Health
& We
lfare
and Pension Funds
of Philadelphia and Vicinity
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| Frequently Asked Questions (FAQ)This page contains answers to common questions handled by our support staff.
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.
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.
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.
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.
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.
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.
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.
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.
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. 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 23rd 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.
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.
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.
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.
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.
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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