HOW TO FILE CLAIMS

Claims matters are handled by:

Administrative Office
P.O. Box 191030
Sacramento, California 95819-1030
Telephone: (916) 457-0155
(outside the Sacramento area): (877) 811-4474

All claims for benefits must be filed on forms provided by the Plan, which are available from the Administrative Office, except as required by law. A claim shall be considered to have been filed as soon as it is received at the Administrative Office or such other location as may be indicated on the claim form, provided it is substantially complete, with all necessary documentation required by the form. If the form is not substantially complete, or if required documentation has not been furnished, you will be notified as soon as possible of what is necessary to complete the claim, but not later than 5 days (24 hours in the case of a failure to file a claim involving emergency care).

The Plan may require additional evidence to establish whether or not any claim should be paid. The Plan may, for example, require supplementary documentation or the results of a physical examination or laboratory test in order to adjudicate a medical claim. If the patient fails to cooperate with such requests, the claim may be denied.

You should file your claims within 90 days after the expenses are incurred. Claims will still be considered for payment when it is not possible to provide notification within 90 days, but you should always file your claims as soon as possible.

Claims will not be paid if they are submitted more than 12 months after the expense was incurred, except in the absence of legal capacity.

The Plan requires a completed W-9 form from providers before the Plan can pay claims directly to the provider. If the provider fails to comply with the Plan’s request for a completed W-9, claim payments will be made to the participant and the participant will be advised of his/her responsibility to pay the provider.