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Submitting a Claim to Fidelis
Sometimes when you get medical care or a prescription drug, you may need to pay the full cost right away. Other times, you may find that you have paid more than you expected under the coverage rules of the plan. In either case, you can ask our plan to pay you back (paying you back is often called “reimbursing” you). It is your right to be paid back by our plan whenever you’ve paid more than your share of the cost for medical services or drugs that are covered by our plan.
There may also be times when you get a bill from a provider for the full cost of medical care you have received. In many cases, you should send this bill to us instead of paying it. We will look at the bill and decide whether the services should be covered. If we decide they should be covered, we will pay the provider directly.
Here are examples of situations in which you may need to ask our plan to pay you back or to pay a bill you have received. For more information, please read your Evidence of Coverage or call Member Services.
1. When you’ve received services or purchased supplies that are not usually covered by Medicare but that are covered by Fidelis. Examples of this are:
- Payments you make when you go to see a dentist or eye doctor, or when you get a hearing test. If you pay right away for these services, you can ask us to reimburse you.
Download Additional Benefits Claim Form
- Payments you make when you make a purchase over the counter at your pharmacy for incontinence supplies or food supplements.
Download Over the Counter Claim Form
Download Out-of-Network Pharmacy Claim Form
- Payments you make for approved transportation to physician appointment.
Download Transportation Claim Form
2. When you’ve received emergency or urgently needed medical care from a provider who is not in our plan’s network
You should ask the provider to bill the plan for our share of the cost.
- If you pay the entire amount yourself at the time you receive the care, you need to ask us to pay you back for our share of the cost. Send us the bill, along with documentation of any payments you have made.
- At times you may get a bill from the provider asking for payment that you think you do not owe. Send us this bill, along with documentation of any payments you have already made.
- If the provider is owed anything, we will pay the provider directly.
- If you have already paid more than your share of the cost of the service, we will determine how much you owed and pay you back for our share of the cost.
3. When a network provider sends you a bill you think you should not pay
Network providers should always bill the plan directly, and ask you only for your share of the cost. But sometimes they make mistakes, and ask you to pay more than your share.
- Whenever you get a bill from a network provider that you think is more than you should pay, send us the bill. We will contact the provider directly and resolve the billing problem.
- If you have already paid a bill to a network provider, but you feel that you paid too much, send us the bill along with documentation of any payment you have made and ask us to pay you back the difference between the amount you paid and the amount you owed under the plan.
4. When you use an out-of-network pharmacy to get a prescription filled
If you go to an out-of-network pharmacy and try to use your membership card to fill a prescription, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription.
- Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost.
5. When you pay the full cost for a prescription because you don’t have your plan membership card with you
If you do not have your plan membership card with you, you can ask the pharmacy to call the plan or to look up your plan enrollment information. However, if the pharmacy cannot get the enrollment information they need right away, you may need to pay the full cost of the prescription yourself.
- Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost.
6. When you pay the full cost for a prescription in other situations
You may pay the full cost of the prescription because you find that the drug is not covered for some reason.
- For example, the drug may not be on the plan’s List of Covered Drugs (Formulary); or it could have a requirement or restriction that you didn’t know about or don’t think should apply to you. If you decide to get the drug immediately, you may need to pay the full cost for it.
- Save your receipt and send a copy to us when you ask us to pay you back. In some situations, we may need to get more information from your doctor in order to pay you back for our share of the cost.
All of the examples above are types of coverage decisions. This means that if we deny your request for payment, you can appeal our decision. Chapter 9 of this booklet (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) has information about how to make an appeal.
Send us your request for payment, along with your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipts for your records.
To make sure you are giving us all the information we need to make a decision, you can fill out our claim form to make your request for payment.
- You don’t have to use the form, but it’s helpful for our plan to process the information faster.
- Either down load a copy of the form from our website (www.fidelissc.com) or call Member Services and ask for the form. The phone numbers for Member Services are on the cover of this booklet.
Mail your request for payment together with any bills or receipts to us at the address at the top of the claim form or contact Member Services.
Please be sure to contact Member Services if you have any questions. If you don’t know what you owe, or you receive bills and you don’t know what to do about those bills, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us.
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