MMC Benefits Handbook
Filing a Claim
How do I file a claim for medical benefits?
If you use an in-network provider, in almost all cases, you do not have to file a claim form. The provider will file a claim directly with the Claims Administrator. Once the claim is processed you will be billed for the appropriate coinsurance amount and/or deductible.
If you receive services from a provider who does not participate in the network, you need to file a claim form to receive benefits.
You can obtain a Medical Benefits Request Form from the Claims Administrator.
Read and follow the form's instructions. Be sure to file a separate claim form for each member of your family. Make copies of all itemized bills and attach the originals to the claim form. You will also need to indicate whether you want the payment to go to the provider or to you.
Mail the completed claim form and all relevant documentation as the form instructs. You may include more than one bill with a claim, even if the bills are for different medical services.
You have 12 months following the date the expense was incurred to file a medical claim.
How long does it normally take to process a claim for medical benefits?
Most claims are normally processed within 14 business days after the claim is received by the Claims Administrator.
You can find out the status of your claims by visiting the Claims Administrator's website.
How do I file a prescription drug claim form?
All prescriptions filled at a participating retail pharmacy require you to provide an ID card for coverage under the Plan. You are responsible for the applicable deductible or coinsurance. Rarely will you need to file a claim with the Prescription Drug Benefits Manager (one example may be a prescription filled at retail before you have received your ID card). Should you need to file a claim, contact the Prescription Drug Benefits Manager.
Claim forms are available on the Pharmacy Drug Benefits Manager's website. Should you need to file a claim you are responsible for the contracted rate less coinsurance. You have 12 months from the date the expense was incurred to submit a claim.
How do I file a claim for hospital charges?
Hospitals will submit a claim from your hospital stay directly to the Claims Administrator. After receiving reimbursement from the Claims Administrator, the hospital will then bill you for any coinsurance or amount not eligible for reimbursement.
Be sure to review the hospital bill and to request an explanation of any charges that you question or do not understand. You should let the Claims Administrator know if you have a concern about the charges on your hospital bill.
You have up to 12 months following the date the expense was incurred to file a claim.
Can I be reimbursed for claims incurred outside the United States?
No, you cannot be reimbursed for services incurred outside the US unless they are considered emergency services. If you incur eligible emergency medical or prescription drug expenses while living or traveling outside of the US, your claim's processing will be expedited if the receipts are in English or if the person providing the services gives you a letter in English explaining the treatment. The Claims Administrator will convert the bill to US dollars using an exchange rate on the day the services were performed.
You have 12 months following the date the expense was incurred to file a claim.
What is an Explanation of Benefits (EOB)?
An Explanation of Benefits statement outlines how the amount of benefit, if any, was calculated. The statement also shows your year-to-date deductible and out-of-pocket expenses. If you are due reimbursement, a check will be mailed to you with an explanation of benefits statement, or to the provider if you assigned payment.
An Explanation of Benefits statement lets you verify that the claim was processed correctly. Always read your statement carefully, checking to make sure that you were billed only for:
- Services you received, on the day(s) you received them, only from the provider of care
- The exact type of services you received (e.g., if you participated in a group therapy session, make sure that you are not billed for individual treatment)
- The amount you were told the treatment would cost
- The type of medication you received (e.g., if you receive generic medication, check that you are not billed for brand name medication).
If your statement lists services you did not receive, please notify the Claims Administrator.
If you authorize that reimbursement be made directly to your provider, both you and the provider will receive an Explanation of Benefits statement, and the provider receives payment.
What happens if I am overpaid for a claim?
If the Plan overpays benefits to you (or a covered family member), you are required to refund any benefit you receive from the Plan that:
- Was for an expense that you (or a covered family member) did not pay or were not legally required to pay;
- Exceeded the benefit payable under the Plan; or
- Is not covered by the Plan.
If a benefit payment is made to you (or a covered family member), which exceeds the benefit amount, this Plan has the right: