Claims

Thanks for providing our participants with quality healthcare services. We’re here to help you submit claims for the services that you provide and to help you check your patients’ claims statuses.

Contacts

Billing

To ensure claims are paid in a timely manner, please be sure to bill correctly.

Common claims questions

• Why is my claim pending?

  Claims are usually given pending status while we wait for more information from either you or your patient.

  We may need more information from your patients if:

  • They were in an accident
  • They were hurt at work
  • They have other health insurance

  We may need more information from you if:

  It looks like the diagnosis/information on the claim appears to show an injury that was work-related or caused by a motor vehicle accident or a third party. In these cases, to not delay processing of the claim, it is important to send us any relevant information regarding the claim — such as the chart notes or injury forms.

  Once all of the needed information is provided, the claim will be processed. If the information is not received within 45 days, the claim will be denied. The claim can be reopened when all of the information is received.

• How do I know if you received the claim(s) I submitted, or when you received it?

  You can check if a claim was received by:

  • Checking online or
  • Calling the Customer Service office at 702-733-9938

• My patient has two insurances, why did the Culinary Health Fund not pay anything on this claim?

  The Culinary Health Fund coordinates benefits. If we are secondary, and the primary payor has already paid more than our allowable amount, we consider the claim paid, since you have already been paid at least what you would have received from the Culinary Health Fund if we were the only payor. If you are paid less than our allowable amount by the primary payor, we will pay the patient’s liability, up to our allowable.

• May I bill the patient for the primary insurance copay, deductible, or coinsurance if the Culinary Health Fund pays zero?

  Yes, you may bill the patient for the copays, deductibles and coinsurance when the Culinary Health Fund doesn’t pay anything as secondary.

• How long does it take to process a claim?

  • New claims

    The standard filing period is 12 months unless the contract states otherwise.

  • Corrected claims

    Must note on the claim “Corrected Claim” or it will be denied as a duplicate.

  • Clean claims

    Those that have all the information needed to process the claim are processed within 30 business days of receipt (equal to 45 calendar days).

  • Claims requiring additional information

    Claims are pended for 45 days and a letter is sent to the provider and/or patient for the necessary information. If the information is not received within the 45 days, the claim is closed.

• How does the Culinary Health Fund pay a work-related claim?

  Any work-related claims must be denied by Workers Compensation before the Culinary Health Fund will consider payment. If the claim was denied by Workers Compensation, all we need is a copy of the denial letter for the claim to be considered for payment. If the patient never reported the injury to their employer and it is work related, the claim will be denied by the Culinary Health Fund.

Don’t get an occurrence!

We strive to ensure quality healthcare and access for our participants. This goal is accomplished through our contracted PPO network of providers. It’s important for our participants to be referred in-network when possible. It reduces their out-of-pocket costs.

In support of this, we have an Occurrence Process. It holds contracted PPO network providers accountable for giving in-network referrals. Our PPO network providers are financially responsible for referrals made to an out-of-network provider.

Common occurrences include referrals to these out-of-network providers:

• Cardiac monitoring providers
• Laboratories
• Durable Medical Equipment (DME) providers

Check our list of PPO providers to ensure in-network referrals.