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?
No pre-existing condition exclusions will be applied to you or any of your eligible dependents effective on January 1, 2012 in order to comply with the Patient Protection and Affordable Care Act “PPACA” which is commonly referred to as the Health Care Reform Act.
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. Aetna reviews pre-certification requests for the Plan’s medical benefits and 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 Aetna 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.