If health care services are provided through the Preferred Provider Organization (PPO), the PPO Health Care
Provider will usually submit the written proof of claim directly to the Appropriate Claims Administrator.
If you pay for non-PPO health care services at the time services are provided, you may later submit the bill
to the Appropriate Claims Administrator. At the time you submit your claim you must furnish evidence acceptable
to the Appropriate Claims Administrator that you or your covered Dependent paid some or all of those charges.
Plan benefits will be paid to you up to the amount allowed by the Plan for those eligible expenses.
The Appropriate Claims Administrator will not accept a balance due statement, cash register receipts, photocopy,
canceled checks or credit card receipts as proof of claim.
Occasionally a Health Care Provider will send a claim directly to you. In this case you should contact the Appropriate Claims Administrator
to find out if they require you to complete a claim form. If a claim form is required, it may be obtained from the Appropriate Claims Administrator
whose name and address are listed in the Summary Plan Description.
Click here to access the Initial Report of Claims Form.