Claims Process

The claims process

 
Claims, reimbursements and refunds

When you obtain a covered service, the only payment that a provider will collect from you for a covered service is the copayment, coinsurance or deductible amounts shown in this Member Handbook, or in any applicable Schedules of Benefits. Your plan provider has an agreement with the plan to send claims directly to us. If you do receive a bill for covered services, other than for a copayment, coinsurance or deductible, write your FHLAC coverage information on the back of the bill and return it to the provider’s office with a request to bill us directly.

Claims from non-plan providers

There are certain circumstances in which you may receive services from non-plan providers. Non-plan providers are providers who are not contracted with FCHP and are not in our HMO network.

Emergency Services in an Emergency Department of a Hospital and Stabilization Services: If you received emergency services in an emergency department of a hospital or services to stabilize that emergency medical condition from a non-plan provider, we will pay the greater of (a) the median amount negotiated with in-network providers for the emergency services furnished, (b) the usual, reasonable and customary charge, or (c) the amount that would be paid by Medicare (less any cost sharing). If the non-plan provider bills you for more than the amount FCHP paid, you are responsible for paying the provider the balance.

Emergency Services (not in an emergency department of hospital or related stabilization services): If you receive emergency services from a non-plan provider, including ambulance services, we will pay
the usual, reasonable and customary charge for the covered services you receive (less any cost sharing). If the non-plan provider bills you for more than the usual, reasonable and customary charge, you are responsible for paying the non-plan provider the balance. FCHP reserves the right to pay you directly for these charges. If FCHP pays you directly, you will be responsible for submitting payment to the non-plan providers.

Non-emergency Out-of-network Services: Under most circumstances, non-emergency services received from non-plan providers are not covered without prior authorization. If FCHP decides it will pay for these services, FCHP will pay the usual, reasonable and customary charges (less any cost sharing). FCHP reserves the right to pay you directly for these charges. If FCHP pays you directly, you will be responsible for submitting payment to the non-plan providers.

If you receive a bill for urgent care or emergency services from non-plan providers, send it to us within one year of the date of service. You may submit the bill yourself, or the provider may submit it directly. All bills should include a description of the services, the diagnosis, the dates of services and the charge for each service.

Send bills to:
Fallon Health & Life Assurance Company, Inc.
Claims Department
P.O. Box 15121
Worcester, MA 01615-0121

Care in foreign countries

You may submit claims for urgent care or emergency services in a foreign country if the services are not provided free of charge by that country. The bills must be itemized and in (or translated into) English. Payment will be made to you, and you must pay the provider.

Recovering money owed

FHLAC has the right to recover any money you owe to us, a health plan physician, or a health plan facility, or any other person or facility providing services to you on behalf of the plan. FHLAC will do so by offsetting the amount you owe us with any reimbursement payments we may owe you. This will satisfy our obligation to pay for services you receive.

Claims questions/refunds

If you have a question regarding a claim you should contact Customer Service. If you feel you are entitled to an adjustment or refund due to discrepancies in the effective date of your coverage or your contract type, send a letter to:

Fallon Health & Life Assurance Company, Inc.
Customer Service Department
10 Chestnut St.
Worcester, MA 01608

Adjustments or refunds will be approved in accordance with our underwriting guidelines. FHLAC will not approve an adjustment or refund if it is for something that took place more than one year before we receive your letter, or if it is for an amount less than $5.

Coordination of benefits

Coordination of benefits (COB) takes place when more than one health insurance plan covers a service. This includes plans that provide benefits for hospital, medical, or other health care expenses. Under COB, one plan pays full benefits as the primary carrier. The other (the secondary carrier) pays the balance of covered charges. The primary and secondary carriers are determined by the standard rules that are used by all insurance companies.

We have the right to exchange benefit information with any other group plan, insurer, organization or person to determine benefits payable using COB. We have the right to obtain reimbursement from you or another party for services provided to you. You must provide information and assistance and sign the necessary documents to help us receive payment. You must not do anything to limit this repayment. If payments have been made under any other plan that should have been made under this plan, FHLAC has the right to reimburse the plan to the extent necessary to satisfy the intent of COB. If FHLAC pays benefits in good faith to a plan, we will not have to pay such benefits again. FHLAC also has the right to recover any overpayment made because of coverage under another plan.

FHLAC will not duplicate payment for any service. FHLAC will not make payment for more than the full benefit available under this contract. If FHLAC provides or arranges services when another carrier is primary, we have the right to recover any overpayment we have made from the primary carrier or other appropriate party. If FHLAC does not receive the necessary documentation from you, we may deny your claim.

In order to obtain all the benefits available, you must file claims under each plan.

Subrogation

Subrogation (a process of substituting one creditor for another) applies if you have a legal right to payment from an individual or organization because another party was responsible for your illness or
injury.

FHLAC may use your subrogation right, with or without your consent, to recover from the responsible party or that party’s insurer the cost of services provided or expenses incurred by us that are related to your illness or injury. FHLAC will notify you of the right to reimbursement prior to settlement or judgment. If you are reimbursed by the responsible party, FHLAC has the right to recover from you the
cost of services provided or expenses incurred.

Our right to repayment comes first, even if you are not paid for all your claims against the other party, or if the payment you receive is described as payment for other than health care expenses. Any recovery from your personal injury protection coverage under a Massachusetts automobile policy shall be limited in accordance with the law. If we do not receive the necessary documentation from you, FHLAC may deny your claim.

Workers’ compensation

The plan does not cover any services or supplies that are covered by workers’ compensation insurance or a similar program. If you are eligible for workers’ compensation or a similar employer’s liability coverage, FHLAC may request information from you before processing claims. If FHLAC does not receive the necessary documentation from you, we may deny your claim.

Medicare

If you are entitled to Medicare, Medicare is generally considered to be your primary health insurance, even if you also have health coverage provided by the plan.

However, there are some circumstances in which the plan might be primary over Medicare. Your age, work status and (if you are eligible for Medicare due to disability) the presence of specific disabling
medical conditions may affect which coverage is considered to be your primary insurance.

If you are covered under a group health plan and are eligible for Medicare only because of End Stage Renal Disease (ESRD), we will be the primary payer for covered services for a period of 30 months starting with the date you become eligible for Medicare coverage. After 30 months, Medicare will become the primary payer and we will become the secondary payer. As the secondary payer, our payments will be reduced by the Medicare allowed amount for the same covered services. Payments will be reduced if you are eligible for ESRD Medicare coverage, even if you decline to enroll.

If you are entitled to Medicare, and Medicare is your primary carrier, we have a legal right to obtain reimbursement for services provided to you by us or a provider you see on a referral, if the services are covered by Medicare.