How Do You File Claims

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What Steps Do You Follow
How Are Managed Choice POS Benefit Payments Coordinated With Other Coverage
When Does Managed Choice POS Recover Payment from Another Person or Insurance Company

You should file medical claims for Managed Choice POS out-of-network or out-of-area benefits and dental claims as soon as possible after you have expenses. To receive benefits, you must file claims by June 30 of the year following the year the charge is made.

Claims are usually not required for Managed Choice POS in-network benefits or for benefits from the separate psychiatric and substance abuse network.

What Steps Do You Follow

To file a claim for out-of-network, out-of-area, or dental benefits, follow the steps listed on the back of the appropriate claim form.

When benefits are paid by Managed Choice POS, you will receive an explanation of benefits (EOB) showing how benefits were determined. The explanation of benefits also shows the amount the plan did not pay. If you have a Flexible Spending health care account, you can receive reimbursement from that account for any eligible charges not paid by the plan.

You can also receive reimbursement from your Flexible Spending health care account for any copays you have under:

The in-network benefits,
The separate psychiatric and substance abuse network

How Are Managed Choice POS Benefit Payments Coordinated With Other Coverage

If you or your dependents are covered by Managed Choice POS and by another group health care plan, governmental program, or no-fault automobile insurance, benefits will be coordinated between the plans on a nonduplication basis.

Nonduplication means that when Vought Aircraft is the secondary payer, the total benefits paid will never exceed what the company would have paid as primary coverage. For example, if the total covered expense is $200, assume the company plan would have paid 80% or $160. However, another employer is primary and pays the first 70%, which is $140. Vought Aircraft, as secondary coverage, would make up the difference of the additional $20.

When Managed Choice POS is your primary coverage, send your original bills with your claim form to the Managed Choice POS claims processing office. Keep copies of the bills. After your Managed Choice POS claim is processed, send a copy of the EOB and copies of the bills to the secondary plan along with a copy of the Managed Choice POS coordination of benefit rules.

If Managed Choice POS is your secondary coverage, you will need to file a claim with your primary health care plan first. After you have received written notification of payment or denial from your primary coverage, submit a copy of the notice along with your claim, together with a copy of the other plan's coordination of benefits rules, to your Managed Choice POS claims processing office. If you use in-network benefits, your Managed Choice POS claims administrator will coordinate benefits payments with the primary carrier on your behalf.

Managed Choice POS is always primary for you while you are an active employee. In addition, while you are covered as an active employee, and assuming you have enrolled your dependents, Managed Choice POS is primary if:

The expenses are for your child and your month and day of birth occur earlier in the calendar year than the birthdate of the child's other parent. If both parents have the same birthdate, then the primary plan is the one that has been in effect the longest. This rule applies only if the parents are married to each other and both parents have the child enrolled.
The other plan is the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).
The expenses are for your spouse who is either disabled or at least age 65 and covered by Medicare.
Your dependents have no other coverage.

If one of the other group plans that covers you coordinates benefits based on gender, its provisions prevail. In such cases, the plan of the male spouse is primary for any dependent children.

When a child is claimed as a dependent by parents who are separated or divorced, the primary plan is determined in the following order:

The plan of the parent who has been charged with financial responsibility for the dependent child's health care expenses by a court
The plan of the parent who has custody of the child
The plan of the step-parent who is married to the parent with custody of the child if the step-parent claims the child as a dependent
The plan of the parent who does not have custody.

If the above rules do not establish which plan is primary, the plan which has covered the child for the longest period of time becomes the primary plan. If the other group plan(s) that covers you does not contain a coordination of benefits provision, the plan without coordination of benefits becomes the primary plan.

When Does Managed Choice POS Recover Payment from Another Person or Insurance Company

In some situations, another person or insurance company may be legally responsible for your health care expenses - for example, those resulting from an automobile accident caused by someone else.

In such situations, Managed Choice POS is entitled to repayment from any settlement you receive. When you accept payment from Managed Choice POS, you agree to provide any documents that would allow the plan to recover payments it has made on your behalf. The legal term for the plan's right of recovery is subrogation.