Human Resources

Claim Filing Procedures and Deadlines

The following procedures and deadlines pertain to the QCHP, Prescription Drug Plan and Behavioral Health Services.  Utilization of network Providers usually eliminates the need to file paper claims.  However, if an out-of-network Provider is utilized the procedures and deadlines must be followed.  Contact the appropriate Plan Administrator with any questions about Covered Services, benefit levels or Claim Payments. 

For a CIGNA claim form click on the following link:  

CIGNA Claim Form

Claim Filing Deadlines

All claims should be filed promptly.  The Plans require that all Claims be filed no later than one year from the ending date of the Plan Year in which they charge was incurred.

Claim Filing Procedures

All communication to the Plan Administrators must include the Member's Social Security Number (SSN) or Alternate Member Identifier (AMI) and appropriate Grop Number as listed on the Identification Card.  This information must be included on every page of correspondence.

• Complete the appropriate claim form from the appropriate Plan Administrator.

• Attach the itemized bill from the Provider of services to the Claim form.  The itemized bill must include name of patient, date of service, diagnosis, procedure code, and the Provider’s name, address and telephone number.

• If the person for whom the Claim is being submitted has primary coverage under another group plan or Medicare, the Explanation of Benefits (EOB) from the other plan must also be attached to the Claim.

• The Plan Administrator may communicate directly with the Plan Participant or the Provider of services regarding any additional information that may be needed to process a claim.

• The benefit check will always be sent and made payable to the Member (not any dependents), unless benefits have been assigned directly to the Provider of service.

• If benefits are assigned, the benefit check is made payable to the Provider of service and mailed directly to the Provider.  An EOB is sent to the Plan Participant to verify the benefit determination.

• Claims are adjudicated using industry standard Claim processing software and criteria.  Claims are reviewed for possible bundling and unbundling of services and charges.  Providers may occasionally bill for services that are not allowed by the Claim review process. 

Benefits for Services Received While Outside the United States

The Plan covers Eligible Charges incurred outside of the United Sates for generally accepted medically necessary services usually rendered within the United States.

All Plan benefits are subject to Plan provision and Deductibles.  The benefit for facility and professional charges is 80% of U&C.  Notification is not required for medically necessary service s rendered outside of the United States.

Payment for the services will most likely be required from the Member at the time of services.  Plan Participants must file a Claim with the Plan administrator for reimbursement.  When filing a Claim, enclose the itemized bill with a description of the services translated to English and the dollar amount converted to U.S. currency, along with the name of the patient, date of service, diagnosis, procedure code and the Provider's name, address and telephone number.

In general, Medicare will not pay for health care obtained outside the United States and its territories. If Medicare is primary, include the Explanation of Medicare Benefits (EOMB) denying payment, along with the Claim form and send to the Plan Administrator.

Hospital Bill Audit Program

The Hospital Bill Audit Program applies to PPO and non-PPO Hospital charges.  The Program provides that the Plan Participant should discover an error or overcharge on a Hospital bill and obtains a corrected bill from the Hospital, the Plan Participant will be eligible for 50% of the resulting savings, up to a maximum of $1,000 per Admission.

Reimbursement documentation required.

1. Original incorrect bill.

2. Corrected copy of the bill.

3. Member's name and telephone number.

Submit Documentation to:

Note:  PPO Hospital claims which are paid on a per diem basis are not eligible under the Hospital Bill Audit Program, as the Plan pays based on the negotiated rate, not on actual charges.  Related bills such as radiologist, surgeon, etc., are not eligible under the Program.