Administrative Forms

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Administrative Forms

The following forms and information pertains to any health claims or services on or after September 1, 2017.

COMMUNICATION GUIDES FOR MEMBERS

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.

UNIVERSAL NEW ENROLLEE FORM

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.

UNIVERSAL CHANGE ENROLLMENT FORM

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.)

COORDINATION OF BENEFITS (COB) FORM

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.

MEDICAL CLAIM FORM

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.

EXPLANATION OF BENEFITS (EOB) EXAMPLE

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.

 

The following forms and information pertains to any health claims or services prior to September 1, 2017

COMMUNICATION GUIDE FOR MEMBERS

AUTHORIZATION TO RELEASE INFORMATION (HIPAA)

EMPLOYEES: This form is to be used when you wish to authorize Meritain Health or Care Coordinators by Quantum Health to release your Protected Health Information (PHI) to an Individual, Provider or Organization. It is important to note Meritain Health will not release information concerning an employee’s spouse or over age 18 dependent child without this form completed by the spouse or over age 18 dependent child.

2016 – 2017 ENROLLMENT GUIDE

EMPLOYEES: This guide contains a summary of all rates and benefits associated with the programs endorsed by the Trust and offered by your employer. It should be noted not all employers offer all of the programs contained in this document.

MEMBER STATEMENT EXAMPLE

EMPLOYEES: This is a sample of the Member Statement and how to read it. Member statements are sent to you the 2nd week of the month and only if you had activity during the given period.  Explanation of Benefits (EOB’s) will continue to be sent in the case of coverage or benefit denial.

MEDICAL CLAIM FORM

EMPLOYEES: Please use the attached medical claim form to file your non-network expenses. The form must be completed in it’s entirety in order to facilitate quick handling of your claim.

PRESCRIPTION DRUG MAIL ORDER FORM

EMPLOYEES: This form is to be used in the event you wish to have any or all of your medical prescriptions set up for home delivery.  Please note the instructions and requirement on the attached form.