Frequently Asked Questions.
QUESTION: Why do I always have to give so much personal information when I call or come into the Fund Office?
ANSWER: Due to the HIPAA law that come into affect on 4/14/2003 and as well as for your protection, we do verify personal information to determine we are speaking with you, your spouse or your personal representative. When you come into the Fund Office, we do require a picture ID for verification for yourself and any person(s) that are with you. You may also be required to fill out an authorization form for the person(s) that are with you.
QUESTION: It is hard for me to call the office during business hours but you will not give any information to one of my family members/friends. What can I do?
ANSWER: You can designate one or more persons to obtain claim information on your behalf. Please complete a Personal Representative Form or you can call the Fund office and request a Personal Representative form. Once the form is completed and returned, the system will be updated with the names of your personal representatives. Please note that your personal representative will need your social security or alternate ID number and the dates of birth of the persons they are authorized to get information on.
QUESTION: It is hard for me to call the office during business hours. What can I do to find out the information I need?
ANSWER: The Member Self-Service Portal can be accessed 24 hours a day/7 days a week to help you access important information about your health care benefits. You can access this portal from your computer or mobile device. Here are some exciting features of the Member Self-Service Portal.
- Check your eligibility within a one-year span.
- Verify your demographic information.
- Update your address.
- Check the status of a claim(s) for you, your spouse and/or under-aged dependent(s).
- View and print an Explanation of Benefits (EOB) for a claim.
- Check your Health Reimbursement Account (HRA) balance.
- Check the status of your HRA claims.
QUESTION: You will not give me any information on my child who is age 18 or older. What can I do so I can get information about my child’s eligibility and/or claims?
ANSWER: Please have your child complete a Dependent Child Over Age 18 Personal Representative Form. You can call the Fund office and request a Dependent Child Over Age 18 Personal Representative form. Once the form is completed and signed by your dependent and each personal representative designated by your child has signed the form, it must be returned to the Fund Office. Our system will be updated with the names of your child’s personal representatives. The personal representatives designated by your child will be able to obtain eligibility and claim information for that child.
Annual Claim Forms
QUESTION: I filled out the annual claim form and sent it back but you keep sending it back to me. Why?
ANSWER: An annual claim form is required each year. To prevent any delays in processing your claims, it is important to answer all questions in each section completely. It is important to give us complete information regarding your spouse and if you or your dependents are covered under another insurance plan. Please be sure the annual claim form is signed and dated.
QUESTION: I know I have enough hours to be eligible, when will I be notified?
ANSWER: It is your responsibility to check with the Fund Office on a regular basis to check your eligibility. When you contact the Fund Office we can start the process by getting your current address and let you know what information we will need from you. Once the eligibility is reached and the system is updated, you will automatically receive your insurance cards within two weeks.
QUESTION: I just received a COBRA notice but I have been working. What should I do?
ANSWER: COBRA notices are mailed automatically around the 12th of the month when the systems shows that eligibility has ended. Please remember that eligibility is updated on a monthly basis after the hours have been worked. At this time we have not received the hours/contributions from your employer.
QUESTION: I just received a COBRA notice because my child turned 19. I thought he/she is covered up to age 26.
ANSWER: Effective June 1, 2011, the plan will cover dependent children up to age 26, regardless of circumstances such as being a full-time student, being married, or place of residence. Specifically, the Plan will cover eligible dependent children as follows:
- The Plan will cover your eligible children through age 25.
- Children will not be required to be students.
- Except for a disabled child, an under age 26 child’s residence, financial dependence and marital status will not affect eligibility.
- The Plan will exclude any child age 19 or older who is eligible for other group coverage through the child’s employer or through the employer of the child’s spouse, regardless of whether the child enrolls in such coverage.
Children who are eligible for insurance through their employer or their spouse’s employer are not eligible dependents under the Retiree Medical Plan. To determine if your child is “eligible” for other group coverage through his/her employer or his/her spouse’s employer, the child must complete and sign an annual claim form each year. These claim forms are sent out when the child turns age 19 and every May. The completed and signed claim form must be returned by June 1st each year. Failure to submit an annual claim form completed and signed by the child by June 1st, may result in a delay of benefit payments. The dependent annual claim form can also be found here: Dependent Annual Claim Form or in the Member Self Service Portal under the Forms tab.
QUESTION: My child turned 19, but the claims are being denied. How can this be prevented?
ANSWER: Your dependent children age 19 and older must complete and sign an annual claim form each year to verify their continuing eligibility under the Retiree Medical Plan. These claim forms are mailed to your child when he/she turns age 19 and every May until the child is age 26. The completed and signed claim form must be returned by June 1st each year. Failure to submit an annual claim form completed and signed by the child by June 1st, may result in a delay of benefit payments. The dependent annual claim form can also be found here: Dependent Annual Claim Form or in the Member Self Service Portal under the Forms tab.
QUESTION: What do I need to do to add my new spouse to the policy?
ANSWER: We will need a copy of the certified marriage license. The certificate that you receive from the church is not acceptable.
QUESTION: What do I need to do to add my newborn child to the policy?
ANSWER: Please call the Fund Office with the name and date of birth of your newborn. We will need a certified copy of the birth certificate submitted within 90 days of the child’s birth. Eligibility for your newborn child will be terminated after 90 days until we receive the certified birth certificate.
QUESTION: Why can’t you give me a list of the dentists in our plan?
ANSWER: Delta Dental has the most current list of dentists in the plan. Call Delta Dental at 800-452-1987. You can also find a dentist on line at www.deltadentalil.com
QUESTION: My son and I have the same name and we are both on the policy. Why is there a delay in processing our prescriptions when I send them in?
ANSWER: When sending in prescriptions, please indicate the date of birth of the patient on each receipt. This will prevent a delay in processing.
QUESTION: How can I tell if my prescription was run through Caremark so I do not get a 50% penalty?
ANSWER: The Retiree Medical Plan adopted a Prescription Card program for your prescription purchases. This means you should only be paying the pharmacy 20% of the prescription drug costs after 1-1-17. If you are paying the full price of a prescription drug, the prescription was not run through Caremark. Ask the pharmacist to rerun the prescription through Caremark. If there is a problem with your prescription and the pharmacist tells you it is being denied by Caremark, please contact the Fund Office.
Prior to 1-1-17, in addition to the name of patient, name of drug, date of prescription and the amount, you may see “PCS” or “CMK” on the prescription receipt you obtain from the pharmacy. Please be sure to check for this before you leave the pharmacy. If you are not sure, ask the pharmacist to show you.
QUESTION: I get test strips for my glucose monitor but you send my cash register receipts back to me. What do I need to get these paid?
ANSWER: Ask the pharmacist to write out a pharmacy receipt that includes the patient name, date, description of the item, and amount of the item. Some pharmacies will also put this on a regular prescription receipt.
QUESTION: I am going out of town and I need to refill my prescription(s) early but the pharmacist tells me it is too so. What can I do?
ANSWER: Call the Fund Office with at least a 48-hour notice and we can do an early refill override on your prescription(s) so you avoid the 50% reimbursement penalty.
QUESTION: When I go to the pharmacy, my test strips and lancets for my glucose monitor are not covered using my prescription drug card. What do I need to do to get these paid?
ANSWER: Your medical supplies for your glucose monitor are covered under the medical portion of the Plan and your claims for these supplies should be sent directly to the Fund Office for reimbursement. When you purchase them at the pharmacy, ask the pharmacist to write out a pharmacy receipt that includes the patient name, date of purchase, description of the item, and the amount of the item. A cash register receipt is not valid for benefit payment as it does not contain all of the information needed to process the claim.
QUESTION: I want to get an eye exam and glasses at an eye doctor in the plan. What do I have to do?
ANSWER: You can find a network provider by visiting the VSP website at www.vsp.com, selecting the CHOICE network or by calling VSP Member Services at 1-800-877-7195, Monday–Friday, 7:00 a.m. - 9:00 p.m.
Covered Medical Procedures and Services
QUESTION: How do I find out if medical services are covered?
ANSWER: Contact the Fund Office:
- Prior to having surgery performed to verify coverage, and ensure that the proposed procedure is covered by the Plan. Additionally, it is important to verify that the provider is in the Blue Cross Blue Shield network to avoid large out of pocket expenses.
- Prior to starting a new treatment for your existing medical condition to ensure that the treatment is FDA approved.
In some instances, you will be asked to submit a pre-service inquiry. This means your physician must submit the proposed procedure, diagnosis, office notes, test results, photos if available, and letter of medical necessity. If the pre-service inquiry is for a new treatment, the provider must also submit the treatment plan. This information must be sent at least three weeks prior to the scheduled date for the proposed procedure to allow enough time for a thorough review and response.
If the proposed procedure is not approved, you may submit a request for review of the Fund’s benefit determination. You should include any additional medical information and/or documentation from the attending physician that will support the treatment plan.
General Anesthesia and/or Hospitalization with Dental Procedures:
If general anesthesia or inpatient or outpatient hospitalization is proposed for a dental procedure, you must have a pre-service inquiry submitted to the Fund Office. Dental procedures are not covered under the medical portion of the Plan unless they are replacing natural teeth lost due to an accident within two years of that accident or are for treatment of a tumor.
Durable Medical Equipment:
If a provider has proposed ordering Durable Medical Equipment, please call the Fund Office to verify coverage. The Fund Office will need the doctor’s orders, and in some cases, a letter of medical necessity. Some equipment may be purchased with the doctor’s orders and others may need to be rented and later converted to a purchase depending on the length of use.
Limited Benefits – Lifetime or Calendar Year Maximum:
Some benefits are limited to a yearly or lifetime maximum. Some examples are: Smoking Cessation (for eligible retirees and spouses only) is limited to $1,000 lifetime per person or Chiropractic Care being limited to 30 visits per person annually. If you are receiving treatment for a limited benefit you can contact the Fund Office to find out if you are near the maximum payable benefit.
Explanation of Benefits:
Each time the Fund Office receives and processes a claim on your behalf you will receive an Explanation of Benefits in the mail. Please review the Explanation of Benefits to ensure that the services submitted to the Fund Office for payment of benefits were actually rendered. If you ever suspect a billing error, please contact the Fund Office right away.
For further information on whether or not a particular procedure or service is covered under the Plan of Benefits, please refer to the Summary Plan Description or contact the Fund Office:
- By calling 708-562-0200 between the hours of 8:00A.M. and 5:00 P.M,
- By writing to Chicago Laborers’ Welfare Fund, 11465 Cermak Road, Westchester, IL 60154, or
- By e-mailing at email@example.com