SSMC Employee Health Benefit Plan
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SECTION VIII - CLAIM SUBMISSION AND REVIEW PROCEDURES
A. How to Submit a Claim
If Medicare or another health plan is considered the primary plan, claims should first be submitted to those plans and
then to POMCO with copies of their explanation of benefits or denial.
Claims for health expenses resulting from an occupational cause, auto accident or incident covered under No-
Fault Automobile Coverage, or expenses for which benefits could be payable by a third party plan not issued
to or owned by you or your Dependent, should be submitted to the appropriate insurance company or payer.
These type of claims are not payable under the Plan. Be sure to advise the Provider of these situations to
avoid overpayment of Plan benefits.
1. Network Provider Claims. Claim submissions are not required by you. The PHO Network Provider
(participating Provider) bills POMCO directly for benefits. You or your Eligible Dependents need only
present your Plan identification card to confirm Plan eligibility and provide any information requested by
the Provider. The PHO Network Provider may request payment for applicable Copayments or
Deductibles at the time of the services or bill these amounts later. Be sure to give the PHO Provider full
information on other health plans and history of any Accidental Injuries.
2. Hospital Inpatient or Outpatient Claims. Usually, the Hospital or other facility will mail claims
directly to POMCO. If you are billed directly, follow the instructions for Other Claims Submissions
described later in this section. If you or your Eligible Dependents are covered by more than one plan, the
Hospital will usually bill the plans according to the Order of Benefit Determination. Example: If
Medicare is primary, the Hospital will first bill Medicare and then POMCO. Usually, the Hospital will
provide payment information for Medicare and/or other health plan benefits when they submit your
claims to POMCO. If not, POMCO will contact you with a written request for copies of the other Plans'
explanation of benefits or denial. Be sure to give the Hospital information on all your health plans to
help proper billing.
3. Prescription Drug Claims. If this Plan is primary coverage, refer to Section IV - Covered Services
under Prescription Drug Expenses for details on how to obtain benefits from EHS.
4. Other Claim Submissions. If Medicare is primary, the Provider usually bills Medicare directly. All you
need to do is provide the necessary information to enable the Provider to submit to Medicare. The
Provider may then bill this Plan directly. If this Plan is secondary to other health plans, you must first file
claims through the other plan and then to POMCO, with a copy of their explanation of benefits. If you
are billed directly for covered services, you must take the following steps to submit a claim for benefits:
a. A claim form should be obtained from the SSMC Human Resources Department or from POMCO.
Be sure to read the instructions printed on the claim form. Remember: You must attach a completed
claim form each time you send in medical bills and a separate claim form is needed for each family
member.
b. Once you have completed your portion of the claim form, the Provider can complete his or her
portion, if needed, or you may attach itemized bills. If an itemized bill is attached, it must clearly
state the patient's name, diagnosis, full description of service rendered and an itemized list of charges
with dates of service. If you assign benefit payment to the Provider, the bill should also include the
Provider's signature and tax identification number.
