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Procedures for Claiming Benefits

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CLAIMS PROCESSING

Medical, prescription drug, dental and vision claims are processed separately. Completed medical, prescription drug, dental and vision claims must be sent accordingly for processing to the following:

MEDICAL BENEFIT CLAIMS:

Allegiance Benefit Plan Management, Inc. 
P.O. Box 3018
Missoula, MT 59806-3018
Phone: (855) 999-1057 or (406) 523-3199
Fax: (406) 721-2252
www.askallegiance.com/som


PRESCRIPTION DRUG CLAIMS:

Navitus Health Solutions
P.O. Box 999
Appleton, WI 54912-0999
Phone: (866) 333-2757
www.navitus.com
 

DENTAL BENEFIT CLAIMS:

Delta Dental Insurance Company
P.O. Box 1809
Alpharetta, Georgia 30023-1809
Phone: (866) 496-2370
www.deltadentalins.com/stateofmontana
Claims for dental benefits must be filed on a standard claim form which may be obtained from Delta Dental Insurance Company.

 

VISION BENEFIT CLAIMS:

Cigna Vision, Claims Department
P.O. Box 385018
Birmingham, AL 35238-5018
Phone: (877) 478-7557
www.mycigna.com
 
 
PROCEDURES FOR CLAIMING MEDICAL, PRESCRIPTION DRUG, DENTAL AND VISION BENEFITS

Medical, prescription drug, dental and vision claims must be submitted to the Medical Plan, Prescription Drug Plan, Dental Plan or Vision Plan within twelve (12) months after the date services or treatments are received or completed. Non-electronic claims may be submitted on any approved medical, prescription drug, dental or vision claim form, available from the provider. The claim must be completed in full with all the requested information. A complete claim must include the following information:

  • Date of service;
  • Name of the Participant;
  • Name and date of birth of the patient receiving the treatment or service and his/her relationship to the Participant;
  • Diagnosis [code] of the condition being treated;
  • Treatment or service [code] performed;
  • Amount charged by the provider for the treatment or service; and
  • Sufficient documentation, in the sole determination of the Plan Administrator, to support the Medical or Dental Necessity of the treatment or service being provided and sufficient to enable the Medical, Prescription Drug, Dental or Vision Plan Supervisor to adjudicate the claim pursuant to the terms and conditions of the Medical Plan, Prescription Drug Plan, Dental Plan or Vision Plan.

Medical, prescription drug, dental and vision claims are processed separately. See the “CLAIMS PROCESSING” section for where to send medical, prescription drug, dental and visions claims.

A claim will not, under any circumstances, be considered for payment of benefits if initially submitted to the Medical Plan, Prescription Drug Plan, Dental Plan or Vision Plan more than twelve (12) months from the date t that services were incurred.

Upon termination of the Medical Plan, Prescription Drug Plan, Dental Plan or Vision Plan, final claims must be received within three (3) months of the date of termination, unless otherwise established by the Plan Administrator.

CLAIMS ARE NOT DEEMED SUBMITTED UNTIL RECEIVED BY THE APPROPRIATE PLAN SUPERVISOR.

The Plan Administrator has the right, in its sole discretion and at its own expense, to require a claimant to undergo a medical, prescription drug, dental or vision care examination, when and as often as may be reasonable, and to require the claimant to submit, or cause to be submitted, any and all medical, prescription drug, dental or vision care and other relevant records it deems necessary to properly adjudicate the claim.

CLAIM DECISIONS ON CLAIMS AND ELIGIBILITY

Claims are considered for payment according to the Plan’s terms and conditions, industry-standard claims processing guidelines and administrative practices not inconsistent with the terms of the Medical Plan, Prescription Drug Plan, Dental Plan or Vision Plan. The Plan Administrator may, when appropriate or when required by law, consult with relevant health care, prescription drug care, dental care or vision care professionals and access professional industry resources in making decisions about claims that involve specialized medical, prescription drug, dental or vision knowledge or judgment. Initial eligibility and claims decisions are made within the time periods below stated. For purposes of this section, “Covered Person” will include the claimant and the claimant’s Authorized Representative;

“Covered Person” does not include a health care, prescription drug care, dental care or vision care provider or other assignee, and said health care provider or assignee does not have an independent right to appeal an Adverse Benefit Determination simply by virtue of the assignment of benefits.

“Authorized Representative” means a representative authorized by the claimant to act on their behalf in pursuing a benefit claim or appeal of an Adverse Benefit Determination. The claimant must authorize the representative in writing, and this written authorization must be provided to the Plan Administrator. The Plan Administrator may recognize this Authorized Representative only after the Plan Administrator receives the written authorization.

INFORMATION REGARDING URGENT CARE CLAIMS IS PROVIDED TO YOU UNDER THE DISCLOSURE REQUIREMENTS OF APPLICABLE LAW; THE PLAN DOES NOT MAKE TREATMENT DECISIONS. ANY DECISION TO RECEIVE TREATMENT MUST BE MADE BETWEEN THE PATIENT AND THE PATIENT’S HEALTHCARE PROVIDER, PRESCRIPTION DRUG CARE PROVIDER, DENTAL CARE PROVIDER OR VISION CARE PROVIDER. HOWEVER, THE MEDICAL PLAN, PRESCRIPTION DRUG PLAN, DENTAL PLAN OR VISION PLAN ONLY PAYS BENEFITS ACCORDING TO THE TERMS, CONDITIONS, LIMITATIONS AND EXCLUSIONS OF THE MEDICAL PLAN, PRESCRIPTION DRUG PLAN, DENTAL PLAN OR VISION PLAN. SOME SERVICES ARE EXCLUDED UNDER THIS PLAN REGARDLESS OF MEDICAL NECESSITY.

 There are no Pre-Service Urgent Care requirements under this Plan, and therefore, there   are no rights to appeal a pre-service Urgent Care claim denial.

1. Urgent Care Claims - An Urgent Care Claim is any claim for medical care or treatment with respect to which:

  • In the judgment of a prudent layperson possessing an average knowledge of health and medicine may seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or
  • In the opinion of a Physician with knowledge of the claimant’s medical condition, may subject the claimant to severe pain that may not be adequately managed without the care or treatment that is the subject of the claim. 

2. Pre-Service Claims - Pre-Service Claims must be submitted to the appropriate Plan before the Covered Person receives medical treatment, prescription drug, dental or vision care services. A Pre- Service Claim is any claim for a medical, prescription drug, dental or vision care benefit which the appropriate Plan terms condition the Covered Person’s receipt of the benefit, in whole or in part, on approval of the benefit before obtaining treatment. Pre-Service Claims are procedures stated in the Summary Plan Descriptions which the Plan Administrator recommends be utilized before a Covered Person obtains medical, prescription drug, dental or vision care. 

3. Post-Service Claims - A Post-Service Claim is any claim for a medical, prescription drug, dental or vision benefit under the applicable Plan with respect to which the terms of the Plan do not condition the Covered Person’s receipt of the benefit, or any part thereof, on approval of the benefit prior to obtaining medical care, prescription drug care, dental care or vision care, and for which medical, prescription drug, dental or vision treatment has been obtained prior to submission of the claim(s). In most cases, initial claims decisions on Post-Service Claims are made within thirty (30) days of the appropriate Plan’s receipt of the claim. The appropriate Plan shall provide timely notice of the initial determination once sufficient information is received to make an initial determination, no later than thirty (30) days after receiving the claim.

4. Concurrent Care Review - For patients who face early termination or reduction of benefits for a course of treatment previously certified by the appropriate Plan, a decision by the appropriate Plan to reduce or terminate benefits for ongoing care is considered an Adverse Benefit Determination. (Note: Exhaustion of the appropriate Plan’s benefit maximums is not an Adverse Benefit Determination.) The appropriate Plan shall notify the Covered Person sufficiently in advance to allow an appeal for uninterrupted continuing care before the benefit is reduced or terminated. Any request to extend an Urgent Care course of treatment beyond the initially prescribed period of time must be decided within twenty-four (24) hours of the appropriate Plan’s receipt of the request. The appeal for ongoing care or treatment must be made to the appropriate Plan at least twenty-four (24) hours prior to the expiration of the initially-prescribed period.