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.
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:
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.
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.
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.
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
P.O. Box 997330
Sacramento, CA 95899-7330
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.
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:
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.
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.
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.
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:
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
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.
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:
|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
||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
||Within 48 hours of
the earlier of:
|| Within 15 days of the
||Within 30 days of the