Saturday, November 26, 2022

Frequently Asked Health Care Questions


Q. As a Kaiser member, can I get my eye exam and materials with Kaiser?
A. No, as a Kaiser member, you may not get your eye exam in a Kaiser facility. 
Q. What address do I use to send my claims [Medical/Dental/Vision]? 
A.

Medical
Blue Shield of California
P. O. Box 272540
Chico, CA 95927-2540

Dental/Vision
Sheet Metal Workers Local 104
P. O. Box 1618
San Ramon, CA 94583
For electronic submission use Electronic Payer ID#38238

Q. What documents are required to add a new dependent to my Plan? 
A.

Spouse – copy of your marriage certificate

Child – copy of your child’s birth certificate
If you are enrolling a newborn, a hospital certificate will be good for 90 days from date of birth, and then we will need a copy of the original birth certificate.

Step-child – Proof that you cover more than ½ of the child's support. Acceptable documents may include proof of residency from child's school, tax return claiming child, divorce papers stating that parent is required to provide health insurance.

Adopted child – we will require a copy of the legal adoption papers from the adoption agency stating the date the child was placed in the home.  

Domestic Partner – Certificate of Domestic Partnership from the county, city or state that you reside in and a quarterly co-payment (contact the Trust Fund for current rates).

Q. When do I become eligible for benefits? 
A.

You must accumulate at least 120 hours in your Reserve Hour Bank within a 12- month period.  Coverage begins on the first day of the second month following the month in which your Reserve Hour Bank has at least 120 hours.  

Example of when coverage would begin:

Month when qualifying hours are completed

Skip Month

Coverage Begins

May

June

July 1st

Q. Who are my eligible dependents?
A.
  • Your lawful spouse
  • Your natural children up to age 26
  • Your legally adopted children up to age 26
  • Your step-children up to age 26
  • Child for whom you have been appointed legal guardian by court for length of guardianship or to age 26, which occurs first
  • Your Domestic Partner (certain rules apply - please contact Benefit Office) and Children of Domestic Partner
Q. Will my child(ren) who is/are age 18 through age 26 be covered under the Plan?
A. Yes, coverage is extended to your child(ren) until their 26th birthday. 
Q. How do I find a Blue Shield provider? 
A.Please click here to find the most up-to-date listing of general practitioners, specialists, and hospitals. Be sure to select "Blue Shield PPO" when asked to select a plan to ensure you are searching through the correct network of doctors. 
Q. How do I obtain a Delta Dental of California card? 
A. Please visit Delta Dental of California's website: www.deltadentalins.com to request a new copy of your card. 
Q. Whom should I call if I have questions about my eligibility? 
A. The Plan Office at: (925) 208-9994 or (800) 548-1771.
Q. How do I obtain a replacement Medical Card? 
A.Please do contact the administrator. 
Q.How do I get reimbursed if I paid out of pocket for a prescription? 
A.Go to Forms and print the WellDyneRx Claims Form or contact WellDyneRx at 1-888-479-2000 and request form be mailed. Fill out completely and mail to the address given. Please allow 30 days for claims processing. 
Q. How long should I wait for claim status to show on the website?  
A. Normally, you will see claim status in a bout 15-25 days upon receipt of the claim. 
Q. How do I know the reason on why a claim has not paid?  
A. You are able to view the Explanation of Benefits (EOB) for each claim that has been received. On this EOB, under Reason Code: it will explain the cause of why an entire claim was denied or a line item. If you need further explanation you may call the Trust Fund Office. 
Q. If I have my Medicare, who does my provider submit the claim to?   
A. 

When Medicare is primary, your provider will need to submit to Medicare first. Upon Medicare’s payment/denial, they will then need to submit to Sheet Metal Worker’s. 

Sheet Metal Worker’s is your supplemental insurance. 
Q. I just called my pharmacy for a refill and my prescription cost is different with WellDyneRx. Isn’t my coverage the same?   
A. The plan benefit remains the same, but the preferred drug lists are not identical. There may be instances of higher costs under the new plan. We recommend that you discuss your situation with your physician to see if switching to one of the recommended drugs is appropriate. 
Q. How do I find a local pharmacy?  
A. Participating pharmacy information may be obtained by visiting the WellDyneRx website at www.welldynerx.com and clicking on 'Find a Pharmacy' or by calling the WelldyneRx Help Desk at 1-888-479-2000.   
Q. How do I get a copy of the Preferred Drug List?  
A. You can visit WellDyne website at www.welldynerx.com, and click 'Preferred Drug Listing'. Please be aware that WellDyneRx has a number of preferred drugs that differ from the preferred drug list utilized by Envision.  
Q. I lost my prescription ID card, how do I get a replacement?  
A. WellDyneRx Help Desk at 1-888-479-2000. 
Q.  I have a question about my co-pay? Who do I call?  
A.  WellDyneRx Help Desk at 1-888-479-2000. 
Q. How do I view my claims? 
A. After you log in you'll see your claims information under the 'Member Information' menu item.  
Q. How do I get a Mail Order prescription?  
A. A mail order program is also available under the WellDyneRx drug program.  
Q. What if I do not see the status of a claim I am checking on?  
A. One of the most common reasons for not being able to view a claim status is the provider has not submitted the claim. This may be due to a wrong address to where the provider is submitting the claim. Or it may simply have to be re-submitted. You may call your provider of service and inform them that they may need to re-submit a particular claim.  
Q. What number do I call for claim status?  
A. 1-800-548-1771 
Q. What do I need to do in order to get a disability freeze? 
A. 

You need to get a note from your doctor or you can have your doctor fill out the disability certification form located under the "Forms" section and mail or fax it in to the Plan office. We will need the required information below in order to freeze your hours:

  1. Diagnosis
  2. Disability dates (From and To). If your doctor does not know when you will be returning to work, we will need an estimated date. 
  3. Doctor's signature  

Q. What if I become disabled?  
A. There is a disability freeze benefit that provides free coverage to you and your family when you are off work due to a disability or on the job inquiry. It freezes your reserve hour bank so you do not have to use these hours to give you coverage. This benefit will freeze your reserve hour bank for up to 12 months for the same disability. "Please refer to the Summary Plan Description booklet for eligibility rules." 
Q. How do I add my new baby or spouse to my insurance plan?  
A. You must fill out an enrollment form. You can download one off of this website located under "Forms" and mail it into the Trust Fund Office. If you are adding a newborn or new spouse, you must submit it within 90 days from the date of birth or marriage. Please attach all required documentation.