This section describes the proper procedures to follow when filing a Claim for benefits and what to do if your Claim is denied. 

A Claim is a request for Plan benefits made according to the Plan’s reasonable Claims procedures described in the Summary Plan Description (SPD).  A claim can be a Pre-Service, Urgent Care, Concurrent, or Post-Service Claim.

For a complete description, Continue Reading.

1.     Pre-Service Claims for:

·       Elective, non-emergency Hospital admissions

·       Surgical treatment for morbid obesity

·       Hospice Care

·       Home Health Care

Where to File a Pre-Service Claim for #1

Call Anthem Blue Cross at 1-800-274-7767

2.     Pre-Service Claims for all non-emergency outpatient services for:

·       Arthroscopy procedures

·       Cataract procedures

·       MRI, CT and PET scans

·       Chemotherapy

·       Radiation therapy

·       Physical therapy

·       Sleep studies

·       Durable Medical Equipment of $500 or more

·       All genetic testing

·       Routine costs associated with an approved clinical trial

Where to File a Pre-Service Claim for #2

Call the PHA Care Counselor at 1-855-754-7271

An Urgent Care Claim is any Claim for medical care or treatment that, if handled within the time frames of a Pre-Service Claim, could seriously jeopardize the life or health of the individual or his ability to regain maximum function or, in the opinion of the Physician with knowledge of the individual’s medical condition, would subject the individual to severe pain that cannot adequately be managed without the care or treatment in the Claim.

Where to File Urgent Care Claim

Call Anthem Blue Cross at 1-800-274-7767

Urgent Care Claims are not to be submitted by the U.S. Postal Service

A Concurrent Claim is a Claim that is reconsidered after an initial approval was made and, after reconsideration, results in a reduction, termination or extension of a benefit. An example of a Concurrent Claim is an inpatient Hospital stay that was originally authorized for 5 days and is reviewed after 3 days to determine if the full 5 days is still appropriate. In this example, a decision to reduce, terminate or extend the inpatient Hospital stay is made concurrently with the provision of medical treatment. Reconsideration of a benefit with respect to a Concurrent Claim that involves the termination or reduction of an approved benefit will be made by the Trust Fund Office or Anthem Blue Cross as soon as possible but, in any event, in time to allow you to appeal the decision before the benefit is reduced or terminated.

Any request by a claimant to extend approved urgent care treatment will be acted upon by Anthem Blue Cross within 24 hours of receipt of the Claim, provided the Claim is received at least 24 hours prior to the expiration of the approved treatment. A request to extend approved treatment that does not involve urgent care will be decided upon according to Pre-Service or Post-Service time frames, whichever apply.

Claims that are not Pre-Service, Urgent Care or Concurrent are considered Post-Service Claims. An example of a Post-Service Claim is any Claim submitted for payment after medical services or treatment has been obtained.

Usually, you will be notified of the decision on your Post-Service Claim within 30 days from the date the Plan receives your Claim. This period may be extended one time by the Plan for up to 15 days if an extension is necessary due to matters beyond the control of the Plan. If an extension is necessary, you will be notified before the end of the initial 30-day period of the circumstances requiring the extension of time and date by which the plan expects to make its decision.

Where to File a Post-Service Claim

Post-Service Claims are considered “filed” as soon as they are electronically filed with Fund’s designee, Anthem Blue Cross, or the “host plan” under the BlueCard PPO national network. Claims not submitted electronically can be mailed to:

Anthem Blue Cross

P.O. Box 60007

Los Angeles, CA 90060-0007