Claims

Q. When must claims be filed?

A. You must file claims no later than two years after the date you incur the expense.

In most cases, you do not have to file claims if you follow procedures set out for purchasing outpatient prescription drugs (listed in the Prescription drug program section of this SPD) and enroll in the Medicare Direct program. In the event you do need to file a claim, be sure to follow the instructions described in this section.

Outpatient prescription drug claims

You do not have to file a claim for outpatient prescription drugs if you:

• Use a participating network retail pharmacy and identify yourself as an Express Scripts participant, or
• Purchase drugs through Express Scripts Pharmacy, the home delivery pharmacy.

Otherwise, you must submit a completed Direct Reimbursement Claim Form to Express Scripts. You may obtain a claim form by calling Express Scripts at the number shown in the front of this SPD.

Note: If you enroll in a Medicare Advantage (Part C) plan which provides a Medicare prescription drug benefit or a Part D Prescription Drug Plan, you are not eligible to submit claims for outpatient prescription drug benefits under the Plan.

Other medical claims

The Plan has contracted with Aetna to process claims for expenses other than outpatient prescription drugs. If you need to file a claim:

• Submit a completed claim form which can be found at www.exxonmobilfamily.com.
• Include copies of what Medicare has paid (explanation of benefits, EOB).
• If expenses submitted are not covered by Medicare, submit itemized bills and Medicare's denial EOB.
• Keep a copy of a submitted claim.
• Keep your explanation of benefits.

You may obtain claim forms by contacting Aetna. See Information sources at the front of this SPD. 

Medicare Part A claims

On admission, a hospital generally asks if you have any coverage other than Medicare. Show your Plan identification card.

The hospital usually bills Medicare first, the Plan second, and then bills you for the balance.

Medicare Part B claims

You or your provider or physician should submit your bills first to Medicare. If your provider or physician submits the itemized bill to Medicare, be sure to get a copy. Medicare processes the claim and sends you an explanation of benefits. Send the explanation of benefits to Aetna along with a copy of the itemized bill. Be sure to include the primary participant's Aetna Member Identification number. Aetna processes the claim and sends you an EOB.

Medicare Direct

Medicare Direct, also known as Medicare Crossover, is a program providing you an easier way to handle Medicare Part A and Medicare Part B bills for services received such as office visits, outpatient hospital treatment and medical supplies.

With this program, Medicare forwards information about claims directly to Aetna. This allows faster claims processing as well as less cost and paperwork for you. Plan benefits are paid directly to the provider if you have assigned Medicare benefits to the provider.

To enroll in Medicare Direct, contact Aetna Member Services. You may begin or stop using this program at any time. Changes in your enrollment may take from 45 to 60 days to implement. There is no additional cost for using Medicare Direct.

Bills for dental services

This Plan does not cover dental services.

Expenses incurred outside the United States

If you receive medical care or mental health treatment when traveling or living outside the United States, generally you must pay the medical or mental health treatment 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. Services outside the United States do not require precertification or predetermination. Aetna can only determine coverage of the claim once they receive the itemized bill. 

Bills should be submitted in the appropriate foreign currency. The claims administrator will convert the bill to U.S. dollars using the website Oanda as of the date the medical services were rendered.

Claim denial and reconsideration

If all or part of a claim is denied, the claims administrator will provide you with a written explanation, including the Plan provisions supporting the denial and describing additional information, if any, that may improve the claim's likelihood of being approved. See Administrative and ERISA information.

Right of reimbursement and subrogation

If your claim results from an accident or other injury 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 medical insurance you may carry, such as medical coverage under your automobile insurance. The Plan's right to subrogation and reimbursement also constitute an equitable lien against any payments by such third party made or payable to you, your covered family members, or anyone acting on your behalf, now or in the future, regardless of how the payments are characterized. For example, injury, illness or disability related payments that you receive for expenses such as past medical expenses, future medical expenses, attorneys' fees and expenses, or other costs or compensation, up to the full amount of all benefits paid by the Plan, must first be used to repay the Plan before any money goes to you. By accepting benefits from the Plan you are agreeing to this arrangement. The Plan's right to do this is called its right to impose an equitable lien or constructive trust.