State Police Enlisted Unit Benefit Booklet

CLAIM FILING INFORMATION

This section of your booklet provides you with information on how to file a claim when your services are provided by a vision care provider outside of Michigan or by a provider who does not participate in the Vision Care Plan. It also tells you what to expect once your claim has been processed and how to appeal a service that has been denied for payment or when the payment is less than you expect.

Claim Forms

Your participating provider will submit claim forms for you.  If your provider is a non-participating provider or if you receive services outside of Michigan, you may have to submit your own claim for payment.

You may obtain claim forms by calling the BCBSM State of Michigan Customer Service Center at the following numbers:

Lansing area (517) 322-9515
In Michigan 1-800-643-4652
Toll free/Nationwide 1-800-843-4876

What You Should Know About Filing a Claim

When you receive covered services, ask your provider to bill BCBSM for the service. Do not file a claim if your provider is sending BCBSM a claim for your services. If your provider will not bill BCBSM for service, ask for an itemized statement of services. When you file a claim, you must submit an itemized receipt with your claim.

Each itemized receipt must contain the following information:

• The provider's name, address (including city, state, and zip code) and telephone number
• The provider's Federal Tax Identification or Social Security number
• The patient's name (do not use nicknames)
• The subscriber's nine-digit contract number as indicated on the State Vision Plan (BCBSM-printed) identification card (This is the social security number of the employee.)
• Exact date of service
• The amount charged for each individual service or item supplied. If the charges are for eyeglasses, the charges must be broken down to show a charge for each of the following:  frames, lenses, tints, coating, or special items such as custom lenses or curves. Also, the cost of the examination should be shown separately.
• Diagnosis
• Cash register receipts, cancelled checks or money order stubs may accompany your itemized receipt but may not be substituted for an itemized receipt.
• A separate claim form must be completed for each eligible contract member. Multiple services for the same patient can be attached to one claim form.
• Type or clearly print all information.
• Make copies of all statements and forms for your records before sending the originals to the BCBSM State of Michigan Customer Service Center. All materials submitted will be retained by BCBSM.
• Look at the claim form to make sure it is accurate and complete. Incomplete forms may be returned to you causing payment to be delayed. Be sure to sign and date each claim form.

Explanation of Benefits Statement

Each time BCBSM processes a claim with your contract number, an Explanation of Benefit Payments (EOB) statement will be sent to you showing what services were paid or denied. This statement is for your information. This is not a bill. It is provided to help you understand how your services were paid and to make sure the information received was correct. Review the statement for any discrepancies and keep it for your records.

Appeals Procedure

If BCBSM denies part or all of your vision claim, the Explanation of Benefit Payments statement will give you the reason. You will also receive a Non-Payment Voucher that will indicate the reason a claim was denied for payment. If you disagree with the denial, you may request a review of the claim by writing or calling the BCBSM State of Michigan Customer Service Center within 60 days of the payment or rejection of the claim.

Your request for review should include the following information:

• Your group number, contract number and the date of service in question
• The reason you feel your claim should have been paid
• Any additional information or documentation that supports your position BCBSM will review your appeal and send you a decision in writing within 60 days after your request is received. If a delay occurs in the review of your appeal because of a need for more information, BCBSM will notify you.

If you have any problems securing a review of your claim, contact Michigan Department of Civil Service, Group Insurance Section, P.O. Box 30002, Lansing, Ml 48909. Decisions made by the Plan Administrator (BCBSM) can be appealed to the Michigan Department of Civil Service Group Insurance Administrator.