Active Health & Welfare – Claims

Medical

A claim form may be obtained from your Union office or the Trust Fund Office by calling (800) 635-3105.

Claims for services that have been received should be filed as soon as reasonably possible but they must be submitted within 12 months from the later of the date the expense is incurred or the date of payment under another Plan which is primary. Any exception to the foregoing will be determined at the sole discretion of the Board of Trustees.

Urgent Care and Pre-Service Claims must be submitted to the Review Organization by phone. They are not to be submitted via the US Postal service.

All Urgent and Pre-Service Claims should be submitted to Anthem Blue Cross Utilization Review Department by Phone at: (800) 274-7767

All Urgent and Pre-Service Claims for Mental Health and Substance Abuse benefits should be submitted to the Managed Health Network listed in your Plan Document/Summary Plan Description.

PPO providers should follow the “Claim Submission” instruction shown on your Direct Pay Medical Plan Identification card. All Non-PPO provider claims should be filed with the Trust Fund Office.

Health Reimbursement Account

In order to be reimbursed, you must use the Plan’s HRA claim form and provide and provide applicable receipts, bills, invoices or other statements from the medical provider. A claim for reimbursement of an Eligible Medical Care Expense must be submitted to the HRA Claims Administrator within 12 months of the date the expense was incurred. After 12 months, the expense will no longer be eligible for reimbursement. Incurred expenses must total at least $100 before they can be submitted for reimbursement. You may include multiple Eligible Medical Care Expenses to be included in a claim in order to reach the $100 minimum. If your claim(s) do not meet or exceed the $100 limit, you may submit one claim per quarter.

Dental

Take the Dental Plan description and the Automotive Industries Welfare Fund Dental Claim Form to your dentist. Ask your dentist to include the Schedule Procedure Number(s) when he completes your Claim Form. To understand your financial responsibility on the claim, discuss with your dentist his fees, as they compare to Plan exclusions; limitations; and any pre-determination requirements and benefits as shown in the Schedule of Dental Procedures. When your dental services are completed, the Claim Form should be mailed to the Trust Fund Office as shown on the form. The Claim Form must be signed by both you and the dentist. Dental Claim Forms are available from your employer, your Union or the Trust Fund Office.

Orthodontics

Take an Automotive Industries Welfare Plan Dental Claim Form to your Orthodontist. Ask your Orthodontist to show you the treatment plan and related charges when he completes your Claim Form. The Claim Form should be mailed to the Trust Fund Office as shown on the form. The Claim Form must be signed by both you and the Orthodontist. Dental Claim Forms are available from your employer, your Union or the Trust Fund Office.

Vision Care

If you use a VSP provider, you will not need to file a claim form. You will pay your copayment at the end of your first visit, and your provider will take care of billing VSP for the remainder.

If you use a non-VSP provider, you will need to file a claim for reimbursement of the applicable amount(s). Call VSP at 800-877-7195 to have an Out-of-Network Reimbursement Form mailed or faxed to you (you can also fill out the form online at www.vsp.com and print it out). Mail the completed form with your itemized receipt to VSP at:

Vision Service Plan
Attn: Out-of-Network Provider Claims
P.O. Box 997105
Sacramento, CA 95899-7105

NOTE: You must submit your claim within 180 days from the date on which Allowable Expenses were incurred. Benefits will not be allowed if you submit your claim more than 180 days after the date on which Allowable Expenses were incurred. If you have any questions about submitting your claim, contact VSP.

Burial, Life Insurance, AD&D

Burial Benefit and Life Insurance and AD&D claims should also be filed with the Trust Fund Office no later than one year after the death or accident. Claim forms are available from your Union office or you may call the Trust Fund Office at (800) 635-3105. In the event of death, certified copy of the death certificate must accompany the claim form.

Disability Benefits

Claim forms are available through the Local Union Offices, the employers or the Trust Fund Office. Part I of the claim form must be completed by the Employee; Part II of the claim form must be completed by the employer; and Part III of the claim form must be completed by the Doctor when the Employee is claiming disability benefits because of an accident, when hospital confined as an inpatient, when disabled for more than five work days because of an illness or when specifically requested by the Plan. Failure to fully complete all required parts of the claim form by these parties may delay benefits to the Employee. Claims must be filed within 180 days of the disability. IMPORTANT Please attach a copy of check stubs provided by State Disability or Worker’s Compensation showing your weekly benefit entitlement with your initial claim submission.