How to File a Medical Claim
Medical claims are processed by HealthSmart Benefit Solutions and should be submitted to:
HealthSmart Benefit Solutions, P.O. Box 2451, Charleston, WV 25329-2451
This post office box should be used only for PEIA claims. Please do not submit PEIA claims to other HealthSmart post office boxes. This will only delay their processing. To process a medical claim, HealthSmart requires a complete itemization of charges including:
- the patient’s name
- the nature of the illness or injury
- date(s) of service
- type of service(s)
- charge for each service
- diagnosis and procedure codes
- identification number of the provider and
- Medical ID number of the policyholder
If you have other insurance which is primary, you need to submit an Explanation of Benefits (EOB) from the other insurance which shows the amount the primary insurance paid with each claim, or ask your provider to do so if the claim is being submitted for you.
You have six (6) months from the date of service to file a medical claim. If PEIA is your secondary insurer, you have six (6) months from the date of your primary insurer’s Explanation of Benefits processing date to file your claim with PEIA. If you do not submit claims within this period, they will not be paid, and you will be responsible for payment to the
If your claim is for an illness or injury wrongfully or negligently caused by someone else, and you expect to be reimbursed by another party or insurance plan, you must file a claim with PEIA within six (6) months of the date of service to ensure that the covered services will be paid. Later, if you receive payment for the expenses, you will have to repay the amount you received from PEIA. See “Subrogation” on page 92 for details.
Filing Claims for Court-ordered Dependents (COD)
If you are the custodial parent of a child who is covered under the other parent’s PEIA plan as a result of a court order, you may submit claims directly to HealthSmart using the special claim forms provided by PEIA. You can also receive all benefit information published by PEIA, and reimbursements for medical claims can be sent directly to you. For prescription drugs, you must use your I.D. card at a participating pharmacy. To make arrangements for this, please contact PEIA at 1-304- 558-7850, or toll-free at 1-888-680-7342.
Claims Incurred Outside of the U.S.A.
If you or a covered dependent incur medical expenses while outside the United States, you may be required to pay the provider yourself. Request an itemized bill containing all the information listed above from your provider and submit the bill along with a claim form to HealthSmart or the prescription drug administrator.
HealthSmart or the prescription drug administrator will determine, through a local banking institution, the currency exchange rate and you will be reimbursed according to the terms of the plan you’re enrolled in.Source: www.peia.wv.gov