Claim and Appeals Procedures
Benefits normally will be paid directly to the provider of the service unless the claim indicates the bill already has been paid; however, the Plan reserves the right to pay you, or a relative in the event of your death. Benefits are not assignable.
Claims must be filed within 180 days after the end of the calendar year in which the expense is incurred.
Medical and Mental Health
Always present (or be prepared to present) your Illinois Central College Health Care Plan ID Card when receiving covered services because the Card contains billing directions for your hospital or doctor. Hospitals and doctors should send their standard forms directly to Consociate Plans at the address shown on your ID Card. Miscellaneous covered expenses may be submitted by you directly to Consociate Plans along with a completed Medical Claim form available in the Benefits Office.
Dental and Vision
Obtain a Dental or Vision Service Report form from the Benefits Office; complete the employee portion; then have the dentist or doctor complete the balance of the form and send it directly to Consociate Plans at the address shown on the form.
The Plan reserves subrogation rights and the right to recover any overpayment from you or any person or organization. If payments which should have been made by the Plan are made by another health care program, the Plan shall have the right to pay over to such organization or party making such payments any amount it shall determine is warranted to satisfy this provision, and the Plan shall be discharged fully from liability.
An appeal may be made by an employee enrolled in this Plan when there is an alleged misinterpretation or misapplication of the specific benefits provided by this Plan that cannot be resolved satisfactorily through regular claim channels. Download the Insurance Claim Complaint Appeal Procedure to begin.
Questions and complaints regarding the initial settlement of an insurance claim should be directed verbally or in writing to the Claim Administrator.
After a claim has been denied by the Claim Administrator, an appeal may be sent to the Risk Management and Benefits Director at the College. The appeal must be submitted within the number of days specified, must be in writing and must be accompanied by copies of itemized bills and benefit explanation worksheets on which claims were denied. Reasons must be provided for why you feel the claim should be paid under applicable provisions of this Health Care Plan Description. A decision will be sent to you within 60 days after a full appeal is received.
A six-member Insurance Appeal Advisory Committee shall be designated to review complaints regarding claim denials and to recommend disposition of disputed claims.
Copies of the procedure and form for submitting an appeal to the committee can be found on page 13 or are available through the Benefits office.
The Plan Sponsor’s decision on an appeal shall be final and not subject to litigation.