How to File a Claim

When you or your dependent incur an expense which is covered by the Plan, you must file the claim for benefits no later than one year after the date of service. Proof of your claim must be submitted with a completed claim form. Claim forms are available in the Benefits Office. After you complete the form mail it to: Medical Mutual of Ohio, P.O. Box 956, Toledo, OH 43697.

Super Med Plus network physicians and hospitals will submit medical claims for you. Participating providers may file claims but are not required to do so.

Appealing a Denied Claim

You may, within 60 days after receiving a claim's denial, request a review. This request should be submitted in writing to: Medical Mutual of Ohio, P.O.Box 943, Toledo, OH 43656.

Usual, Customary and Reasonable (UCR) Charges

Usual, customary and reasonable (UCR) charges are used to establish a fair and equal way to pay claims. Medical and dental costs vary from city to city and in different parts of the country. Claim expenses for similar procedures reflect this difference. UCR amounts consider differences and set up reasonable limits for medical and dental care charges. A usual, customary and reasonable charge is the maximum amount considered as a covered expense under the BGSU Medical and Dental Care Plans.

Medical Mutual of Ohio (MMO) particpating providers and PPO providers will not balance bill for charges in excess of the UCR allowance. Thus, by using participating providers, you are only liable for any applicable deductibles and copayments.

Recertification

Some procedures require recertification after a prescribed number of treatments (ten visits in many instances). Your physician must certify that additional treatments are necessary and MMO must approve the treatments for continued coverage.

Self-Audit Reward for Medical Charges

We are all concerned with the rising cost of health care. To help monitor our medical and dental bills, BGSU has instituted a Self-Audit Reward Program.

After you receive any medical service or supply, or you are confined in a hospital, you should request an itemized bill to verify that the services and supplies billed were actually received. If there is an error, request the provider to send MMO a corrected bill and notify the Benefits Office. You will receive 50% of the difference between the original bill and the corrected bill, up to $1,000 per hospital stay or per service.

Understanding Coordination of Benefits (COB)

Coordination of benefits is a process in which Medical and Dental Plans (such as the BGSU Health Care Program, Medicare or your spouse's plan with another employer) coordinate payments for the same covered expense. When more than one plan provides coverage to the same person, a sequence is set up for the payment of claims. One plan pays expenses first and the other usually pays any eligible remaining amounts. Coverage under two or more plans, however, does not automatically mean 100% payment since usual, customary and reasonable limitations, medical necessity and eligible expenses are factors in paying claims. Deductibles, copayment and coinsurance requirements are also factors.

Order of Benefit Determination Under COB

As long as you and your eligible dependents are covered under the BGSU Health Care Program and another plan, and the other plan coordinates benefits, the order of benefit determination is as follows:

• The plan which covers you as an employee and not as a dependent is primary;

   

• A dependent child is covered by the plan of the parent whose birthday falls earlier in the year. The term "birthday" in this instance refers only to the month and day in a calendar year, not the year in which the parent was born;

   

• In cases in which none of the above set up the order of payment, the primary plan is the one which covered you the longest - unless you are covered under one plan as an active employee and another plan as a retired employee. In this case, the primary coverage is the coverage provided by the employer for whom you are actively working.

   

Divorce or Legal Separation Under COB

If you are divorced or legally separated and can claim your dependent children for federal taxes and/or have custody, the order of determining benefit coverage is:

• If the court decree makes one parent responsible for health care expenses, that parent's plan is primary. The plan covering the other parent is secondary.

   

• If the court decree gives joint custody and does not mention health care, the birthday rule as discussed above is followed.

   

• If the custodial parent has remarried, the order of benefit determination is:

   

  1. The plan covering the custodial parent; then

      

  2. The plan covering the child as a dependent of a step parent; and finally

      

  3. The plan covering the non-custodial parent.

      

Subrogation

In the event of an accident or injury which may involve third party payer, the Plan will subrogate with the payers(s). The creation of a Subrogation Agreement is a condition precedent to the payment of benefits under this Plan. In addition, you must execute and deliver any documents as the Plan may require to preserve the right of the Plan to recover benefits through subrogation.

When Coverage Ends

Active Employees

As a full time employee, your coverage under the BGSU Health care Program ends if:

• The Plan ends; or

   

• Your employment ends; or

   

• You no longer satisfy the eligibility requirements; or

   

• You submit a fraudulent or partially fraudulent claim for benefits under the Plan; or

   

• Your COBRA coverage or period ends; or

   

• You fail to make any required contribution or payments, including COBRA payments.

   

The Plan may, but is not required to offer a conversion policy following termination of coverage.

Dependent Coverage

Dependent coverage ends if:

• You are no longer eligible for dependent coverage; or

   

• Your dependent no longer satisfies the Plan's definition of a dependent; or

   

• Your coverage ends.

   

Continuation of Coverage (COBRA)

Please visit our special COBRA page for more information.

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