These standard claim submission instructions are also provided when providers access the Benefit Verification system. Both the participant’s ID Card and the verification forms contain more specific information, including the electronic payor id, needed for submitting claims for payment.


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How to Submit a Claim

Benefits under this Plan shall be paid only if the Plan Administrator decides, in their discretion, that a Covered Person is entitled to them. When a Covered Person has a claim to submit for payment this information is designed to assist in the process.

Providers should follow the EDI Submission Instructions on the ID Card.

To Submit for Payment That Person Must:

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Why J.P. Farley Icon

Submit a claim to the Claims Administrator for consideration.

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Claim must include the Group #, Unique Identification Number or Insured’s Social Security #.

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Have the Physician or Dentist complete the provider’s portion of the form.

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For Plan reimbursement, attach bills for services rendered.

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Send to the Claims Administrator at the electronic or mailing address listed on the summary of benefits & plan ID card.

All Bills Must Show

Name of Plan

Employee/Subscriber’s Name

Name of Patient

Provider’s Name, Address, Telephone Number

Dates of Service(s)


Type of Services Rendered, with Diagnosis and Procedure Codes


When Claims Should Be Filed

Benefits are based on the Plan’s Provisions at the time the charges were incurred. Claims should be filed as dictated by the terms of the plan for processing. Claim submissions should be filed promptly with all necessary information for proper consideration. Refer to the terms of the plan document for exact plan filing requirements.

Assignment of Benefits

By accepting assignment of benefits, the provider of services assumes both the right to payment by the Plan for services performed and accepts the limits of the Plan along with any defined deductibles and co-insurance that is required by the covered person as payment in full for the services rendered and billed for. The provider of services agrees to forgo reimbursements from the Plan or the Participant for amounts billed for the services that are in excess of the amount the Plan allows, plus any co-insurance required by the Covered Person.

Claims payment may be audited, adjusted, negotiated and/or re-priced to minimize overpayment of claims in excess of Plan allowances. If provider does not accept assignment of benefits as payment in full, benefit will be 100% of the Medicare allowable amount. The Medicare allowable amount is determined based on the date of service.

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