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Home > Health Plan > How To File a Claim
HOW TO FILE A CLAIM Some plans do not include every benefit mentioned. Refer to your plan booklet to verify which benefits are included in your plan.
For prompt processing of your claims, please follow the guidelines described here. For more detailed information, refer
to the Health Benefits Plan Claim Procedures page of
this website.
If you do not file a claim for benefits within 24 months of the date the service is received, the claim will not be processed
and no benefits will be paid.
Claims for Hospital, Surgical, Medical Benefits
Most healthcare providers will submit your claims for you. All BlueCross BlueShield PPO providers will file your medical
claim for you. Do not file a separate claim if you use a PPO provider, even if the hospital or doctor gives you a paper
bill. If you use a non-BlueCross BlueShield provider, be sure to show your ID card to your provider so they will know
where to send your claim.
If your provider does not submit your claim for you, it then is your responsibility to file the claim with the Benefits Fund
Office. A Hospital, Surgical, Medical claim form must be filled out by you and your
attending physician and returned to the Benefits Fund Office.
Have the form completed by your doctor and attach the following:
Claims for Special Laboratory Benefit
If you use the Special Laboratory Benefit for laboratory testing, Quest Diagnostics will file the claim directly for you using the
electronic claim payor number (36659) and the ID number that appears on your UFCW Lab and Drug Card. Check your plan
(Plan D5 or Plan B5) for a description of the
Special Laboratory Test Benefit and how to use it.
Claims for Income Protection Benefits
Claims for Vision Benefits
Claims for Dental Benefits
Claims for Prescription Benefits
If you have your prescriptions filled at an NPA/Express Scripts
participating pharmacy using your ID card, there is no claim form for you to file—you pay only the co-pay and the
pharmacist handles the rest.
If you do not use a participating pharmacy, you may request to be reimbursed for a portion of the cost of your
prescription. Forms for “direct reimbursement" are available from the Benefits Fund
Office and are to be completed by you and your pharmacist.
Claims for Life Insurance and Accidental Death and Dismemberment Benefits (AD&D)
To request payment of life insurance benefits, the following is required:
Authorization to Release Personal Health Information
Help us communicate benefits to you and your family. Federal law requires that every adult covered person must give a
written authorization before we may disclose personal health information to another person, such as a spouse, about the
individual's treatment or coverage. If an authorization is not on file, we can disclose information only to the covered
person.
You should complete and return an Authorization for Release of Personal Health Information
as soon as you receive it from the Benefits Fund Office. We will then know to whom we are authorized to disclose
information regarding your health benefits coverage and medical treatment.
Payment or Status of Your Claim
To obtain the status of your claim, call Customer Service at the Benefits Fund
Office.
The person who calls must be you or someone you have authorized and should be
able to provide the following information:
Forms
Claim forms are available on-line at Forms and Publications or by
calling the Benefits Fund Office. You may call for forms 24 hours a day.
Separate claim forms are required for each family member.
Send completed forms and all bills, receipts, or other documentation to:
United Food and Commercial Workers Unions and
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