Claim Filing Procedures

Hospital

Empire HealthChoice, Inc. Deluxe PPO

Should you or any of your dependents require emergency care or admission to a participating hospital, you should present your Empire identification card and Medicare card (where appropriate) at the time of service. The hospital will bill Empire for benefits payment. No claim forms are required for hospital coverage since all hospital benefits, excepting emergency care, must be pre-certified.

Medical Benefits

Empire HealthChoice, Inc. Deluxe PPO

There are no claim forms to file for medical benefits for services rendered by participating PPO providers. You simply identify yourself as a member of PPO by showing your identification card to the provider and make any required copayment. The providers are responsible for filing all claims for benefits directly Empire HealthChoice, Inc. Deluxe PPO.

Dental Benefits

MetLife Preferred Dentist Program

All necessary forms for dental and orthodontic work can be obtained by calling MetLife at 1-800-942-0854. Claim forms can be downloaded from the MetLife web site (www.metlife.com/dental). You must bring a claim form with you to your appointment. You must complete the employee portion of the claim and your dentist will complete the rest. Then, either you or your dentist can submit it to MetLife for processing. If your dentist uses his/her own computerized form, attach a copy to your MetLife claim form and send it to MetLife.

If you require treatment in excess of $300, you and your dentist should submit a pre-treatment estimate outlining the treatment plan and related charges. This way, you will know what services MetLife will cover and at what payment level. Services that usually require a pre-treatment estimate include crowns, bridges, inlays, onlays and periodontics.

Prescription Drug Program

No claim forms are required for prescriptions obtained through the mail service or card program. If you are required to purchase a prescription because of circumstances beyond your control, contact the Welfare Fund Office (212-465-8888) to obtain a Direct Reimbursement Claim form. Your reimbursement under this program will be significantly less than your purchase price of the prescription. After you and your pharmacist have completed the claim form, return it to the Fund Office for processing.

Vision Care Benefits & Hearing Aid Benefits

There is a special combined claim form for these benefits. Should you or any of your qualifying dependents require an application, contact the Fund Office (212-465-8888). After you have completed the application and followed its specific instructions, submit it to the Welfare Fund’s Medical Benefits Program for processing. An itemized receipt for the services rendered or products purchased must accompany the application