Medical, Dental and Prescription Drug Claims
At Trustmark Group Benefits, accuracy and timeliness in claims processing is a top priority. Our claims processing area randomly checks the accuracy and productivity of our claims processors. This auditing system enables us to maintain high levels of accuracy, quality and customer service.
Our claims processing teams strive to process claims as efficiently as possible. However, some claims may require additional processing time, including:
- Claims that require requests for additional information to determine correct benefits, such as operative reports for multiple medical procedures.
- Claims on which Coordination of Benefits information has been omitted.
- Claims that require a signed reimbursement agreement because third-party liability is indicated or probable.
- Claims that require further investigation due to questionable or unusual healthcare provider billing practices.
Below is pertinent information about claim submission and instructions for submitting the following types of claims to us:
- Prescription Drugs
- Accidental Death and Dismemberment
- Long Term/Short Term Disability
If employees have questions about where to send various types of claims, please have them contact the Eligibility/Benefits phone number on the back of their ID card.
All claims or statements must be itemized and include the following information:
Coordination of Benefits (COB)
- The member’s name
- The patient’s name (if it’s a dependent)
- Fully itemized bills including diagnoses, procedure codes, dates of service, and place of service
- Healthcare providers name, Tax Identification Number (TIN) and mailing address
- For accidental injury, provide details of how, when, and where the accident occurre
With the Coordination of Benefits (COB) provision, any benefits paid under another group health plan must be taken into account to determine the benefits payable under your health plan. Therefore, you should inform members that the primary carrier must determine benefits before the secondary carrier can determine benefits, otherwise, delays in claim processing may occur.
When Trustmark is the secondary payer, the best way to shorten the claim processing time is to supply as much information as possible about the other coverage and any other insurance payments that are made (refer to the Coordination of Benefits section of your Certificate of Insurance or Group policy).
To assist the member in finding a preferred provider we have provided network directories. Up to date information is available by calling the provider network phone number on the back of their ID Card, or visit us online.
Online you can access our Physician/Hospital look up feature. You may also check your provider networks’ website.
Procedure for submitting Medical Claims:
- When a member visits a healthcare provider, the provider will make a copy of the back of the ID card.
- In most all instances, your healthcare provider will bill Trustmark directly for healthcare services and supplies you receive. The member's claim will either be electronically filed or mailed by the provider to the medical claim address on the back of the ID card for processing.
Prescription Drug Claims
Procedure for submitting Prescription Drug Claims:
- In the event the provider does not send a medical claim to Trustmark, the member should submit the claim by using a Medical Claim form. These are available within your Group Administration Kit or can be found by visiting us online.
A medical claim form is not required in order to submit a claim, but it does assist in the claim paying process.
- The member should fill out the information on the claim form.
- The member should enclose all itemized medical bills. Bills for drugs prescribed by a healthcare provider and payable under the medical plan should also be enclosed with the claim form.
- The member should mail the claim form and all other items to the address listed on the back of the ID card.
If your plan includes a prescription drug card with copays, instruct members to call the Eligibility/ Benefits phone number found on the back of the ID Card for assistance.
If your plan includes the Rx Price Assurance plan, where prescription drug claims are paid under the medical plan, submit the claim for processing using the same procedures for submitting a medical claim.
Procedure for submitting Dental Claims:
There are two ways for a member to submit dental claims:
- When a member visits a dental care provider, the provider will make a copy of the back of the ID card.
- In almost all instances, your dental provider will bill Trustmark directly for dental services and supplies you receive. The member's claim will either be electronically filed or mailed by the provider to the dental claim address on the back of the ID card for processing.
Explanation of Benefits
- In the event the provider does not send a dental claim to Trustmark, the member should submit the claim by using a Dental Claim form. These are available within your Group Administration Kit or can be found by visiting us online.
A Dental claim form is not required in order to submit a claim, but it does assist in the claim paying process.
- The member should fill out the information on the Dental Claim form.
- The member should enclose all itemized dental bills and mail along with the dental claim form to the address listed on the back of the ID card.
Once a claim is processed, an Explanation of Benefits (EOB) will be sent to the member. EOBs are used to convey the details of how benefits are paid and to request information on a claim that remains pending. The EOB includes information important for the member to read and review so they can understand the specifics of their claim payment.
Refer to the Group Benefits marketing piece entitled: How to Interpret the Explanation of Benefits
. This marketing piece presents a sample EOB and provides a detailed explanation of how to read and understand the EOB.