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 Employee Connect 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 copayment 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 website at www.aetna.com and following the instructions.
If you participate in the Pre-Tax Spending Plan Health Care Flexible Spending Account, Aetna processes any reimbursements due to 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.
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.
Right of reimbursement and subrogation
If your claim results from an accident or other injury that may be the fault of another party, the Plan will be subrogated to your (or your covered family member's) right of recovery against any party. In addition, you must reimburse any amount paid by the Plan that you recover from any responsible party. The Plan does not require reimbursement from any voluntary medical payments coverage you may carry under your motor vehicle or homeowner's insurance. The Plan will seek reimbursement/subrogation from coverage you may carry for uninsured/underinsured motorists. The Plan's right to subrogation and reimbursement also constitute an equitable lien against any payments by any responsible 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. This creates a priority recovery right in favor of the Plan and is not subject to any application of a "make-whole" or "common fund" rule under local or other law. 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.
You are required to promptly notify the Plan of any occurrence that may give rise to the Plan's reimbursement/subrogation rights and to cooperate with the Plan (or its representative) to secure these rights.
Please refer to the Plan's master documents for additional information on the Plan's reimbursement/subrogation rights.
Claims when traveling and working 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. Covered expenses are payable at 75% for Option A or 80% for Option B subject to any applicable deductibles, copays and coinsurance.
Please note, a dose or doses of prescription medication or injections given at the time of treatment in a doctor’s office is covered under the POS II Medical Plan as a part of the medical service rendered. Self-administered or take home use prescription medication may be covered under your prescription drug benefit and you must submit claims separately to Express Scripts for reimbursement.
Bills should be submitted in the appropriate foreign currency. The claims administrator will convert the bill to U.S. dollars as of the date of service.