High Option Plan

How to File a Claim

In most cases, providers and facilities file claims for you.

When you must file a claim:

You receive services outside the United States
Another group health plan is primary
You use an Out-of-Network provider

Submit services on the CMS1500 or a claim form that includes the information shown below:

Patient's name, date of birth, address, phone number and relationship to enrollee;
Member identification number as shown on your identification card;
Name, address, and tax identification number of person or facility providing the service or supply;
Signature of physician or supplier including degrees or credentials of individual providing the service;
Dates that services or supplies were furnished;
Diagnosis;
Type of each service or supply;
Charge for each service or supply; and
If another group health plan is primary, send a copy of their explanation of benefits.

Where to File

All medical claims (except when Medicare is the primary payer) should be submitted to:

            NALC Health Benefit Plan
            Cigna Payor 62308
            P.O. Box 188004
            Chattanooga, TN 37422-8004

Mental Health and Substance Use Disorder Claims

OptumHealth^SM Behavioral Solutions provides our mental health and substance use disorder (MHSA) benefits. Some MHSA services require priorauthorization, call 877-468-1016 to receive authorization.

Claims should be submitted to:

            OptumHealth^SM Behavioral Solutions
            P O Box 30755
            Salt Lake City UT 84130-0755

When Medicare is the primary payer, and will not cover your services, call the Plan at 703-729-4677 or 888-636-NALC (6252) to obtain benefits. Claims for Medicare-primary patients should be submitted to:

            NALC Health Benefit Plan
            20547 Waverly Court
            Ashburn VA 20149

Note: You do not need to preauthorize treatment when Medicare covers your services.

When Medicare is Primary

When Original Medicare is the primary payer, Medicare processes your claim first. Your copy of the Medicare Summary Notice (MSN) will include a statement confirming that a secondary claim has been filed with the Plan. If Medicare is primary, and your MSN does not show this message, submit a paper claim, including the MSN, to:

            NALC Health Benefit Plan
            20547 Waverly Court
            Ashburn VA 20149

CVS Caremark®

If you purchase prescriptions at a non-network pharmacy, foreign/overseas pharmacy, or elect to purchase additional refills at a preferred network pharmacy, other than at a CVS Caremark® Pharmacy, or at an NALC CareSelect Network pharmacy, complete the short-term prescription claim form. Mail it with your prescription receipts to the NALC Prescription Drug Program. Receipts must include the patient's name, prescription number, name of drug or NDC#, prescribing doctor's name, date of fill, charge, name of pharmacy, metric quantity, and days supply.

When you have other prescription drug coverage, and the other carrier is primary, use that carrier's drug benefit first. After the primary carrier has processed the claim, complete the short-term prescription claim form, attach the drug receipts and other carrier's payment explanation and mail to the NALC Prescription Drug Program.

            NALC Prescription Drug Program
            PO Box 52192
            Phoenix, AZ 85072-2192

Note: If you have questions about the Program, wish to locate a preferred network pharmacy, NALC CareSelect Network retail pharmacy, or need additional claim forms, call 800-933-NALC (6252) 24 hours a day, 7 days a week.

Questions?

Call the Plan at 703-729-4677 or 888-636-NALC (6252) if you need assistance.