This page contains answers to common questions handled by our support staff.
- What claim form do I use for benefits?
- Why did I receive a letter for more information after a claim was submitted?
- I have already answered the letter and got another in the mail today asking for the same information. Why?
- I received a “Claim Denial Notice” on a claim, but never received the original letter. What can I do now to get the claim processed?
- I received an “Explanation of Benefits” for a claim I submitted. Could you explain all the information on the sheet.
- What is the major medical deductible and major medical copayment?
- When I received my Explanation of Benefits there was a non-covered amount that was denied because the charge exceeds the Fund’s usual, customary and reasonable allowance.
- Do I need to pay this amount to the provider?
- What can I do about any amounts that were not paid on my claim?
- I have been a member for many years and recently moved. Is there anything I need to fill out with my new address?
- I filled out the Census Card, but now I received a letter asking for more information on my new born. Why?
- How do I change my beneficiary for my death benefit?
- I have been sick for two weeks, can I collect any benefits?
- If my disability happened during the course of my employment, would it be all right to collect weekly disability benefits?
- What card do I use for my benefits?
- Why did I get denied for vitamins on my prescription card when my doctor prescribed them for me?
- Are death benefits taxable?
Q: What claim form do I use for benefits?
A: There are four claim forms used for benefits: medical, dental, vision, and death. The medical claim form can be used for traditional benefits, such as physician office visits. It is also used for weekly disability benefits. The dental form is used for dental services and the vision form is used for vision services. There is also a separate form for death benefits.
If you have
Personal Choice or
Keystone HMO benefits, submit you card for services to either the hospital or physician; you do not need to fill out a medical form unless, in the case of
Personal Choice, you seek treatment from an “out-of-network” provider. (Remember: no benefits are provided under the
Keystone HMO plan if you seek treatment out-of-network).
If you have
Traditional benefits, your hospital charges are covered under the Blue Cross Program, therefore, you should present your card at the hospital. Any physician charges must be submitted on a medical claim form. Check the top of the form for the services being submitted: surgeon, anesthesia, lab/x-ray, or physician. You must fill out the top part of the form, lines 1 to 13 (line 13 assigns the payment to the provider.) The physician fills out the bottom part, lines 14 through 30.
For
vision services fill out the top of the form, lines 1 through 8, then the general information and the authorization release. If you want the payment to be made directly to the provider, you should sign the authorization to pay the doctor on the bottom of the form. The physician fills out the middle of the form.
For
dental services fill out lines 1 through 13 (line 13 assigns the payment to the provider). The dentist fills out lines 14 through 30.
For
weekly disability benefits, you must fill out lines 1 to 12 on the medical claim form; the physician fills out lines 14 through 30, excluding his charges for services; your employer must fill out the company statement on the back of the form.
For
death benefits the entire form must be filled out. For a member benefit, an original certified copy of the death certificate and a W-9 form completed by the beneficiary listed must accompany the claim form. When applying for an accidental death benefit, a copy of the police accident report is required. For a spouse benefit, an original certified copy of the death certificate, a completed W-9 form and a copy of the marriage certificate are needed. For a dependent child, provide an original certified copy of the death certificate, a completed W-9 form and a copy of the birth certificate.
Claim forms may be obtained from the Fund office, from your Local Union, from your Employer, and the link on this site to our Forms Gallery. A separate claim form must be filled out for each family member and provider of service.
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Q: Why did I receive a letter for more information after a claim was submitted?
A: When a claim form is received in our office it is processed through our computer system. If there is incorrect or additional information needed to process the claim, a letter will be sent to you. The additional information needed to complete the processing of your claim may include accident information, paid receipts, additional information from the provider, or questions related to other insurance coverage that may be involved.
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Q: I have already answered the letter and got another in the mail today asking for the same information. Why?
A: When processing a claim on our system, many claims are filed for the same accident or date of service. Therefore, the answer you have sent in may have crossed in the mail with the new claim just received.
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Q: I received a “Claim Denial Notice” on a claim, but never received the original letter. What can I do now to get the claim processed?
A: If a pending letter is not answered within 45 days, this “Claim Denial Notice” letter is automatically processed by the computer system. All you need to do is answer the information in the letter and return it to the Fund office as soon as possible to further process the claim.
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Q: I received an “Explanation of Benefits” for a claim I submitted. Could you explain all the information on the sheet.
A: When a claim is processed by the Fund office, you will receive an Explanation of Benefits Statement, known as an EOB. If you receive a check when the payment is made to you, the EOB appears on the lower portion of the statement. The EOB will help you understand how the claim was processed.
The medical explanation of benefits will list the member, patient and provider names, the type and date of service, the total charges, which charges are not covered under your Plan, basic amount paid, allowances to major medical, deductible and copayments taken on the claim, total paid, and explanation codes. It will also set forth the most current deductible, copay, and lifetime major medical amounts for the patient. For a further explanation regarding your individual claim, feel free to call our Claims Unit at 1-800-523-2846, ext. 1910.
If your medical claim was processed through Independence Blue Cross, Blue Cross will prepare and send to you an Explanation of Benefits Statement. The same type of information (although using different codes) will appear on the statement. Questions concerning these EOB statements can be directed to the Teamsters Dedicated Claims Unit at Blue Cross (1-800-354-8283).
The dental explanation of benefits will list the member, patient and provider names, the tooth treated (by tooth number), date of service, total charges, non-covered charges, procedure codes, amount allowed, and explanation codes. It will also list the yearly amount of dental benefits that have been processed for the patient.
The explanation codes on the bottom of the EOB explain why an amount is not covered.
This EOB should be kept as a record of the claims that have been processed for you and your dependents.
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Q: What is the major medical deductible and major medical copayment?
A: For those enjoying coverage under the Fund’s
Traditional benefit program, there are benefits you have that are considered “basic” and “major medical” benefits. Basic benefits are covered from the first dollar in full, up to the basic benefit limit. The balance is then automatically considered under the major medical portion of your coverage. When any amount is considered under major medical, there is a deductible that must be satisfied before further benefits are paid. Some benefits do not have a deductible, such as in-hospital doctor visits and out patient professional charges for a diagnosis related to a mental or nervous disorder. The deductible is $100 per person per year, with a family maximum of $200 per family per year. If a patient’s deductible is not satisfied until the final three months of the Plan Year, not only is the deductible considered to be satisfied for that Plan Year, but also for the
next Plan Year as well.
After your deductible is satisfied, a copayment amount equal to 25% of the allowed major medical charges is applied. Once the patient’s copayment amount reaches its yearly maximum ($625 per patient per year), all allowed charges are paid at 100% for the balance of that plan year. There are limitations to the charges that may be considered under your major medical coverage; check your Summary Plan Description Book for further information.
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Q: When I received my Explanation of Benefits there was a non-covered amount that was denied because the charge exceeds the Fund’s usual, customary and reasonable allowance. Do I need to pay this amount to the provider?
A: The usual, customary and reasonable allowance is determined by the Fund to be the most consistent charge by a provider for any given service. Your doctor may bill you for the disallowed amounts. Some providers will accept the Fund’s allowance and not bill the patient for the difference (other than for patient deductible and copay amounts). If you feel that the amount disallowed as being above the usual, customary and reasonable allowance is unfair, you have the right to have the claim reviewed for further consideration by sending in a letter of appeal. Please refer to the Claim Review Procedures set forth in the Summary Plan Description.
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Q: What can I do about any amounts that were not paid on my claim?
A: The deductible and copayment amounts are your responsibility as described under your plan. However, if you have any other charges that are not covered, you may request in writing to have the claim reviewed within ninety days of receiving the denial. Your review letter must include your name and social security number, the name of the patient and the relationship to you, the date of service, and the claim number. State why you feel the claim should be reviewed for additional payment. The claim will be reviewed by the Fund’s Review Committee. Additional information may be requested from you or the provider of service to further consider and review the claim. Once all the necessary information is received on the claim, the Review Committee will issue a decision within sixty days reaffirming, modifying or setting aside the former action.
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Q: I have been a member for many years and recently moved. Is there anything I need to fill out with my new address?
A: If you have any changes in your family, you must notify the Fund office by filling out a new Census Card. These changes, such as moving to a new address, marriage, birth of a child, separation, divorce, or death of your spouse, should be noted on the Census Card and sent to our office as soon as possible. You must remember that this Census Card is our only way to know your family information, therefore, it if very important to fill out a new card for any changes as soon after those changes occur. This card is used to enter your information into our computer system. Your name, Social Security number, date of birth, address, dependent information, employer’s name, and local number are all entered. This information is then used to process claims, generate insurance cards, and correspondence. Do not use nicknames as these may cause problems if a claim is filed by a provider using a different patient name. You must print clearly, as incorrect information is sometimes difficult to correct.
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Q: I filled out the Census Card, but now I received a letter asking for more information on my newborn. Why?
A: The Fund requires a birth certificate for a newborn to be added as a dependent on your benefits. Other situations where the Fund would write for additional information involve dependent children over the age of nineteen, who may qualify as your covered dependent until their 23
rd birthday, but only if they are enrolled as a full time student at an accredited educational institution. We require proof of attendance each semester, therefore, a letter must be submitted for the fall and spring semesters. Similarly, in the case of handicapped children, who are incapable of self-support, the Fund requires certain medical certifications.
In certain situations you may be required to submit a certified copy of your most recent federal income tax return and other necessary documents in order to establish proof of dependency for a dependent to be covered under your benefits.
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Q: How do I change my beneficiary for my death benefit?
A: The process is quite simple. Fill out a new Beneficiary and Census Card. The section at the bottom of the card is where a member designates the beneficiary for the member death benefit. However, even though only one piece of information may have changed,
all information on the entire card must be filled in and completed.
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Q: I have been sick for two weeks, can I collect any benefits?
A: Weekly disability benefits are provided for any non-occupational illness or accidental injury. You must be prevented from performing any and every duty pertaining to your occupation. You must submit a weekly benefit form containing proof of your disability. You must be under the care of, and being treated personally by, a legally qualified physician or surgeon. The claim date is determined by the first time you were seen and treated by the physician. If you had an accidental injury or were hospitalized, you will collect from the first work day you saw the physician. If the disability is due to an illness or pregnancy, you will collect beginning on the sixth work day. The maximum period of disability benefits is 26 weeks. This benefit is paid in lieu of wages; therefore, you cannot collect weekly disability benefits while being paid for sick pay, holiday pay, vacation pay, personal holidays, etc.
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Q: If my disability happened during the course of my employment, would it be all right to collect weekly disability benefits?
A: Any claim for a disability that originates during the course of employment should be filed with Workmen’s Compensation. Charges and claims relating to work related injuries are not covered by the Fund. If you do file for Workmen’s Compensation and are denied benefits by a Referee decision, your claim will be honored unless the denial was for procedural reasons.
Q: What card do I use for my benefits?
A: If you have
Personal Choice or
Keystone HMO benefits, present your card to the hospital or physician. If you have
Traditional benefits, present the Blue Cross card to the hospital, and the Fund’s medical claim form to the physician for the doctor charges. When you need to get a prescription filled, use your General Prescription Program card.
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Q: Why did I get denied for vitamins on my prescription card when my doctor prescribed them for me?
A: Even though your physician has prescribed a medication, there are exclusions and limitations to the plan. Some of the prescriptions not covered by the Fund include vitamins, cosmetics or other health and beauty aids, dietary aids, bandages, support garments and contraceptives.
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Q: Are death benefits taxable?
A: Death benefits for active employees and their dependents are provided through a group life arrangement with Union Labor Life Insurance Co. These benefits qualify for the exclusion to gross income under the Internal Revenue Code. Therefore, the benefits paid to the beneficiary are not taxable.
However, the Fund also provides death benefits for some retirees and their spouses, as well as for totally and permanently disabled participants. Death benefits in these cases are paid directly out of the Trust Fund and not through an insurance company. Therefore, these benefits are subject to federal and state taxes.
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