Benefits and Coverage

Claim – Filing Procedures/Claim

When you have a covered expense, it is not always necessary to file a claim. In many cases, the provider will handle all the paperwork.

Claim Filing

You rarely need to file a claim for the following benefits:

HMO benefits. When you use HMO facilities in your usual service area (see HMO materials for more information).
Indemnity Dental benefits. When you use Delta Dental providers.
Prepaid dental benefits. When you use their providers and facilities.
RxAmerica Prescription Drug benefits. When you use RxAmerica participating pharmacies.
Vision care benefits. When you use VSP participating providers.

Claims must always be filed for Indemnity Medical benefits, whether you use a PPO or non-PPO hospital, doctor or other provider. However, the provider usually sends the claim to TBT. Hospitals always handle claim submission. You should ask your doctor or other provider if they will send in the claim. If not, it is your responsibility.

You usually need to file a claim for the following benefits:

HMO benefits. When you travel or receive benefits outside your usual HMO service area.
Indemnity Dental benefits. When you don't use Delta Dental providers.
Prescription drug benefits. If you are a new participant, before receiving your plastic ID card or if you use a non-RxAmerica pharmacy.
Vision care benefits. When you don't use VSP providers.
Life Insurance and Accidental Death & Dismemberment benefits.

How to File a Claim

If you need to file a claim, you need to get the appropriate form through the TBT Plan Administrative Office, your Local Union or Employer. A few forms are enclosed in your Forms folder.
Fully complete and sign your portion of the form.
Where applicable, have the provider (doctor, hospital or other provider) complete the rest of the form or provide an itemized bill that contains the requested information.
Mail the completed form with any related bills or statements to the address printed on the claim form by the deadline. If you don't provide all the requested information and itemized receipts, your claim will be delayed.

When to File a Claim

Claim forms must be filed within 90 days after the date when services were first received. Life insurance or AD&D insurance claims must be filed within 365 days of the death or accident. Contact the TBT Plan Administration Office for these forms, or if you need help filing a claim.

Late Claims

If a claim form is required and you don't send it in within the 90-day deadline (or within 365 days if the claim is for life insurance or AD&D benefits), the claim will not be reduced or denied if it is shown that it was not reasonably possible to file the claim when required. In this case, notice of proof must be provided as soon as reasonably possible. However, in no event, except in the absence of your legal capacity, shall a claim be accepted later than one year from the date when services were first received.

Claim Payment Process

When your claim is received, it will be reviewed to see that it is complete. If incomplete, you will receive a written request to provide missing information from you or the provider. Claims will not be paid until all requested details are returned.

The Plan reserves the right to examine the person whose injury or sickness is the basis of the claim, when and as often as it may reasonably require, to determine whether a claim is covered by the Plan. The cost of such an examination will be paid by TBT.

You will receive a written notice from the TBT Plan Administrator or other representative regarding your claim within 90 days of its receipt. If an extension of time is required to process your claim, you will receive written notice of the need for an extension before the end of the 90-day period, explaining the reasons for the delay. If you are not furnished notice within the 90-day period, your claim will be considered denied.