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How To Submit A Claim When a Covered Person has a claim to submit for payment that person must: (1) Obtain a claim form from the Personnel, Benefits' Office or the Plan Administrator. (2) Complete the Employee portion of the form. ALL QUESTIONS MUST BE ANSWERED. (3) Have the Physician complete the provider's portion of the form. (4) For expediting claim processing and Plan reimbursement, all claims must be submitted and accompanied by a completed, signed claim form and full size (8.5" x 11") itemized bills illustrating the following: Name of Plan Group number of Plan (if applicable) Employee's name Name of Covered Person/patient Name, address, telephone number of the provider of care Diagnosis Type of services rendered, with diagnosis and/or procedure codes Date of services Charges (5) Bills for the services of private duty nurses must show that the nurse is either a Registered Nurse (R.N.), or a Licensed Practical Nurse (L.P.N.). The nurse's license number must be included, as well as a letter from the Attending Physician certifying that the nursing services were Medically Necessary and not provided for the convenience of the Covered Person. (6) Bills for prescription drugs must also show the name of the Covered Person/patient, the prescription number, the name of the prescription drug, and the quantity of the drug that was dispensed. (7) If payment has been made by any other source (including Medicare), for any of the expenses being submitted for payment under this Plan, a Covered Person must include a copy of the explanation of benefits from the carrier along with the claim submission and itemized bills. (8) Send the above information to the Claims Supervisor at the appropriate address as indicated on your I.D. Card For Claim Questions Call: 201.337.0555 800.225.1345