Monday, August 3, 2020

Frequently Asked Health Care Questions


Q. Who is eligible to become a Participant in the Plan?
A. You are eligible to participate in the Plan if you work for an Employer that is required to make contributions to the health and welfare Plan for the work you perform. For most Participants, this means working in a position covered by a Collective Bargaining Agreement between the Employer and the Union.
Q. What if I don’t work enough hours to gain eligibility for the month?
A. If you fail to have the required employer contributions to continue Health Care coverage, you may be eligible to make payment as a self-pay Employee directly to the Plan or you may be eligible to continue with COBRA Continuation Coverage. Please contact the Trust Fund Office at 702-415-2199.
Q. How do I maintain my monthly Health Care coverage?
A. You must have an employer contribution submitted on your behalf each month, or make payment as a self-pay Employee, or elect COBRA Continuation Coverage to continue Health Care coverage.
Q. How do I make a payment towards the continuation of my Health Care coverage?
A. You may make a self payment to remain eligible for the Health Care coverage through the Retiree, Active, or COBRA Continuation programs.
Make Check Payable & Remit to:
Plumbers & Pipefitters Union Local No. 525 Trust Funds BIN # 920071 P.O. Box 29425 Phoenix, AZ 85038-9425
Q. Whom should I call if I have questions about my Health Care eligibility?
A. Please contact the Benefit Fund Office at: 702-415-2199
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
Q. Will my child(ren) who is/are age 19 through age 26 be covered under the Plan?
A. Yes. Due to the new Healthcare Reform Act, dependent children are now eligible to remain on the coverage until the age of 26, regardless of student status.
Q. How do I add my new baby or spouse to my insurance plan?
A. You must submit legal documentation to the Benefit office along with a completed Enrollment Form. You can download the Enrollment Form off of this website located under "Forms" and mail it into the Benefit Fund Office.

Forms Required Are:
  • Spouse – copy of your original marriage certificate
  • Child – copy of your child’s original birth certificate
  • Step-child –copy of child’s original birth certificate along with proof of residency (Tax Returns & Divorce Decree/Court Documents)
  • Adopted child –copy of legal decree of adoption
Q. Whom should I contact if I'm getting a divorce and what documents do I need to submit?
A. Please call the Trust Fund Office and advise the Eligibility and Pension Departments that you are getting a divorce or have already gotten divorced. You will also need to submit a FULL copy of your Dissolution of Marriage Judgment and QDRO (Qualified Domestic Relations Order) to this office.
Q. How do I obtain a replacement Medical and Prescription Card?
A. Please contact the Trust Fund Office at: 702-415-2199.
Q. How do I inquire about the status of my medical claim?
A. You can scroll over Member Benefits above, and select Healthcare Claims.  You can also print EOBs.  If you need assistance, please contact the Trust Fund Office at: 702-415-2199.
Q. Who is the Prescription Drug Benefit Manager?
A. Navitus
Q. How can I contact the Prescription Drug Benefit Manager?
A. 855-673-6504                                        
Q. How do I find a physician or find out if my doctor is a contracted provider?
A.  Log on to www.Anthem.com.  If you have not registered on the website, you may still locate providers using the 3-digit prefix "IFP" when asked.
Q. If a service I need requires Prior Authorization, who do I (or my provider) contact?
A. Nevada Healthcare Solutions (NHS) at (702) 216-1653 or (855) 392-0778.
Q. If I need to utilize Mental Health or Substance Abuse benefits, who do I contact?
A. Behavioral Healthcare Options (BHO) at (800) 873-2246 or (702) 364-1484, available 24 hours a day, 7 days a week.
Q. How do I inquire about the status of my medical or dental claim?
A. First, you must log-in with your username and password. After log-in please hover over "Member Benefits" and then click "Healthcare Claims" from the drop down menu.
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. How do I know the reason 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 single line item. If you need further explanation you may call or email the Trust Fund Office at (702) 415-2199.
Q. How do I obtain a replacement Medical Card?
A. Please contact the Trust Fund Office at: (702) 415-2199.
Q. How do I find a dentist or find out if my dentist participates with Cigna Dental?
A. Please visit https://www.cigna.com/  or call (800) 244-6224.
Q. If I have 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, your claim will automatically cross-over to us for processing as secondary.  If a claims must be submitted in paper form, claims should be submitted to the Plumbers and Pipefitters Local 525 Health and Welfare Trust at PO Box 1618, San Ramon, CA 94583. You can inform your provider that Medicare claims may be received electronically through a Medicare Crossover Clearinghouse as well if they do not wish to send in a paper claim.
Q. Who is the Vision Care Provider?
A. VSP who can be reached at (800) 877-7195 or via their website at www.vsp.com.