Health Care > Paying for Health Care Services and Filing Claims

Health Care

Paying for Health Care Services and Filing Claims

Step 1: When You Receive a Service or Make a Purchase

Medical

Each time you receive care, in most cases, the doctor will bill the Medical Plan first before billing you for the remaining balance owed. This allows the Medical Plan to process the claim and then generate an Explanation of Benefits (EOB) form that is sent to you and the doctor. The EOB form will indicate the amount paid by the Medical Plan and the amount owed by the patient.

Make sure your doctor codes claims appropriately: preventive/routine care vs. diagnostic/non-routine care so it gets paid correctly.

If you participate in the Account Plan, you can use your HRA to pay for your deductible and your co-insurance. In most cases these medical expenses, including mental health and substance abuse, are automatically submitted.

Prescription Drug

When using a participating retail pharmacy in the Network:

Present your prescription and ID card to the pharmacist
Verify the pharmacy has accurate information about you and your covered dependents, including date of birth
Pay the prescription co-insurance
Sign for and receive your prescription.

When using an out-of-network retail pharmacy:

Present your prescription to the pharmacist
Pay 100% of the prescription price
Submit a paper claim form along with the original receipt to Caremark for reimbursement of covered expenses. (You will be reimbursed based on the Network price, less the appropriate co-insurance.)

When using mail-order:

With FastStart you or your doctor can call Caremark at 1-800-875-0867 to place your order. When calling, you or your doctor will be asked for your participant ID, your doctor’s contact information and a list of any other prescriptions you take. Pick up your maintenance prescription at your local CVS pharmacy or ask Caremark to mail it to you.

You can fill out the Mail Service Patient Profile/Order Form and mail it to Caremark with the original prescription(s) and the appropriate co-insurance payment to have your maintenance prescription conveniently delivered to your home.

If you participate in the Account Plan, you can use your HRA to pay your prescription drug costs. These expenses are not automatically submitted to your HRA; you need to submit receipts to receive prescription drug reimbursement from your HRA.

Dental

In general, if you receive treatment from a participating provider, you do not have to file a claim. Each time you receive care, in most cases, the dentist will bill the Dental Plan first before billing you for the remaining balance owed. This allows the Dental Plan to process the claim and then generate an Explanation of Benefits (EOB) form that is sent to you and the doctor. The EOB form will indicate the amount paid by the Dental Plan and the amount owed by the patient.

Health Care FSA

You have until March 15, 2010 to incur expenses that may be reimbursed from your 2009 FSA contributions. Any unused 2009 FSA contributions will be forfeited if not submitted for reimbursement by June 30, 2010.

Most eligible medical and dental expenses processed by Aetna — including prescription drugs from all Network retail pharmacies and mail-order service — will be automatically reimbursed.

To opt out of automatic claim filing (streamline cancellation) or to stop direct deposit payments:

Go to Aetna Navigator
Select Requests & Changes, then click Payment Options
Select Streamline Claims or Direct Deposit, as appropriate, and complete the information.

IMPORTANT: If you opt out of automatic claim filing, that election applies to all health claims: medical, dental and prescription drugs. You will need to opt out after January 1, 2009, even if you opted out for 2008.

For over-the-counter medications and expenses for vision materials (e.g., glasses and contact lenses) and laser surgery, you should save your receipts so you can submit them for reimbursement, as applicable.

Dependent Day Care FSA

Also consider …

Working with Your Doctor to Ensure Highest Benefits

Step 2: Filing Claims

Step 3: Reviewing Your Explanation of Benefits (EOB) Form

Disclaimers