for CHC Members

Please carefully read the following

Each of the following Documents are needed to process your Medical Claims

✓  The CHC Medical Claim Form:  The CHC Medical Claim Form describes the Medical Event causing the need for a Medical Service.  A completed Medical Claim Form is required to process any Medical Claim.  Failure to provide a Medical Claim Form will cause a delay or even a denial of your Medical Claim.

✓  Required Medical Service Documents:  The Medical Services Documents should be given to you by the Medical Provider when you check-out.  If not, please ask for them.  Each of the following documents must be sent to CHC with your Medical Claim Form.  Each document must in a legible, paper, PDF or .jpg format.

✓  A Statement of Services (SOS):  The SOS describes each performed Medical Service.  The SOS may have other names and may include multiple documents.  For instance, it may be called the Intake Report or Initial Physician’s Report.  The SOS must describe; (a) the initial medical analysis performed by each Medical Provider, (b) the description of the cause for the Medical Event, (c) the Medical Services performed, and (d) discharge notes.

For Routine Medical Services:  Usually there is one Statement of Services and one bill from one Medical Provider. For an annual wellness there may be an additional Lab and Test bill.

For Non-Routine Medical Services:  Usually there is more than one Medical Provider. Each Medical Provider’s Statement of Services and medical bill is treated separately when processing your entire Medical Claim.

Frequently the Medical Provider’s Medical Claim Documents will be received by you at different times. Send the Medical Claim Documents to CHC when received. CHC will process each when received, thereby speeding up your reimbursement.

✓  A Billing Statement:  The Billing Statement shows the itemized cost for each medical treatment provided by the Medical Provider including CPT codes and any adjustment in the cost for Self-Pay and other discounts.

✓  Payment Receipt:  A copy of your payment receipt (credit or debit card) or other evidence showing your payment at the time of the Medical Service or the amount owed to the Medical Provider.

Send to CHC:  Email – [email protected].   Postal Address- Community Healthcare Cooperative 16591 Red Cliff Cr Morrison, CO 80465.

Medical Claim Deadline:  Within 30 days after receiving any Medical Service of purchase of a covered Prescription Medication

Medical Treatment Deadline:  Within 7 days of any illness or injury

Note:  Any medical claim submitted beyond the Deadline will not be processed or reimbursed. Deadlines are necessary to give the CHC Concierge time to review your medical bills and to contact the Medical Provider.

Included with your CHC Membership and Healthcare Plan Agreement:   Your ID Cards are included with your CHC Membership and Healthcare Plan Agreement. Simply print them then cut out the ID Card. Be sure each family member has their ID Card with them at all times.

You can also contact CHC and request your ID Cards.

Remember!   Always present your CHC ID Card each time you visit a Medical Provider and receive any Medical Service.

An Existing Medical Condition:  A Pre-Existing Medical Condition is defined as any physical, mental, dental, vision or hearing medical condition that existed, was diagnosed or treated by a Medical Provider or otherwise became known to you within five years immediately prior to the Effective Date.

All Pre-Existing Medical Conditions for any person included in your CHC Healthcare Plan must be disclosed to CHC.

An imminent Life Threatening Medical Condition:   A Life Threatening Medical Condition Medical Condition that

✓  likely could cause the end of life if not immediately treated by a Medical Provider,

✓  Requires hospitalization for more than 24 hours,

✓  Requires immediate attention on the day the Medical Event occurred or is a very severe injury that cannot be immediately treated by a PCP or at an Urgent Care Facility and is immediately referred to a hospital ER.

Only use a hospital ER if and when you have a Life-Threatening medical event.  Otherwise avoid any ER facility

A Medical Event:   A medical condition requiring treatment by a Medical Provider.

A Medical Service:  A medically necessary doctor visit, medical treatment, lab or test, medical equipment or medical merchandise, prescribed, ordered or performed by a Medical Provider.

A Medical Claim:  A Medical Claim is a request from you for reimbursement or the payment for a Medical Service.  A Medical Sub-Claim is the individual Medical Provider bills included with a Medical Claim.  A Non-Routine Medical Claim usually has more than one Medical Sub-Claim.  For convenience, a Medical Claim with Medical Sub-Claims is referred to as a Medical Claim.

Anywhere:   You can receive medical treatment anywhere in the U.S. and World-Wide .

We do suggest you follow these guidelines:

✓  Primary Care Physicians (PCP):  Use for annual wellness exams and general well-being Medical Services.

✓  Urgent Care Facilities: Use for any Non-Routine Medical Service.

✕   Free-Standing ER Facilities:  A Free-Standing ER may direct you to a Hospital ER for treatment.  In which case, you would likely incur two, expensive ER medical treatment costs.

✕   Hospital ER Facilities:  Treatment costs at a Hospital ER are about 10 times more than an Urgent Care.  Only receive Medical Services at a Hospital ER for a life-threatening Medical Event, or if directed by an Urgent Care Facility.

Yes – Anytime!  Any person can be added; dependants over 21, relatives, grand parents, even your pets.

Yes – For Prescription Medications. The definition for a Prescription Medication is a medication requiring a Medical Provider’s authorization.

Prescription Medications are usually an Included Coverage if: (a) you selected the Prescription Medications coverage, and (b) the Prescription Medications currently being taking are disclosed in Addendum A of your CHC Healthcare Plan Agreement.

Otherwise, a Prescription Medication requires; (a) our prior written approval to be an Included Coverage unless the Prescription Medication is approved and is part of a Non-Routine Medical Service, or (b) is an Approved Cost and is less than the Prescription Medications Benefit Amount.

Note:  Any medication prescribed by a Medical Provider for an illness or injury is covered like any Medical Service.

Your Personal Healthcare Advocate:  As a CHC Member you have access to a CHC Concierge.

Your CHC Concierge will help guide you through the maze of today’s medical complexities.  Your CHC Concierge will help you locate affordable medical treatments, review your medical bills for errors, attempt cost reductions and establish payment terms for expensive medical services.

There is no charge for your CHC Concierge Service

Any Time:  Usually you would have selected your CHSA Contribution at the time you purchased your CHC Healthcare Plan.  If not, or you want to start or change the amount, you can contact CHC at any time.

Contact CHC:  Contact CHC using an on-line request, email or by calling.

A Routine Medical Service:  The general definition is a Medical Service for general health and well-being performed or ordered by a Medical Provider.  A Routine Medical Service is usually a single office visit with a cost of $250 or less.

Some examples are doctor office visits, lab and imaging tests, usually associated with an annual wellness exam, and minor medical and wellness treatments.

A Non-Routine Medical Service:   The general definition is: (a) a Medical Service for an unexpected or unplanned Medical Event such as for an Accident, or a Non-Critical or Critical illness, (b) when there is more than one office visit for the same Medical Event or (b) when the Medical Service cost exceeds $250.

Some general examples of a Non-Routine Medical Service are:

✓  An Accident:   A broken bone, a laceration or any type of injury

✓  Non-Critical Illness:  Fever, mild arthritis, abdominal pain, hernia procedure, tooth extraction or crown

✓  Critical Illness:  Heart Attack, Stroke, Cancer, Kidney failure, Diabetes, Paralysis

If possible, contact CHC before receiving any Non-Routine Medical Service.  We want to confirm your coverage and help guide you to where you may receive cost-effective treatment.

For any Non-Routine Medical Service, you must receive treatment from a Medical Provider within 72 hours of the Medical Event causing the need for the Medical Service.

Note:  All Medical Claims must be submitted within 7 days of any Medical Service.

Refer to your CHC Healthcare Plan Agreement for a specific list.

Each of the following Medical Services is usually an Excluded Coverage and a Denied Cost unless CHC provides you with prior written approval before the Medical Service is performed.

✓  Any Medical Service not shown or checked in the Table on your CHC Healthcare Plan.

✓  Any Pre-Existing Medical Condition not disclosed on Addendum A of your CHC Healthcare Plan.

✓  Any Prescription Medication being taken not disclosed on Addendum A of your CHC Healthcare Plan.

✓  Any Elective Medical Service including vasectomy, pregnancy and maternity

✓  Any Medical Service or combination of Medical Services that exceeds or will exceed: (a) $250, (b) 130% of the Medicare reimbursement amount, (c) the respective Medical Services and Prescription Medications Medical Benefit Amount, (d) or in CHC’s sole opinion, exceeds the usual and customary frequency or cost for such Medical Service

✓  Any Medical Service whereby the same or similar Medical Service was performed at an interval or frequency deemed by CHC to be excessive or too frequent

✓  Any Medical Service cost that exceeds the usual and customary cost for such Medical Service

✓  Any Medical Claim or collection of Medical Claims that exceed the Medical Services or Prescription Medications Plan Benefit Amount

✓  Any Medical Claim not timely submitted to CHC for Reimbursement

✓  Any Medical Service whereby a Medical Claim was denied by an insurance company or is not an accepted Medicare reimbursement

✓  Any non-life threatening, or Routine Medical Service received in Hospital ER or a Free-Standing ER instead of by a PCP or at an Urgent Care Facility

✓  Any Medical Service for substance abuse, physical abuse and mental health treatments including any habit or addiction treatments, counseling or services

✓  Any Medical Service whereby the Medical Provider’s diagnosis found no specific medical condition or there is no supporting documentation from a Medical Provider to justify the need for the Medical Service

✓  Any medical bill that was paid or should have been paid by any third-party, including, but not limited to: Stop-Loss insurance, other insurance policies, employer, state or federal programs or plan