Claims

We’re Here To Serve You

How To File A Claim
In most cases, all you need to do is present your OEA Choice Trust identification card to a hospital or physician (provider). They will bill the Trust directly for all services you have received. The Trust will process the claims and send payment to the provider. An explanation of benefits (EOB) explaining our payment will be sent to you. The provider will then bill you for any balances remaining after our payment.

Occasionally, a provider will request up front payment and will not bill us directly. If this happens you are responsible for the payment. We will reimburse you for any of the charges that are covered under your medical plan.

If you or your eligible dependent receives treatment from a provider that will not bill the Trust, the member should send a copy of the billing to us. Please be sure it includes all of the following information:

  • the name of the person who was treated
  • member name and Identification number
  • diagnosis
  • an itemized description of services, including the charges and dates they were received
  • the provider's name and address

If treatment is for an injury, please include a statement explaining the date, time, place and circumstances of the injury.

Claims should be sent to,

OEA Choice Trust
Claims Department
Post Office Box 23600
Tigard, Oregon 97281

Our Claims Department can be reached at 503.620.3822 or 800.452.0914.

Preauthorization

In order to gain the maximum benefits under the member's medical plan, an inpatient admission must be "pre-authorized":

If your physician proposes a hospital admission, they should call ODS Health Plans (ODS) to have the hospital stay "pre-authorized". ODS will review the proposed admission, and authorize the number of hospital days for which benefits will be allowed by the plan. Complications, of course, may extend a hospital stay. This will be monitored and resolved between the hospital/physician and ODS. Your provider may contact ODS at 503.243.4496 or toll free at 800.258.2037. Their fax number is 503.243.5105.

Only the hospital days considered medically necessary by ODS will be covered. For this reason, ODS must be contacted prior to a scheduled admission. Failure to do so may result in reduced benefits.

For all scheduled hospitalizations:

  • at least two weeks, or as soon as possible, prior to a scheduled admission, ODS must be contacted to authorize the hospital stay

Emergency/Urgent Admission:

  • pre-admission authorization is not required for an emergency/urgent admission, however, ODS must be contacted by the employee, family member, or attending physician within 48 hours of the admission
  • an emergency/urgent admission is defined as an unforeseen illness, injury or condition requiring immediate medical attention. Some examples are unconsciousness, severe bleeding, acute pain, or the rapid onset of medical symptoms
  • in an emergency, you should call your physician immediately or go to the nearest hospital facility. If admitted to the hospital, you should show your OEA CHOICE Trust identification card and ask the hospital staff to contact ODS for you. A family member or physician may also notify ODS of the admission

Some outpatient procedures may also require preauthorization. Please have your physician’s office contact ODS to verify if your procedure requires preauthorization.

Coordination Of Benefits

This provision applies when you or your eligible dependent has health care coverage under more than one plan. COB between two plans can be easy, if claims are submitted properly. In many cases, the provider of the service will bill both plans for you. To submit claims to both plans, follow the guidelines below to determine the primary carrier:

The plan that covers a person as an enrolled employee (that is other than a dependent) is primary over the plan which covers the person as a dependent.

For dependent children (parents not separated or divorced) the primary plan is determined as follows:

  • the plan of the parent whose birthday falls earlier in the year is primary over the parent whose birthday falls later in the year
  • if both parents have the same birthday, the plan, which has covered the parent longer, is primary

For dependent children of divorced or separated parents, the primary plan is determined as follows:

  • first, the plan of the parent with custody
  • second, the plan of the spouse of the parent with custody
  • third, the plan of the parent not having custody
  • fourth, the plan of the spouse of the parent not having custody

Exception: If the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the dependent, and the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, that plan is then primary.

The above instructions are basic to determining primary/secondary status. Your situation may be different. If there are questions regarding which plan is primary or secondary, please contact our Customer Service Department at 503.620.3822 or 800.452.0914.

After determining the primary carrier, submit your claims as follows:

  • submit the claim to the primary carrier and retain two copies. Do not submit the claims to the secondary carrier until the primary carrier has processed the claim and sent you an "explanation of benefits" (EOB) indicating how the claim was paid
  • submit a copy of the original claim along with a copy of the primary plan's EOB to the secondary plan

If a member or spouse are both employees with OEA Choice Trust plans, it is not necessary to submit a claim under the secondary plan. If the Trust is aware of the two plans, claims will automatically be processed under both plans.

Grievance and Appeals

Definitions

For purposes of clarity, the following definitions apply:

Complaint means an expression of dissatisfaction that is about a specific problem encountered by an enrollee or about a decision by an insurer or an agent acting on behalf of the Plan and that includes a request for action to resolve the problem or change the decision. A complaint does not include an inquiry.

Grievance means a written complaint submitted by or on behalf of an enrollee regarding the following:

  • Availability, delivery, or quality of health care services, including a complaint regarding an adverse determination made pursuant to a utilization review
  • Claims payment, handling, or reimbursement for health care services
  • Matters pertaining to the contractual relationship between an enrollee and the Plan

Time Limit for Submitting Grievance and Appeals

You have 180 days to submit a written grievance regarding an adverse determination. An adverse determination is a written notice from the Trust, in the form of a letter or an Explanation of Benefits (EOB), which has set forth the following:

  • the specific reason or reasons for the benefit denial
  • reference to the specific Plan provision on which the denial was based
  • a description of any additional material or information necessary for you to complete your claim and an explanation of why such material or information is necessary
  • appropriate information as to the steps to be taken if you wish to appeal the Plan Administrator’s determination, including your right to submit written comments and have them considered, your right to review (on request and at no charge) relevant documents and other information, and your right to file suit under ERISA with respect to any adverse determination after appeal of your claim

The Review Process

The Trust has a multi-level review process. The first level of review is called a Grievance. The second level of review is a First Level Appeal. You must exhaust these two levels of review before you can exercise your right to file a lawsuit in court under ERISA Section 502(a). The remaining review levels are voluntary and are not required prior to exercising your right to sue under ERISA Section 502(a).

However, if you are not satisfied with the outcome of the Grievance and Appeal I levels of review, you may request a Second Level Appeal. If you are not satisfied with the outcome of the Second Level Appeal, and your complaint meets the specifications outlined under External Review, you may request that the complaint be reviewed by an independent review organization. You will need to exhaust the Grievance and the First and Second Levels of Appeal to proceed to External Review, unless the Trust agrees otherwise.

Grievance

If you have a grievance, you may submit the grievance to OEA Choice Trust and ask for a review. If you need assistance on filing a grievance, contact our Customer Service Department at 503.620.3822 or toll free at 800.452.0914 and ask for assistance. You may submit written comments, documents, records, and other information relating to the claim for benefits. Upon request, and free of charge, you may have reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits. The Plan’s response time to your grievance is based on the nature of the claim. Please refer to your Summary Plan Document (SPD) for further details.

When an investigation has been completed, you may expect a written notice of the disposition of your grievance, including the basis for the decision, along with information on your right to a First Level Appeal.

Appeals

If you disagree with the decision made regarding a grievance, you may appeal the decision. Your appeal must be made within 60 days of the date of our action on your initial grievance. You may also call our Customer Service Department at 503.620.3822 or toll free at 800.452.0914 to discuss the issue and it may be possible for you to resolve the question at that time without filing a formal appeal.

First Level Appeal

If you request a First Level Appeal, you should submit your appeal in writing. The Trust will acknowledge receipt of a written appeal, in writing, within seven (7) days and conduct an investigation. Your appeal will receive a full investigation by persons who were not involved in the initial determination. We will keep you informed of the progress, including if additional time or investigation is required for a full and complete review. You may expect a written notice of the disposition of your appeal, including the basis for the decision, along with information on your right to a Second Level of Appeal.

 Second Level Appeal

If you are dissatisfied after the First Level Appeal, you may request a Second Level Appeal by a panel of representatives who were not previously involved in the claim or First Level Appeal. Your second appeal must be made within 60 days of the date of our action on your First Level Appeal. The Trust will acknowledge receipt of a written appeal, in writing, within seven (7) days and conduct an investigation. We will keep you informed of the progress, including if additional time or investigation is required for a full and complete review. Within thirty (30) days of receipt of the appeal, the we will notify you in writing of the action taken.

You will have the right to appear before the panel if you wish or, if you cannot appear, you may request that arrangements be made so you may communicate with the committee by conference call or other appropriate technology. The Plan will allow requests for practitioners or a representative to act on your behalf in the appeal process. Your appeal will be reviewed within thirty (30) working days of its receipt and a written decision will be sent to you within five (5) working days after the decision is made.

External Review

If you are not satisfied with the outcome of the Second Level Appeal, and your claim meets the criteria listed below, you may request that the claim be reviewed by an independent review organization, appointed by the Insurance Division.

1. The claim must involve a dispute relating to an adverse decision on one or more of the following:

  • whether a course or plan of treatment is medically necessary
  • whether a course or plan of treatment is experimental or investigational

2. You must apply in writing for an external review, and not later than the 180th day after receipt of the Trusts final written decision following the grievance and appeal process as described above.
3. You must sign a waiver granting the independent review organization access to the medical records of the patient.
4. You must have exhausted the grievance and appeal process described above.
5. A member who applies for external review of an adverse decision shall provide complete and accurate information to the independent review organization in a timely manner.

The Trust agrees to be bound by the decision of the independent review organization with respect to whether a course or plan of treatment is medically necessary, notwithstanding the definition of medical necessity in the plan; or whether a course or plan of treatment is experimental or investigational.

Additional Member Rights

You have the right to file a complaint or seek other assistance from the Oregon Insurance Division. Assistance is available by phone at 503.947.7984 or in writing at Oregon Insurance Division, Consumer Protection Unit, 350 Winter Street NE, Room 440-2, Salem, Oregon 97310

Oregon Insurance Division
Information included in the “Additional Member Rights” is subject to change upon notice from the Director of the Oregon Insurance Division.