SSMC Employee Health Benefit Plan
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c. If services are due to an Accidental Injury, you must provide complete details on how, where, the
date, and the time such Injury was sustained.
d. Attach Medicare or other plan explanation of benefits or denial, if appropriate. All completed forms
and itemized bills should be submitted to:
POMCO
P.O. BOX 6329
SYRACUSE, NY 13217- 6329
The Claims Administrator will accept other valid claim forms that provide the necessary information to
decide coverage. If you fail to provide necessary information, missing information or additional details could
be requested. This could delay the determination of your benefits. The Claims Administrator will advise you
of the approval or rejection of your claim by mail.
B. Time Limit on Claim Submission
The proof of loss for covered medical expenses should be submitted as Incurred. The proof of loss (claim) is
the itemized bill or the Provider's statement of services rendered. To be covered, the Claims Administrator
must receive claim submissions within 12 months after the date the covered expense was Incurred. Claims
submitted after this time limit will automatically be denied unless a request for an extension has been
received and approved by the Claims Administrator or Plan Administrator. This request must be in writing
and include the circumstances that show it was not r easonably possible for you to submit the claim for those
expenses during the 12 month limit and the late submission was sent as soon as possible. Under no
circumstances, will payment be made for claims received more than two years after expenses Incurred.
C. Payment of Benefits/Authorization to Pay Provider/Other Entity
All payments made by the Plan under this title will constitute full disbursement of the available benefit and
this Plan will not duplicate its payments. Under no circumstances will any authorization obligate the Plan to
pay benefits that are not available.
Hospital Expense Benefits are paid directly to the Hospital or other facility unless the expenses have already
been paid. Participating Provider benefits are paid directly to the Network Provider. All other health benefits
are generally paid directly to you unless you sign the authorization on the appropriate section of the claim
form to have Plan payment made directly to the Provider. A separate claim form should be used for each
Provider to whom you want direct payment to be made. The Plan may, at its option, accept such
authorization of payment to a Hospital, Physician or other Covered Provider.
The Plan may, at its option, elect to pay benefits directly to a Provider or other entity, if appropriate. Without
Provider tax identification information, the Plan may, at its option, reimburse benefits to you rather than the
Provider, even if you authorized benefit payment to that Provider. The Plan must make payments to your
separated/divorced Spouse or mother of your child, state child support agencies or Medicaid agencies if
required by qualified medical child support orders (QMSCO) or state Medicaid law.
When this Plan is considered secondary coverage, the Plan may, at its option, pay available benefits to you,
the Provider, or pay the primary plan for its overpaid benefits. In the case of your death or legal
incompetence, the Plan may elect to pay benefits to any unpaid Provider, your guardian or person with power
of attorney, your estate, your Spouse, your parents, your children or your brothers and sisters as deemed
appropriate.
D. Your Right to Benefits
Although direct payment may be authorized as shown above under Payment of Benefits/Authorization to
Pay Provider. Under no circumstances may you assign your right to benefits under This Plan to any person,
corporation or other organization. You may not assign your right to take legal action under This Plan to any
