Welfare Summary Plan Description

15.13 HOW TO FILE YOUR CLAIMS

If you have any covered Dependents or a spouse, a current enrollment form is necessary to file a claim for Plan benefits and to coordinate benefits if you have additional insurance coverage. A current enrollment form is also required if there is a change in your status or the status of your dependents.

For Life Insurance, AD&D benefits, the Vacation Plan, and Time Loss benefits, mail your claim to the Trust Customer Service Office. (Contact information in the Quick Reference Table at the front of this booklet).

For Medical, Prescription Drug, and Dental benefits, mail your claim to the Administrative Office. (Contact information in the Quick Reference Table at the front of this booklet). For Medicare Retiree claims, submit the claim following the procedures in your TEAMStar booklet.

For Vision benefits mail your claim to the Vision Care Benefit organization. (Contact information in the Quick Reference Table at the front of this booklet):

Be sure your bills are itemized. In many cases, the provider of services will submit the claim directly. The following information must be indicated on the submitted bills or your Physician's standard claim form:

  • Eligible Employee's or Retired Participant's name
  • Eligible Employee's or Retired Participant's social security number
  • Patient's name and relationship to Eligible Employee or Retired Participant
  • Physician's or supplier's name, address, telephone number and Tax identification number
  • Diagnosis (condition treated) and the service procedure code
  • If treatment is related to Injury, date and place of Injury, including details (i.e., auto accident, fall, etc.)
  • Date each service was performed, and the cost for each service