Section 7. Filing a claim for covered services

How to claim benefits	High Option: To obtain claim forms, claims filing advice or answers about our benefits, contact us at 800/222-APWU, or at our Web site at www.apwuhp.com. Consumer Driven Health Plan: Contact Definity Health at 866/333-4648 or visit their Web site at www.definityhealth.com. User ID: APWUHP Password: HPINFO the form HCFA-1500, Health Insurance Claim Form. Your facility will file on the UB- 92 form. For claims questions and assistance, call us at 800/222-APWU. When you must file a claim, such as when you use non-PPO providers, 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, address and taxpayer identification number 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) statement you received from any primary payer (such as the Medicare Summary Notice (MSN)) with your claim. Bills for home nursing care must show that the nurse is a registered nurse, licensed practical nurse or licensed vocational nurse. 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. Claims for prescription drugs and supplies that are not obtained from a network pharmacy or through the Mail Service Prescription Drug Program must include receipts that show the prescription number, the National Drug Code (NDC) number, name of drug or supply, prescribing physician's name, date, and charge. You should provide an English translation and currency conversion rate at the time of services for claims for overseas (foreign) services.
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 of 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. Once we pay benefits, there is a three-year limitation on the reissuance of uncashed checks.
Overseas claims	For covered services you receive in hospitals outside the United States and Puerto Rico and performed by physicians outside the United States, send a completed Claim Form and the itemized bills to the following address. Also send any written inquiries concerning the processing of overseas claims to: High Option: APWU Health Plan, P.O. Box 1358, Glen Burnie, MD 21060-1358. Consumer Driven Option: Definity Health at the claims address shown on the back of your Definity Health ID card.
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.

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