How To Use Your Benefits

If You Need Hospital Care
Present your Plan Identification Card when you enter the Hospital. Immediately notify the Managed Benefits Program Coordinator.

If You Need Physician
Care In Network: If the physician participates in Aetna's Choice POS II, he should submit a bill directly to Aetna. You should be responsible only for the
co-payment.

Out of Network: Show the Physician your Plan Identification Card, and provide
him with a claim form (which you can either obtain from your Employer or the
Claims Administrator) and ask him to bill the Claims Administrator for all of his
services which may be payable under this Plan indicating diagnosis, date(s) and type(s) of service and fee(s). You will be required to complete a Health
Plan claim form and forward it to the Claims Administrator, when the provider
does not submit a properly completed claim form.

Prescription Drugs
When your Physician prescribes medicine, simply take your prescription to an Aetna Participating Pharmacist The pharmacist will fill your prescription and charge you only the co-payment per presciption indicated in the Schedule of Benefits.*

Secondary prescription drug claims submitted with evidence of another payer’s
Explanation of Benefits should be mailed to:

Attn: Commercial Claims Processing
Aetna Pharmacy Management
P. O. Box 14024
Lexington, KY 40512

* Certain prescription drugs may require pre-certification.

WHEN TO FILE A CLAIM
You should file a claim as soon as you receive charges for services covered by your Plan. Claim forms may be obtained from your employer or claims administrator. In situations where charges may be of a nominal nature (injections, office visits, etc.), it is suggested that you accumulate them until they are sufficient to satisfy the deductible. In situations where the deductible has already been satisfied, accumulating smaller bills will simplify everyone's record keeping by reducing the number of checks issued to you.

All claims must be received by the Plan's claims administrator no later than fifteen (15) months from the date of service. This applies to all claims whether the Consortium is primary payer or not.

HOW TO FILE AN OUT-OF-NETWORK CLAIM FOR HEALTH SERVICES

a. patient’s name;
b. description and code of each service rendered;
c. date of each service rendered;
d. charge for each service rendered;
e. diagnosis and code (if more than one diagnosis, an indication of which diagnosis refers to each specific service rendered); and
f. name, address and tax identification number of the provider of service.

Make a photocopy of the billing you receive from the provider for your records, and send the billing (if paid by you, make sure the bill so indicates) with a completed claim form to the Claims Administrator

AETNA, Inc.
P. O. Box 981109
El Paso, TX 79998-1109
1-877-223-1685

1. A separate claim form must be submitted for each family member for whom a claim is being made. The Plan maintains separate payment and deductible records on you and each of your dependents. Only one claim form from the major provider of service is needed for each claim submission. If you have made payment to the provider, be sure the bill is marked paid or is accompanied by a paid receipt.

2. Please review the claim form carefully and follow the instructions it contains.

OTHER GROUP COVERAGE
Since this Plan contains a Coordination of Benefits provision, it is important that you advise the Claims Administrator of any other group health plan covering you or your Dependents. You should complete the appropriate section of your claim form in full.
Note: If this Plan is paying as the secondary plan, generally we must be notified of the amount(s) paid by the primary plan before our payment can be made. Please include copies of all providers’ bills and statements from other insurance plans. To help you understand what Coordination of Benefits is and how it affects you, refer to the "Coordination of Benefits" Provision.

INCOMPLETE CLAIM FORMS
When a claim form is submitted without completion of all appropriate items, it is necessary for the Claims Administrator to request the information. This can cause unnecessary delays in providing you with your benefits.

LATE SUBMISSION OF CLAIM
Claims submitted more than 15 months after the date of service will be denied.

ASSIGNMENT OF BENEFITS
Benefits, other than hospital, are usually paid to you, unless the billing submitted includes an "assignment of benefits" signed by you or if the provider is a member of Aetna's Choice POS II. Choice POS II and hospital benefits are usually paid directly to the provider. Regardless of where the payment is directed, you will always receive written notification of the payment and how it was computed.

LEGAL ACTION
No legal action can be brought to recover under any benefit after 3 years from the deadline for filing claims.

PHYSICAL EXAMINATIONS
The Plan will have the right and opportunity to have a physician or dentist of its choice examine any person for whom certification or benefits have been requested. This will be done at all reasonable times while certification or a claim for benefits is pending or under review. This will be done at no cost to you.

IMPORTANT NOTE
IF THERE IS ANYTHING YOU DO NOT UNDERSTAND ABOUT YOUR PLAN, OR HOW TO USE IT, YOU ARE ENCOURAGED TO CONTACT THE CLAIMS ADMINISTRATOR, YOUR OWN DISTRICTS BENEFITS REPRESENTATIVE OR THE OFFICE OF RISK MANAGEMENT AT BOCES.