Claims and Appeals Under the Lumenos Georgia Health Insurance Plan

To receive a claim for benefits from the Lumenos plan, follow the procedures for filing claims and appealing claims.

Filing Claims

If you receive services from a provider who offers a discount, your provider should submit the claim for reimbursement, on your behalf. If you receive services from a provider who does not offer a discount you must file your own claim. If you need to file your own form, it's a good idea to take the form along with you when you see your provider. You can obtain a member claim form either from your employer's benefit office, by contacting Customer Service at (866) 835-6863 or by logging in to www.lumenos.com under My Benefits - Forms Library.

When you need to file a claim for benefits, complete the appropriate forms and mail them with all required documentation to the Claims Administrator at:

Lumenos
P.O. Box 69309
Harrisburg, PA 17106-9309

NOTE: When services are rendered by a provider who offers a discount, claims should be submitted by the provider to the address denoted on your identification card.

IMPORTANT! Claims should be submitted as soon as possible. Claims submitted more than 6 months from the date of service for claims where Lumenos is primary will not be honored. Claims submitted more than 12 months from the date of service for claims where Lumenos is secondary will not be honored. Previous Plan year HRA claims will be applied against your previous Plan year HRA funds and never against current Plan year funds. Current Plan year claims will be applied against previous Plan year HRA funds but only after you have used all your current Plan year HRA funds.

NOTE! If you are covered under the Lumenos plan and a health FSA maintained by your employer, expenses covered both by the HRA and the Health FSA must be paid first from the HRA. Charges not reimbursed, such as Bridge amounts and coinsurance, may be eligible for reimbursement from an employer-sponsored flexible spending account if they are not reimbursable from any other source.

Generally, the company has delegated its claims administration authority for the Lumenos plan to Lumenos. As the Claims Administrator, Lumenos is responsible for reviewing and processing certain claims, as follows:

• Initial benefit determinations
• First level appeals,
• Second level appeals, and
• All appeals involving urgent care.

Benefit Determinations

There are four types of Plan claims: Pre-Service, Concurrent Care, Urgent Care Claims and Post Service Claims.

Pre-Service Claim-a claim for health care where prior approval for any part of the care is a condition to receiving the care. For example, the Plan requires that you pre-certify hospital admissions.

Concurrent Care Claim-a previously approved claim for an ongoing course of treatment to be provided for a period of time or for a number of treatments.

Post-Service Claim-a claim for care that has already been received and, any claim for which the Plan does not require pre-authorization.

Urgent Care Claim-a Pre-Service or Concurrent Care Claim becomes an Urgent Care Claim when the normal time frame for making a determination would:

• seriously jeopardize the life of the claimant (in the view of a prudent lay person acting on behalf of the Plan who possesses an average knowledge of health and medicine or a physician with knowledge of the claimant's medical condition) or
• subject the claimant to severe pain that cannot be adequately managed without treatment (in the view of a physician with knowledge of the claimant's condition).