Index

About the Medical Plan

Eligibility and Enrollment

Basic Plan Features

The Prescription Drug Program

Mental Health and Chemical Dependency Care

Covered Expenses

Exclusions

Payments

Claims
- How to File Claims
- Claim Denial and Reconsideration
- Right of Reimbursement
- Claims Outside the United States

Partners in Health

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary

  

blue square Claims

Q. When must claims be filed?

A. For an expense to be eligible for reimbursement, the claim must be filed within two years from the date the expense was incurred.

blue square How to File Claims

The Plan has contracted with Aetna to process claims for medical and mental health care. See Information Sources at the front of this SPD for the address and telephone number.

If you use network providers, they will file claims for you. If your providers do not file claims for you, follow the instructions on the claim forms, which are available from the ExxonMobil Me Intranet site, the ExxonMobil Family Internet site, and Aetna Member Services.

If you have paid a provider's invoice in full and are submitting the invoice to Aetna yourself, please make sure that the claim form is completed and note the following:

  • Assignment Section — Do not complete this section or else payment will be made to the provider. Clearly indicate that you, not the provider, should receive the reimbursement.
  • Provider bill should clearly state that the bill is "paid in full."

Aetna Member Services reviews and responds to your claim, usually within 30 days after the claim is received. If special circumstances delay the processing of your claim, you will receive written notice telling you why the claim is delayed and when you can expect to receive a decision.

If you need to file a claim:

  • Submit a completed claim form with necessary documentation within two years from the date the expense was incurred.
  • Aetna will send you an explanation of benefits (EOB) for each claim. The EOB shows what service was performed, how much the provider charged, and what the covered charge was under the Plan. It shows if a deductible or co-payment was involved, as well as the calculation used to determine your benefit.
  • Keep the explanation of benefits for your records.
  • You can review your EOB by going to Aetna's Navigator Web site at www.aetnanavigator.com and following the instructions.

If you participate in the Pre-Tax Spending Plan Health Care Flexible Spending Account, Aetna processes any reimbursements due you after processing your medical claim. This means that, in most cases, you will not need to file a separate pre-tax claim form for this account.

Outpatient prescription drug purchases from a non-network pharmacy must be filed with Medco. See page 26 for details.

blue square Claim Denial and Reconsideration

If all or part of a claim is denied, Aetna Member Services will provide you with a written explanation supporting the denial and describing additional information, if any, that may improve the claim's likelihood of being approved. See the Administrative and ERISA Information section in this SPD.

blue square Right of Reimbursement

If your claim results from an accident that may be the fault of another party, you must reimburse any amount paid by the Plan that you recover from the responsible party. The Plan does not require reimbursement from any personal insurance you may carry, such as medical coverage under your automobile insurance.

blue square Claims Outside the United States

If you receive medical care when traveling or working outside the United States, generally you must pay the medical bills first. For reimbursement, submit an itemized bill along with a claim form. If the original bills are in a foreign language, you should obtain an English translation, if possible, of the services rendered.

Bills should be submitted in the appropriate foreign currency. The claims administrator will convert the bill to U.S. dollars.