Benefits are not available under this dental plan.
May 1st hrs during the previous January thru March; or, if not, Then hrs during the previous October thru March; or, if not, Then hrs during the previous July thru March; or, if not, Then 1, hrs during the previous April thru March. August 1st hrs during the previous April thru June; or, if not, Then hrs during the previous January thru June; or, if not, Then hrs during the previous October thru June; or, if not, Then 1, hrs during the previous July thru June.
November 1st hrs during the previous July thru September; or, if not, Then hrs during the previous April thru September; or, if not, Then hrs during the previous January thru September; or, if not, Then 1, hrs during the previous October thru September. Coverage Effective Date You will become covered for benefits on the date you meet the Initial Eligibility requirements or the Qualifying Schedule requirements.
Continuation of Eligibility Once having become eligible, you shall remain eligible for a full quarter three consecutive months. Should you have been eligible for the previous quarter and not reach the required hours for coverage in the following quarter, you will be permitted to self-pay for the shortage of hours required to maintain your eligibility in the Plan determined by deducting the hours worked from the required three hundred and twenty-five hours.
The deficit hours are paid at the current contractual contribution rate. Coverage Termination Date Your coverage under the Plan will terminate on the earliest of the following: The date the Plan terminates; The date you are no longer a member of an eligible class; The date on which a self-contribution is due and unpaid; The date on which a self-contribution payment is rejected by a bank for insufficient funds; or The date a change is made in the Plan to terminate benefits for your class.
Coverage for Your Dependents Your dependents will become eligible for coverage when you become eligible, or when they become a dependent, if later. When you become eligible for coverage, you will be provided an enrollment package and you will need to complete the required Enrollment forms.
In the event of a Qualified Medical Child Support Order, you are required to provide for dependent coverage. Receipt of this type of notice constitutes a Medical Child Support Order and requires the Fund to add a dependent child to your coverage.
Coordination of Benefits When there is coverage under more than one group plan, the plan that determines benefits first is called the primary plan, and allows for benefits as provided under the plan. The plan that determines benefits after the first plan is called the secondary plan and benefits are limited so that the total amount from all the group plans will not be more than the actual amount of covered expenses incurred.
The rules for which the Health and Welfare Fund will follow for determining which plan is the primary plan are as follows: A plan without a coordination clause will always pay first.
The plan covering the patient as an employee is primary and the plan covering the patient as a dependent is secondary. Should both parents have the same birthday, then the plan that has covered the parent longer will be primary. The plan that covers an individual as an active employee is primary and the plan that covers the individual as an inactive employee is secondary.
The plan that covers an individual as an active employee is primary to the plan covering the individual as a self-pay participant. If both plans do not have this rule, it is ignored. In the case of divorced parents, the following line of benefit determination is applied: The plan of the parent with custody of the dependent child pays benefits first.
The plan of the spouse of the parent with custody of the child pays second. The plan of the parent without custody of the dependent child pays last.
If none of the above situations apply, the plan which has had the individual covered the longest period of time is primary. If there is a court decree which would otherwise establish financial responsibility for the health care expenses with respect to the child, the benefits of a plan which covers the child as a dependent of the parent with such financial responsibility shall be primary and any other plan which covers the child as a dependent will be secondary.
In applying the rules for determining which plan is the primary carrier, the provisions of any plan which would attempt to shift the status of this Plan from secondary to primary by excluding from coverage under such other Plan, any participant or dependent eligible under this Plan, shall not be considered.It shows all your services and supplies that providers and suppliers billed to Medicare during a 3-month period, what Medicare paid, and what you may owe the provider.
The MSN also shows if Medicare has fully or partially denied your medical claim (this is the initial determination, which is made by the company that handles bills for Medicare). I am writing on behalf of my patient, (patient name) to document the medical necessity of (treatment/medication/equipment – item in question) for the treatment of (specific diagnosis).
This letter provides information about the patients medical history and diagnosis and a statement summarizing my treatment rationale. writing. 2. After verifying DME/HME coverage for the member, submit to BCBSKS a copy of the benefits attached to the BCBSKS Predetermination Form to request the write-off amount for the particular piece of equipment or service.
BCBSKS will respond in New Durable . Instructions for Submitting REQUESTS FOR PREDETERMINATIONS Predeterminations typically are not required.
A predetermination is a voluntary, written request by a provider to determine. Guide to Provider Complaints and Appeals Based on feedback from providers, Anthem Blue Cross and Blue Shield (Anthem) is clarifying our guidelines for submitting provider complaints and appeals for disputes relating to claim payment and benefit determinations.
Other Clinical Information: If precertification is required please include clinical information with request. Add additional ICD-9 or CPT/HCPCS codes in this area. Please complete and fax back to