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Claim Filing Instructions
Each claim consists of two parts, the claim form and the
supporting documentation (Kaiser receipts). Following are instructions and
rules to help you avoid mistakes.
IMPORTANT: Documents
must be submitted in plan year by June 30.
THE INSTRUCTIONS:
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The claim form must be
thoroughly completed, signed and dated.
Claim Form in
Microsoft Word
Claim Form in Acrobat
Adobe .pdf*
-
Please type or print
(clearly).
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Reimbursements are
mailed to your address of record at SCUSD. If you have moved and have yet
to report your new address, check the box and enter your new address.
-
Enter the date, patient
name and check the appropriate box for each receipt. After entering this
information, enter the total number of prescriptions and the total amount
you are requesting in the appropriate spaces.
-
Review the plan
provisions and certification. Be advised that when you sign the claim
form you are agreeing to abide by the provisions and certification.
-
Sign and date the claim
form.
-
Attach your Kaiser prescription drug
receipts (originals or copies) to your claim form. Your receipts must
identify the Kaiser pharmacy, the patient’s name, the date, the
prescription or Rx identification number, and the $5 co-pay for each Rx
purchased. Payment receipts that do not include all required information
cannot be accepted and will be returned with a request for correct
documentation.
THE RULES:
Following are a few of the more important
rules pertaining to this Plan. Refer to your plan document for complete
information.
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One (1) claim consists
of at least 10 prescriptions.
-
Prior to June 1, 2008,
claims for less than 10 prescriptions will be returned. You may submit
claims for less than 10 prescriptions between June 1, 2007 and June 30,
2007
(1).
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Claims
must be POSTMARKED no later than June 30, 2008 to be
eligible for reimbursement. DO NOT SUBMIT TO SCUSD send to CBA (address
above). Claims will not be paid after June 30 for that plan year.
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You may mail OR
fax claims to CBA. Please DO NOT do both.
-
If you fax a claim,
please do not contact CBA to confirm receipt.
-
Prior to sending your
claim, review your form and receipts to ensure that all required
information is complete and legible.
-
Retain a copy of your
claim form and supporting documents for your records.
-
You may make copies of
the claim form for future use.
(1) The July 1, 2007 through June 30, 2008 Plan Year is being
offered pending formal approval under your Collective Bargaining Agreement.
If the extension of the Plan is not approved, you will be given 30 days to
submit claims for prescriptions purchased between July 1, 2006 and the last
day of the 30-day notice period. During the 30-day notice period, you will
be permitted to submit claims for less than 10 prescriptions drug co-pays.
If you have any questions, please call
916-231-5448.
Co-pay Plan |
Certificated
Teacher
