The following forms and information pertains to any health claims or services on or after September 1, 2017.
Please refer to this Communication Guide for information concerning claims or services received on or after September 1, 2017. All of this information is also contained on your ID card. We request members use this guide to contact the appropriate vendor or provider of service. HealthSCOPE Benefits only submits enrollment to the voluntary carriers and cannot respond to inquiries concerning those programs benefits, this will only result in a delay of services to the Member.
EMPLOYEES: The Universal New Enrollee form is to be used when you are enrolling in any of the medical, dental, vision or life programs for the first time, OR if you are currently enrolled and wish to drop coverage of any of the available products. (Note: Please be sure all forms are completed in their entirety, signed and dated. If enrolling dependents, their date of birth and SSN are required for enrollment.)
If you did not enroll in the life insurance when first eligible all amounts are subject to medical underwriting. You will need to complete an Evidence of Insurability form that can be found under the Voluntary Benefits / Life Insurance.
EMPLOYEES: The Universal Change Enrollment form is to be used when you are currently enrolled in any of the medical, dental, vision or life programs and wish to make changes during the Open Enrollment period, at the time of a Special Enrollment Event, or a Qualifying Change in Status. See the Plan Document for details on when you may enroll. (Note: Please be sure all forms are completed in their entirety, signed and dated. If enrolling dependents, their date of birth and SSN are required for enrollment.)
EMPLOYEES: The COB form is required each year from all members enrolling in the medical plan. The intent of this document is to determine if members, and their dependents, enrolled on the Egyptian Trust medical plan may have access to other coverage that would need to be coordinated for payment. Members may complete the COB form, sign, date and return to their district office.
EMPLOYEES: The attached medical claim form may be used when filing expenses. Please follow the directions on the form. The form must be completed in it’s entirety in order to facilitate quick handling of your claim.
EMPLOYEES: This is a sample of the Explanation of Benefits you will receive each time a claim is processed. The form will point out the billed charges, discounts and ineligible amounts (if applicable), payments made and patient responsibility along with the status of your accumulated deductibles and coinsurance. Questions about your claims may be directed to HealthSCOPE Benefits at 1-800-397-9598 between the hours of 8 a.m. to 6 p.m. CST, Monday through Friday.