Member Benefits
Medical Benefits
The Plans
The medical plan option available to you is based on your bargaining classification. Click on the links below to view each plan’s summary of benefits:
Both plans are administered by Anthem Blue Cross and Blue Shield and provide discounts for services received from PPO providers. However, the calendar year deductible, coinsurance and other coverage amounts differ by plan.
When you receive care from a PPO network provider, both you and the Fund save money.
The PPO Network
When you need care, you have the option to go in- or out-of-network. Both plans use the Anthem Blue Cross and Blue Shield Preferred Provider Organization (PPO) network.
When you use a PPO provider, you receive the highest level of benefits because the providers have agreed to charge negotiated, discounted rates. Pre-negotiated rates offer savings for you and the Fund. Plus, when you use PPO providers, the calendar year deductible is lower.
You have the option to visit providers outside the PPO network. However, when you do, your deductible and copayment (out-of pocket expenses) are higher because non-PPO providers do not offer negotiated rates.
Is your provider in the Anthem Blue Cross and Blue Shield PPO Network?
How to Find an Anthem PPO Provider
Call 1-800-810-2583 or go online at www.anthem.com and follow these steps:
- Click on the “Members” button in the left-hand corner.
- Under the “Welcome to” banner, click on “National Accounts” from the pull-down menu and hit the “Enter” button.
- Click on “Find a Doctor” on the left-hand side.
- Click on “Yes” in the Security Information box.
- Enter “FDU” in the Identification Prefix box on the ProviderFinder page and click “Next.”
- Fill in the blanks with your address or select the state and county from the pull-down menus and click “Next.”
- Select the type of provider from the pull-down box choices (“All Providers,” “Physician, or other Medical Professional” or “Hospital, Clinic or Other Medical Facility”).
- You can then select from several general or specialty categories.
PPO Network Cost-Savings Example
Using PPO providers can save you money. The example below compares what Jason would pay for hospital expenses at a PPO network hospital and a non-PPO hospital. It assumes Jason has not satisfied his calendar year deductible.
PPO Hospital Non-PPO Hospital Hospital Charge $4,381 $4,381 PPO Network Discount $1,593 $0 Net Covered Charges $2,788 $4,381 Deductible (paid by Jason) $250 $500 Expenses Subject to Reimbursement $2,538 $3,881 Plan pays $2,030.40
(80% of $2,538)$2,328.60
(60% of $3,881)Jason Pays $757.60
(20% plus deductible)$2,052.40
(40% plus deductible)Jason saves $1,294 using a PPO-network hospital. This example reflects actual savings from a network PPO provider. Your actual savings may vary, depending on the specifics of your hospital confinement.
Filing Medical Claims
When you use a PPO network provider, you do not need to file a claim. In most cases, the provider will submit all necessary claim information to the Fund’s Claims Administrator on your behalf. Any reimbursements are sent directly to the provider.
Regardless of whether the provider participates in the PPO network or not, when you receive health care services you should:
- Show your identification card to the provider of service; and
- Ask the provider to file a claim for you.
How to submit a medical claim
In some cases, for instance if you receive your care from a non-PPO provider, you may have to submit a claim for benefits directly to the Fund’s Claims Administrator. If you must submit a claim for health care services received, you should:
- Obtain an itemized bill from the hospital, doctor, or medical facility. An itemized bill generally includes all of the following:
- Patient’s name and address
- Date of Service
- Type of Service and diagnosis
- Itemized charges
- Provider’s complete name, address, and tax identification number
- Download a claim form.
- Complete the claim form and attach the itemized bill to the form.
- Send the claim form and bill to the address on the claim form.
Payment for eligible benefits will be made to the health care vendor unless your claim includes a paid receipt. If a receipt is submitted with your claim, payment will be sent to you.
A claim is not considered filed until it is received by the Fund’s Administrative Office. The Fund’s Administrative Office will process your claim within 30 days of the date it is filed, unless special circumstances require additional processing time. If additional information is needed to process your claim, the Fund may request additional information from you or the provider. You and/or your physician will have at least 45 days to submit the additional information.
When certain expenses are not eligible under the Plan, you will be notified by the Fund’s Administrative Office that the claim is denied, with an explanation of the reasons for the denial. You will receive a Notice of the Adverse Benefit Determination in writing which contains the following:
- The specific reasons for the adverse benefit determination;
- The specific reference to the Plan and/or Summary Plan Description provisions on which the adverse benefit determination was based;
- A description of any additional materials or information necessary for you to perfect your claim and an explanation of why such material or information is necessary;
- The notice of any internal guidelines or protocols used in making the decision, if applicable, and your right to receive a copy;
- A notice of your right to a written explanation of any exclusion which affects your claim; and
- A description of this Plan’s Appeals Procedure.
- Obtain an itemized bill from the hospital, doctor, or medical facility. An itemized bill generally includes all of the following:
Before receiving outpatient mental health and substance abuse treatment, you must contact ComPsych® for a referral at 1-877-627-4239.
How to precertify inpatient treatment for mental health and substance abuse treatment.
Either you or your provider must call ComPsych at 1-877-627-4239 to precertify inpatient hospital treatment for mental health and substance abuse. If you do not, you will be charged a $250 penalty fee.
* In an emergency, seek care immediately, then call your primary care doctor as soon as possible for further assistance and directions on follow-up care. Failure to make contact within seventy-two (72) hours of an emergency admission will result in application of the $250 penalty fee.Once you or your physician contacts ComPsych, they will determine the appropriateness of your hospitalization as soon as possible, and within 15 days. If additional information is needed from you or your physician to make the decision, you will be notified as to what information must be submitted. You and/or your physician will have at least 45 days to submit the additional information. Once ComPsych receives the information from you or your physician, you will be notified of the decision on the claims, generally within 10 days.
In the event that ComPsych does not approve the admission as requested, a denial or “Adverse Benefit Determination” will apply and you will receive a Notice of the Adverse Benefit Determination that includes:- The specific reasons for the adverse benefit determination;
- The specific reference to the Plan and/or Summary Plan Description provisions on which the adverse benefit determination was based;
- A description of any additional materials or information necessary for you to perfect your claim and an explanation of why such material or information is necessary;
- The notice of any internal guidelines or protocols used in making the decision, if applicable, and your right to receive a copy;
- A notice of your right to a written explanation of any exclusion which affects your claim; and
- A description of ComPsych’s appeals procedure.
