|
 |
How long do I have to submit a
medical or dental claim for payment? |
Claims must be received within 12 months from
the date of service.
Back to Top
|
Where should claims be mailed? |
Claims should be mailed to:
PEHP
560 East 200 South, Suite 100
Salt Lake City, Utah 84102-2004
Back to Top
|
How does PEHP coordinate payment
with other insurance coverages? |
The PEHP plans contain a non-profit provision
to coordinate with other plans under which a member is covered so that
the total benefits available will not exceed 100% of the allowable expenses.
When a claim is made the primary plan pays its benefits without regard
to any other plans. The secondary plan adjusts its benefits so that
the total benefits available will not exceed the allowable expenses
or 100% of the charges. No plan pays more than it would without the
coordination provision. When coordinating as secondary with a HMO, Preferred
Provider Organization, or Medicare, PEHP will only cover the copayments
that the insured is legally obligated to pay.
It is the responsibility of the member to provide
complete and accurate information regarding other coverages and to
be sure benefits are coordinated in the proper order. An employee
is always primary on their plan. PEHP follows the Birthday Rule, which
states the plan of the spouse whose birthday (regardless or the year
of birth) is earliest in the calendar year is primary on the dependent
children.
In order for PEHP to pay as secondary a member
must submit an Explanation of Benefits (EOB) along with an itemized
statement from the provider to PEHP. When submitting claims for prescription
drug copayments from another insurance plan, it is necessary to attach
the receipt to a Paid Prescription drug claim form. Claim forms can
be obtained from your employer or by contacting PEHP’s Customer Service
Dept.
Back to Top
|
Who should I call if I have
a problem? |
PEHP has a Customer Service Department that can
be reached at:
1-801-366-7555 or
1-800-765-7347
Members of Utah School Boards Association Platinum,
Gold or Silver Plans should call:
1-801-366-7588 or
1-800-753-7588
Back to Top
|
How do I appeal a denied claim?
|
If you feel your claim has been denied inappropriately,
you may request a full and fair review by writing to the Medical Review
Board within 60 days after you receive notice of denial. Requests
for review of claims should be mailed to:
Medical Review Committee
Public Employees Health Program
560 East 200 South
Salt Lake City, Utah 84102-2004
If you disagree with the decision or action taken
by the Medical Review Committee, you have the right to an appeals
process through the Utah Retirement Systems Retirement Board.
Back to Top
|
Do I have to be enrolled
in PEHP medical to be enrolled in PEHP dental? |
PEHP’s medical and dental policies are separate.
Unless your employer requires otherwise, you may be enrolled in either separately.
Back to Top
|
How do I pre-authorize a
claim? |
Pre-authorization is required for certain specified
benefits of PEHP which may be subject to limitations and to receive
the maximum benefits of the policy for hospitalization, surgical
procedures, durable medical equipment, or other services as required.
A member should have their provider submit a written
pre-authorization for those procedures that require it. It should
be sent to the attention of the Claims Review Department. After review
the Claims Review Department will provide a written approval or denial
to the provider and a copy to the insured.
Pre-authorization does not guarantee payment
should coverage terminate, should there be a change in benefits,
should benefit limits be used by submission of claims in the interim,
or should the actual circumstances of the services be different
than originally submitted.
Back to Top
|
What is Healthy Utah? |
Healthy Utah is a health and wellness program offered
to members whose employer has elected to offer a PEHP plan that contains
this program. It is a fun, easy and fast way to take care of yourself
– whether you are interested in checking your blood pressure, learning
low-fat cooking, developing stress management skills or borrowing
a book on parenting.
The Healthy Utah Program has Wellness Connection
Seminars, Health Screenings, a ten week weight management program
taught by a registered dietitian, a No-Nag, No-Guilt, Do-It-Your-Own-Way
Smoking Cessation program, Health Promotion Programs and Cash
Incentives for setting and meeting certain health and fitness
goals.
For more information on Healthy Utah, visit their
web site at www.healthyutah.org.
Back to Top
|
What is WeeCare? |
WeeCare is a pre-natal program available to all
PEHP members. The WeeCare Program was designed by PEHP in cooperation
with the Utah State Department of Health, Division of Family Services
and the Baby Your Baby program. The goal is to find women who may
have health problems that could lead to a high-risk pregnancy.
PEHP rewards mothers who participate in the WeeCare
program. Mothers-to-be who contact WeeCare, at 1-801-538-9943 or 1-800-662-9660,
prior to the 14th week of pregnancy will receive a $100 cash rebate
at the time of delivery. Those who call between 15 and 28 weeks of
pregnancy qualify for a $50 cash rebate. All who enroll before 28
weeks of pregnancy receive 100% coverage for prenatal vitamins during
their pregnancy. Participants receive important information to promote
a safe and healthy pregnancy, as well as the book What to Expect When
You’re Expecting or What to Expect in the First Year.
For more information about WeeCare, visit their
web site at http://health.utah.gov/rhp/weecare.
Back to Top
|
