| Frequently Asked
Health and Welfare Questions The following
are answers to Frequently Asked Questions (FAQ’s). Please consult
your specific plan’s Summary Plan Description for additional
information.
- What is the
procedure for claims submission to the Plan?
Network
claims will be submitted for you by the provider. Non-Network claims
should be submitted directly to the Fund Office. Claims forms are
available at the Fund Office, and also should be available at your
employer’s worksite or local union office. All claims for payment of
benefits from the Plan must be submitted within one year from the
date the service was rendered, or the onset of disability, or they
will not be processed.
- Why does the Fund
send me a claim form for accident details if an injury or
diagnosis of pain of a body part is indicated?
If a claim
is a result of an accident or injury by a third party, the Plan
treats the third party as primarily liable for your medical
expenses. By asking you for additional details, the Fund is
requesting the information it needs to determine if a third party is
responsible for payment. If the Fund pays a claim which is actually
the responsibility of a third party, it may take action to recover
these payments. By determining up front which party is responsible
for payment, the Plan saves time and money on incorrect payments and
costly litigation. These savings help to control premium costs.
- Why does the Fund
send Co-ordination of Benefits forms to me once every year? I
informed the Fund last year about my spouse’s employment
situation.
Employment
and health coverage situations change, and the Fund needs to make
sure that the correct information is on file so that claims are paid
correctly. If a claim is paid based on incorrect information, the
Fund may take action to recover payment. For example: a claim was
submitted for your spouse. The Fund’s latest information supplied by
you indicated that your spouse was not covered by another health
plan. Your spouse became employed and was covered by another health
plan since the last time you contacted the Fund. The Fund paid your
spouse’s claim in error. In this case, the Fund may seek payment
from your spouse’s health insurance provider if it becomes aware of
your spouse’s insurance.
- How does the
Prescription Plan work?
If you
have prescription coverage under the Plan, you should have received
a health insurance card and a separate prescription insurance card.
Consult your plan documents for specific coverage information.
Always take your prescription insurance card with you to the
pharmacist. Your pharmacist may need to contact the prescription
carrier if your drug is an injectable, costs over $500 or to confirm
your eligibility.
If you do
not have your prescription card with you and your prescription is
urgent, get your prescription filled, pay the charge and call the
Fund as soon as possible (by the next day, if possible). If you do
not have your prescription card and your prescription is not urgent,
contact the Fund before paying for the prescription.
- Are there
exclusions for pre-existing conditions under the Plan?
Yes, but
only to the extent permitted by a federal law called Health
Insurance Portability and Accountability Act of 1996 (HIPAA).
If you
received medical advice or treatment for a condition in the 90 days
before your date of hire, or in the case of a new employer entering
the Fund for the first time with respect to which the obligation to
make contributions begins, that condition is a pre-existing
condition under the Plan. Generally, the Plan will not pay benefits
for that condition for a period of 12 months from your date of hire
or in the case of a new employer entering the Fund for the first
time, the date on which your employer is obligated to make
contributions on your behalf.
However,
if you had other prior coverage before your date of hire, or in the
case of a new employer entering the Fund for the first time, the
date from which the obligation to make contributions begins, that
period of prior coverage may offset part or all of the 12-month
exclusion on a day-to-day basis. In order to enjoy the benefit of
that offset, you will need to provide a “Certificate of Creditable
Coverage” from your other insurance(s) to the Fund office. Any
period of prior coverage before a break in coverage of more than 63
days will not be counted to offset the 12-month exclusion.
Please
contact the Fund Office if you have any questions on these rules.
- Does the Plan’s
Managed Care Program require that I get pre-certification for
the care I receive?
Pre-certification is required for all non-emergency hospital
admissions and surgery and most out-patient surgeries. MRI’s, CAT
Scans and PET Scans do not require pre-certification. Please call
the Fund Office if you have questions regarding the necessity of
pre-certification in a particular situation.
Plan
medical advisors make the final pre-certification determination.
Health Assurance reviews pre-certification requests for the Plan’s
medical benefits; United Behavioral Health reviews pre-certification for the
Plan’s mental health/substance abuse benefits.
The
pre-certification rules of the Central PA Teamsters Health and
Welfare Fund govern and are separate and different from those of
other Health Assurance plans.
If you are
using a Network physician, it is the doctor’s responsibility to
contact the Fund Office and follow its instructions to obtain
pre-certification. If you use a non-Network provider, it is your
responsibility to contact the Fund Office and follow its
instructions to obtain pre-certification.
If you
have emergency surgery, you or your provider must notify the Fund
Office within 2 business days after treatment/hospitalization.
Please
note: Pre-certification approval does not automatically mean that a
claim will be approved. The Trustees reserve the right to deny
benefits if subsequent information leads the Plan’s professional
advisors to conclude that the treatment was not medically necessary.
To
pre-certify, you must call the Fund Office at 610-320-5500,
toll-free in PA at 1-800-422-8330 or toll-free nationwide at
1-800-331-0420.
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