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
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