Claims Filing Procedures Sample Clauses

Claims Filing Procedures. Participating Dentists

Claims Filing Procedures. This program begins to pay only after the Deductible amount you incur toward eligible expenses shows on our records. When your Physician, Hospital, or other Provider of health care services submits bills for you, your Deductible will be recorded automatically and then your program will begin its share of the payment. If you file your own claims, you must submit copies of all your bills, even those you must pay to meet your Deductible. Then our records will show that you have Incurred the Deductible amount, and your health care coverage will begin to help pay the balance of your eligible expenses.

Claims Filing Procedures. Hospital Claims 36 Ambulatory Surgical Facility Claims 36 Physician and Other Provider Claims… 36 Insured Filed Claims 36 Direct Claims Line… 37 Grievance Procedure… 37 This Agreement is issued pursuant to, and is governed by, the terms of the Oklahoma Health Insurance High Risk Pool Act, 36 O.S. § 6531 et seq. In the event of a conflict between the terms of this Agreement and the terms of the Act, the provisions of the Act will control. Subject to the Exclusions, terms, conditions, and limitations of this Contract and of the Oklahoma Health Insurance High Risk Pool Act, an Insured is entitled to Benefits for Covered Services described in the Covered Health Care Services section in the amounts specified in this Schedule of Benefits. BENEFIT PERIOD Calendar Year DEDUCTIBLE Calendar Year Family Deductible If the Insured has purchased coverage which includes his/her Dependents then no more than two individual Insureds of the family must satisfy their individual Deductibles in each Benefit Period; and No family member Insured will contribute more than the individual Deductible amount. MAXIMUM PAYMENT $1,000,000.(One Million Dollars) per lifetime per Insured. This amount shall include the Benefits provided under any other contract or agreement underwritten by the Plan. COVERED SERVICES AMOUNT OF BENEFIT OUTPATIENT PRESCRIPTION Retail Pharmacy (in network-30 day supply): 100% after $10 Co- payment for Generic drugs; $20 Co-Payment for Preferred drugs; and 30% of drug cost or $30 Co-Payment, whichever is greater, for Non-Preferred drugs. This benefit is available only for prescriptions purchased through the pharmacy card or its mail order option (and in formulary). At dispensing, based on the availability of a generic drug, should there, in fact, be a generic drug available and yet the plan participant requests the dispensing be filled with a name brand drug, then he/she pays the generic co-pay plus the difference in cost between the generic and name brand drug. MENTAL AND NERVOUS/ 50% of Allowable Charges until $4,000 is reached. ALCOHOLISM/ DRUG ADDICTION ALL OTHER SERVICES, UNLESS STATED DIFFERENTLY 80% of Allowable Charges for in network and all emergency services (after the deductible). 60% of Allowable Charges for out of network (after the deductible). For eligible expenses (both in network and out of network) over $10,000 (after the deductible) plan pays 100% of Allowable Charges.

Claims Filing Procedures. 1. When a Participating Provider renders services, generally, the Participating Provider should either file the claim on the Member’s behalf or provide an electronic means for the Member to file a claim while the Member is in the Participating Provider’s office. However, the Member is responsible for ensuring that the claim is filed. 2. Written notice of receipt of services on which a claim is based must be furnished to the Corporation, at its address on the Identification Card, within twenty (20) days of the beginning of services or as soon thereafter as is reasonably possible. Failure to give notice within the time does not invalidate nor reduce any claim if the Member can show that it was not reasonably possible to give the notice within the required time frame and if notice was given as soon as reasonably possible. Upon receipt of the notice, the Corporation will furnish or cause a claim form to be furnished to the Member. If the claim form is not furnished within fifteen (15) days after the Corporation receives the notice, the Member will be deemed to have complied with the requirements of this Plan of Benefits as to proof of loss. The Member must submit written proof covering the character and extent of the services within the time fixed for filing proof of loss. 3. For Benefits not provided by a Participating Provider, the Member is responsible for filing claims with the Corporation. When filing the claims, the Member will need the following:

Claims Filing Procedures. Filing a Claim

Claims Filing Procedures i. Administrator shall provide and update, as appropriate, Provider on request, with a manual or other document that sets forth the claims filing procedures, including: • The address where the claims should be sent for processing; • The telephone number at which providers' questions and concerns regarding claims may be addressed; • The name, address, and telephone number of any entity to which the Administrator or HMO has delegated the claims payment function, if applicable; and • The address and telephone number of any separate claims processing center for specific types of applicable services.