Generally, if you use UHC providers, you will not have to file your own claim for benefits—the UHC provider will do it for you.
If you have a claim that is denied, you may appeal to the Board of Trustees in writing within 90 days.
The Recovery Incentive Program provides a cash incentive for you if you discover and arrange for recovery of overcharges made on your hospital bills that result in savings for the Fund.
Under the Medicare Secondary Payor law, the Fund Office must have social security numbers for you and each of your dependents. Benefits will not be paid without the patient’s social security number on file.
All claims for medical, mental health/substance abuse and dental benefits must be properly completed and filed within one year of the date of service. Otherwise, no benefits will be paid. Reimbursement for claims from a non-participating vision provider must be filed with VSP within six months from the date of service.
The Board of Trustees reserves the right to have you examined, at its own expense and by a physician of its own choosing, as it sees fit when deciding on a claim.
Filing a claim is easy if you follow the steps described in this section. If a claim is denied or reduced, there is a process you can follow to have your claim reviewed by the Board of Trustees.
What You Need To Do
- Show your EWTF Benefit Card so that your physician will know where to submit your claim.
- If you use a UHC provider, UHC will file your claim for you.
- Call UHC at 844-659-5060 or go to www.UMR.com to request claim forms if you are applying for reimbursement for charges incurred from a non-UHC medical or hospital provider.
- File your claims and all requested forms within one (1) year of the date of your treatment or service in order to receive your benefit.
- Return the completed, signed form, along with any attachments to UHC at:
PO Box 30541
Salt Lake City, UT 84130-0541
- If you are applying for reimbursement for charges from a dentist, contact United Concordia Dental (UDC) at 1-866-851-7568 to request a claim form, and return the completed claim form to UDC at:
- United Concordia Companies, Inc.
PO Box 69421
Harrisburg, PA 17106-9421
- United Concordia Companies, Inc.
- If you are a retired participant covered under Medicare, submit your claim and Medicare Explanation of Benefits to UHC at:
PO Box 30541
Salt Lake City, UT 84130-0541
Filing a Claim
Generally, there are no claim forms to file if you use UHC providers for medical care,
CIGNA Dental PPO providers for dental care, and the VSP network for vision benefits.
If your provider does not submit your claim, it is your responsibility to do so.
To assure prompt, accurate action on your claim, be sure that the claim form and the attached bills are complete. They should contain all necessary information such as the name of the patient, the diagnoses, dates and descriptions of services, and itemized charges.
All claims must be properly completed and filed within one year of the date of service, except that non-participating vision provider claims must be submitted to VSP within 6 months of the date of service. Otherwise, no benefits will be paid.
Under the Medicare Secondary Payer law, the Fund Office must have Social Security numbers for you and each of your dependents. Benefits will not be paid without the
patient’s Social Security number on file.
Status of Claim
If you are calling UHC to check the status of your medical or hospital claim, United Concordia to check the status of your dental claim, or VSP to check the status of your optical claim, you will need to have the following information:
- Member’s identification number;
- Name of the patient;
- Date of service;
- Name of the provider of service (i.e.: doctor, hospital, etc.);
- Billed amount; and
- EWTF reference number, if known.
Contact With Your Providers
Under the EWTF contract with UHC, your providers of medical services must contact UHC at 1-866-596-8447 if there are any questions about your claims. (NOTE: This rule does not apply to your dental providers or if your provider submits your claims to Medicare as the primary coverage. Your dental providers should contact United Concordia at 1-866-851-7568. For Medicare claims, your providers should contact United HealthCare (UHC) at 1-866-596-8447.
Proof of Payment
The EWTF will require proof of payment for any and all claims, including payment of deductibles and/or Patient’s Portion before the out-of-pocket maximum has been reached. The Fund will notify you if further proof of payment is required.
Federally Issued Identification Numbers
A federally issued Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN) for you and each of your dependents must be provided to the Fund Office upon enrollment. If you fail to provide either a Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN)for yourself or any of your dependents this will result in termination of coverage under the Plan for that person. In the case of newly added children or a spouse, the Fund Office will wait for a period of up to six (6) months for you to provide a Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN)before canceling coverage.
Payment of Claim
Generally, payment of a claim is made directly to you, unless you “assign” your benefit, as explained below. If you die before all claims have been paid, if you fail to provide a forwarding address, or if you are deemed to be incompetent, the Board of Trustees will make payment to your spouse or any other person they determine is entitled to the payment.
Overpayment of Benefits
If the Fund pays benefits in error, such as when the Fund pays you or your dependent more benefits than you are entitled to, or if the Fund advances benefits that you or
your dependent are required to reimburse either because, for example, you have a
compensable Workers’ Compensation claim or have received a third party recovery,
you are required to reimburse the Fund in full and the Fund shall be entitled to recover any such benefits.
The Fund shall have a constructive trust, lien and/or an equitable lien by agreement in favor of the Fund on any overpaid or advanced benefits received by you, your dependent or a representative of you or your dependent (including an attorney) that is due to the Fund under this Section, and any such amount is deemed to be held in trust by you or your dependent for the benefit of the Fund until paid to the Fund. By accepting benefits from the Fund, you and your dependent consent and agree that a constructive trust, lien, and/or equitable lien by agreement in favor of the Fund exists with regard to any overpayment or advancement of benefits, and in accordance with that constructive trust, lien, and/or equitable lien by agreement, you and your dependent agree to cooperate with the Fund in reimbursing it for all of its costs and expenses related to the collection of those benefits.
Any refusal by you or your dependent to reimburse the Fund for an overpaid amount will be considered a breach of your agreement with the Fund that the Fund will provide the benefits available under the Plan and you will comply with the rules of the Fund. Further, by accepting benefits from the Fund, you and your dependent affirmatively waive any defenses you may have in any action by the Fund to recover overpaid amounts or amounts due under any other rule of the Plan, including but not limited to a statute of limitations defense or a preemption defense, to the extent permissible under applicable law.
If you or your dependent refuse to reimburse the Fund for any overpaid amount, the Fund has the right to recover the full amount by any and all methods which include, but are not necessarily limited to, offsetting the amounts paid against your and/or any of your dependents’ future benefit payments payable by the Fund under the Plan. For example, if the overpayment or advancement was made to you or on your behalf as the Fund participant, the Fund may offset the future benefits payable by the Fund to you and any of your dependents. If the overpayment or advancement was made to or on behalf of your dependent, the Fund may offset the future benefits payable by the Fund to you and any of your dependents.
The Fund also may recover any overpaid or advanced benefits by pursuing legal action against the party to whom the benefits were paid. The Fund has the right to file suit against you in any state or federal court that has jurisdiction over the Fund’s claim.
Assignment of Benefits
Normally, the provider will ask you to approve an assignment of benefits form to have payment of claims made directly to your provider. Under no other circumstances may benefits under the Plan be assigned.
If your claim is denied, you may appeal the decision in writing within 180 days. Submit your written appeal to:
Electrical Welfare Trust Fund
10003 Derekwood Lane, Suite 130
Lanham, MD 20706-4811