Under the Fund Rules, the issuance and submission of a claim form does not constitute acceptance of an individual’s eligibility by the Fund, or a guarantee of benefit payment. The determination of eligibility and the amount of any benefits payable are subject to the terms of the Plan at the time a claim occurs. Claim forms are not required for in-network providers.

MEDICAL/DENTAL

There is a separate claim form for each type of benefit

Medical Dental

Be sure to request the proper claim form so You may receive the benefits to which You are entitled. Follow these steps:

Step 1 –	Obtain the proper claim form from: I.B.E.W. Local 25 Health & Benefit Fund 372 Vanderbilt Motor Parkway Hauppauge, New York 11788 www.eibofli.com
Step 2 –	Complete the Plan Participant’s Statement on all claims. If the claim is for a Dependent, complete the Dependent information. Important: If You fail to provide complete details in the Participant or Dependent sections of the claim forms, it will be necessary to return the form to You, which will delay settlement of Your claim.
Step 3 –	Have Your Physician or Dentist fill in his/her portion of the claim form.
Step 4 –	Attach all related bills to Your form. It is important that they contain the right information. Related bills received late may be sent separately.
Step 5 –	Review all forms for completeness. Make sure You sign the claim form.
Step 6 –	Mail the completed and signed claim form, including all related bills, promptly to: MagnaCare P.O. Box 1001 Garden City, NY 11530-2124

MAGNACARE LABORATORY CLAIM INFORMATION

The following steps are recommended to prevent potential problems:

1. In order to ensure that the proper information is transmitted to the lab, present Your MagnaCare identification card at Your doctor’s office and make sure that the doctor’s staff enters the member’s identification number and “MagnaCare” on all forms and that a copy of the card is placed in Your file. The member is the active participant with the Fund, not the spouse or dependent.
2. If Your physician orders tests, ask the person who handles the specimen to indicate on the lab requisition form that You are a MagnaCare participant, and mention that the plan will
   pay 100% of covered expenses, after the in-network $25 co-payment, if a MagnaCare lab is used.
3. If You go to a drawing station instead of a doctor’s office, make sure that the specimen is sent to a participating lab by following steps 1 and 2 above
4. If You receive a bill for services rendered at a participating MagnaCare laboratory, this means that the lab is missing the information necessary to identify You as a MagnaCare participant. DO NOT IGNORE THE BILL. On the bill, write the identification number of the member and “I.B.E.W. Local 25 Health & Benefit Fund,” and if possible, attach a copy of Your MagnaCare card. Mail the bill to:MagnaCare
   P.O. Box 1001
   Garden City, NY 11530-2124
   Attn: Laboratory UnitOnce MagnaCare receives Your bill, they will contact the lab to have Your claim submitted for processing and place Your account on hold.

NOTES ON FILING YOUR CLAIM FOR BENEFITS

Claim forms must be fully completed and submitted with related bills within one year from the date of treatment.

Benefits will be paid for the period covered by the statement on the claim form. If a disability or confinement continues beyond that point, an additional claim form must be requested and filed. Proper consideration of a claim for benefits can be given only when the completed claim form and all supporting documents are received. The Fund will not accept claims which are more than one year old.

COMMON CLAIM DELAY PROBLEMS AND CAUSES

Incomplete Participant and Dependent information:

1. Regarding whether You or Your spouse has other insurance coverage: name of group, name of insurance company, address, policy number, etc.
2. Regarding accidental injuries: how occurred, where, when, etc.
3. Regarding dates of birth or age to determine whether You or Your spouse are eligible for Medicare
4. Regarding date of birth of Dependent

What is needed if You or Your spouse has other health benefit coverage?

1. Information on Your Claim Form with name of other policyholder, name and address of insurance company, or other group health plan and whether group or individual coverage.
   This information is necessary to process any claim
2. Copies of all bills must be submitted to both plans
3. If lump-sum receipts are submitted, these must be itemized
4. Copies of payments from Your primary coverage must be submitted before a claim can be considered

MagnaCare is not guaranteeing the payment of some portion or all of the Plan’s health benefits. MagnaCare is only providing claims administrative services.

DEATH BENEFIT

Notify the Fund Office of the death of a Plan Participant.

Claims forms will be sent to the designated beneficiary for completion and should be returned to the Fund Office with one certified copy of the death certificate.