes, one 15-day extension.
Yes, two 30-day extensions. You will be notified of the first extension within 45 days. You will be notified of the second extension within the first 30-day extension.
What happens if the Plan needs additional information? The Plan will tell you what information is needed within 5 days of receipt of the claim. You have 45 days to respond. The Plan will tell you what information is needed within 24 hours of receipt of the claim. You have 48 hours to respond. The Plan will tell you what information is needed within 30 days of receipt of the claim. You have 45 days to respond. The Plan will tell you what information is needed within the time periods outlined above. You have 90 days to respond.
If additional information is requested, when must the Plan make its determination? Within 15 days of the earlier of:
  • the day you respond, or
  • the end of the 45-day response period.
Within 48 hours of the earlier of:
  • the time you respond, or
  • the end of the 48-hour response period.
Within 15 days of the earlier of:
  • the day you respond, or
  • the end of the 45-day response period.
Within 30 days of the earlier of:
  • the day you respond, or
  • the end of the 90-day response period.