SPECIAL CLAIMS PROCEDURES
FOR MEDICARE MEMBERS
If you are a Medicare Member, there is a special claims procedure you must follow when you think we have failed to provide or pay for a service that is covered by your Service Agreement
that is covered under Part B of Medicare. Part B services typically include physician services (inpatient and outpatient), outpatient surgery, outpatient rehabilitation (such as physical therapy), outpatient dialysis services, administered drugs, ambulance services, durable medical equipment, prosthetics and orthotics.
If you have a claim for one of these services, you must submit it in writing to us. We will notify you of our decision within 60 days, giving specific reasons for any denial. If you are dissatisfied with our decision, you can submit a written request for reconsideration to us or through any Social Security office within 60 days from the date of our decision. We will review your request and act on it within 60 days. If we decide to uphold our original unfavorable decision, in whole or in part, we will send the entire file to Medicare for review. Medicare will make a reconsideration decision and notify you about it. If that decision is not in your favor and involves a claim of $100 or more, you can request a hearing before an administrative law judge by writing to us or Medicare or Social Security within 60 days of the reconsideration decision. If the administrative law judge's decision is not in your favor, there are further administrative appeals available to you.
If you have a claim that does
involve a Medicare Part B service, you must follow the Out-of-Plan Emergency Claims Procedure and Health Plan's Appeals Procedure described above. Please remember that binding arbitration is the last resort for all claims about covered services,
for claims involving a Medicare Part B service.