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Section
7. Filing a claim for covered services |
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| How
to claim benefits |
To
obtain claim forms, claims filing
advice or answers about our benefits,
contact us at 1-800/638-6589 or 301/984-1440
(for TDD, use 301/984-4155), or at our Web
site at www.SambaPlans.com.
In most cases, providers and facilities file
claims for you. Your physician must file on
the form CMS-1500, Health Insurance Claim
Form. Your facility will file on the UB-04
form.
When you must file a claim -- such as for
services you received overseas or when
another group health plan is primary --
submit it on the HCFA-1500 or a claim form
that includes the information shown below.
Bills and receipts should be itemized and
show:
- Name of
patient and relationship to
enrollee;
- Plan
identification number of the
enrollee;
- Name and
address of person or firm providing
the service or supply;
- Dates
that services or supplies were
furnished;
- Diagnosis;
- Type of
each service or supply; and
- The
charge for each service or supply.
Note: Canceled
checks, cash register receipts, or balance
due statements are not acceptable
substitutes for itemized bills.
In addition:
- You must
send a copy of the explanation of
benefits (EOB) form you received
from any primary payer (such as the
Medicare Summary Notice (MSN)) with
your claim.
- Bills
for private duty nursing must show
that the nurse is a registered or
licensed practical nurse.
- Name and
address of person or firm providing
the service or supply;
- Claims
for rental or purchase of durable
medical equipment; private duty
nursing; and physical, occupational,
and speech therapy require a written
statement from the physician
specifying the medical necessity for
the service or supply and the length
of time needed.
Note: Claims for
prescription drugs and supplies are
addressed in Section
5(f), page 52.
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| Records |
Keep
a separate record of the medical expenses of
each covered family member as deductibles
and maximum allowances apply separately to
each person. Save copies of all medical
bills, including those you accumulate to
satisfy a deductible. In most instances they
will serve as evidence of your claim. We
will not provide duplicate or year-end
statements. |
| Deadline
for filing your claim |
Send
us all the documents for your claim as soon
as possible. You must submit the claim by
December 31 of the year after the year you
received the service, unless timely filing
was prevented by administrative operations
of Government or legal incapacity, provided
the claim was submitted as soon as
reasonably possible. You are responsible to
make certain that your claims are filed
within the timely filing deadline. Once we
pay benefits, there is a three-year
limitation on the re-issuance of uncashed
checks. |
| Overseas
claims |
Claims
for overseas (foreign) services should
include an English translation. Charges
should be converted to U.S. dollars using
the exchange rate applicable to the date the
service was rendered. For inpatient hospital
services, the exchange rate will be based on
the date of admission. Send itemized bills
for covered services provided by hospitals
or doctors outside the United States to
SAMBA, 11301 Old Georgetown Road, Rockville,
MD 20852-2800. |
| When
we need more information |
Please
reply promptly when we ask for additional
information. We may delay processing or deny
benefits for your claim if you do not
respond. |
To print this entire FEHB Brochure or a section of this
Brochure, click here.
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