United Food & Commercial Workers

Unions and Employers

Midwest Health and Pension Funds

UFCW Calumet Region Insurance Fund

How to File a Claim

Your plan may not include every benefit mentioned. Refer to your plan booklet to verify which benefits are included in your plan.

 
For prompt processing of your claims, please follow the guidelines described here. For more detailed information, refer to the Health Benefits Plan Claim Procedures page of this website.

If you do not file a claim for benefits within 24 months of the date the service is received, the claim will not be processed and no benefits will be paid.

Claims for Hospital, Surgical, Medical Benefits

Most healthcare providers will submit your claims for you. All BlueCross BlueShield PPO providers will file your medical claim for you. Do not file a separate claim if you use a PPO provider, even if the hospital or doctor gives you a paper bill. If you use a non-BlueCross BlueShield provider, be sure to show your ID card to your provider so they will know where to send your claim.

If your provider does not submit your claim for you, it then is your responsibility to file the claim with the Fund Office. A Health Claim Form must be filled out by you and your attending physician and returned to the Fund Office.

Have the form completed by your doctor and attach the following:

  1. Doctor’s itemized bills.
  2. An itemized bill from the hospital, if you are confined.
  3. Pathologist’s and radiologist’s itemized bills.
  4. Bills for ambulance or anesthesia charges involved in your claim.
  5. A complete assignment form, if one is issued on your claim.

Claims for Laboratory Testing Benefit

If you have laboratory testing done by a stand-alone outpatient laboratory (not at a hospital’s outpatient laboratory department) or by a physician who is a BlueCross BlueShield PPO provider and processes the tests in his or her office, the provider will file the claim for you. Examples of stand-alone laboratories are Quest Diagnostics and LabCorp of America.

If the laboratory testing is done by a hospital that is a BlueCross BlueShield PPO provider, the provider will file the claim for you. However, benefits may be paid at a much lower rate. See the Laboratory Testing benefit description under Plan D5 or Plan B5 for details on this benefit and how to use it.

If your provider does not submit your claim for you, it then is your responsibility to file the claim with the Fund Office. A Health Claim Form must be filled out by you and returned to the Fund Office along with an itemized bill from the provider.

Claims for Income Protection Benefits

  1. Obtain an Income Protection Claim Form or Health Claim Form from the Fund Office.
  2. Fully complete the claim form. You, your doctor and your employer must each complete a section of the form in a timely manner.
  3. Send the completed form to the Fund Office.

Claims for Vision Benefits

  1. Obtain a Vision Claim Form from the Fund Office prior to your vision appointment, or as soon as possible after emergency treatment.
  2. You and your eye doctor should fully complete the form.
  3. Send the completed form to the Fund Office.

If your eye doctor is an ophthalmologist who is a BlueCross BlueShield PPO provider, he or she will file your Vision claim for you. Also, the ophthalmologist’s fee will be subject to the PPO discount. To find a PPO provider, go to www.bcbs.com or call 800-810-BLUE (2583).

Claims for Dental Benefits

  1. Obtain a Dental Claim Form from the Fund Office prior to your dental appointment or as soon as possible after emergency treatment.
  2. You and your dentist should fully complete the form.
  3. Send the completed form to the Fund Office.

Claims for Prescription Benefits

If you have your prescriptions filled at a participating pharmacyusing your ID card, there is no claim form for you to file—you pay only the co-pay and the pharmacist handles the rest.

If you do not use a participating pharmacy, you may request to be reimbursed for a portion of the cost of your prescription. Forms for “direct reimbursement” are available from the Fund Office and are to be completed by you and your pharmacist.
 

Claims for Life Insurance and Accidental Death and Dismemberment Benefits (AD&D)

To request payment of life insurance benefits, the following is required:

  1. Obtain a Fort Dearborn Life Insurance Company claim form. Call the Fund Office to obtain this form.
  2. A certified copy of the death certificate.
  3. Send the completed form and death certificate to the Fund Office. 

For dismemberment under the AD&D Insurance Benefit, a Health Claim Form must be completed and submitted to the Fund Office.

Authorization to Release Personal Health Information

Help us communicate benefits to you and your family. Federal law requires that every adult covered person must give a written authorization before we may disclose personal health information (PHI) to another person, such as a spouse, about the individual’s treatment or coverage. If an authorization is not on file, we can disclose information only to the covered person.

You should complete and return an Authorization for Release of Personal Health Information as soon as you receive it from the Fund Office. We will then know to whom we are authorized to disclose information regarding your health benefits coverage and medical treatment.

Payment or Status of Your Claim

To obtain the status of your claim, call the Fund Office.

The person who calls must be you or someone you have authorized (as described in the section immediately above) and should be able to provide the following information:

  1. Your name and UFCW ID # (or Social Security number).
  2. Your current address and phone number.
  3. The nature and date of the accident or illness.
  4. The name and location of the hospital or doctor.

Forms

Claim forms are available on-line at Forms and Publications or by calling the Fund Office.

Separate claim forms are required for each family member.

Send completed forms and all bills, receipts, or other documentation to:

United Food and Commercial Workers Unions and
Employers Midwest Health Benefits Fund
PO Box 21501
Eagan, MN 55121
 

 

(Updated 10/17/14)