If a Covered Person chooses to use a Personal Representative, the Covered Person must submit proper documentation to the Plan stating the following: the name of the Personal Representative, the date and duration of the appointment, and any other pertinent information. In addition, the Covered Person must agree to grant his or her Personal Representative access to his or her Protected Health Information. The Covered Person should contact the Claim Administrator to obtain the proper forms. All forms must be signed by the Covered Person in order to be considered official. PROCEDURES FOR SUBMITTING CLAIMS Most providers will accept assignment and coordinate payment directly with the Plan on the Covered Person’s behalf. If the provider will not accept assignment or coordinate payment directly with the Plan, the Covered Person will need to send the claim to the Plan within the timelines outlined below in order to receive reimbursement. The address for submitting medical claims is on the back of the group health identification card. A Covered Person who receives services in a country other than the United States is responsible for ensuring the provider is paid. If the provider will not coordinate payment directly with the Plan, the Covered Person will need to pay the claim up front and then submit the claim to the Plan for reimbursement. The Plan will reimburse the Covered Person for any covered amount in U.S. currency. The reimbursed amount will be based on the U.S. equivalency rate that is in effect on the date the Covered Person paid the claim, or on the date of service if the paid date is not known. A complete claim must be submitted in writing and should include the following information: • Covered Person’s/patient’s ID number, name, sex, date of birth, address, and relationship to Employee • Authorized signature from the Covered Person • Diagnosis • Date of service • Place of service • Procedures, services, or supplies (narrative description) • Charges for each listed service • Number of days or units • Patient’s account number (if applicable) • Total billed charges • Provider’s billing name, address, and telephone number • Provider’s Taxpayer Identification Number (TIN) • Signature of provider • Billing provider • Any information on other insurance (if applicable) • Whether the patient’s condition is related to employment, an auto Accident, or another Accident (if applicable) • Assignment of benefits (if applicable) TIMELY FILING Covered Persons are responsible for ensuring that complete claims are submitted to the Third Party Administrator as soon as possible after services are received, but no later than 12 months from the date of service. If Medicare or Medicaid paid as primary in error, the timely filing requirement may be increased to three years from the date of service. A Veterans Administration Hospital has six years from the date of service to submit the claim. A complete claim means that the Plan has all of the information that is necessary in order to process the claim. Claims received after the timely filing period will not be allowed. -98- 7670-00-413597