Title
Case #03-18 Claims Reimbursement without Explanation of Benefits
Report
Issue:
The board must decide whether or not to approve reimbursement for orthotics in the amount of $85, without submission of an explanation of benefits. Additionally, the board must decide whether or not to change the LEOFF 1 Policies and Procedures language to waive the explanation of benefits requirement.
Staff Contact:
Carl Watts, Personnel Analyst, General Government/Human Resources, 360.753.8305
Background:
A LEOFF 1 fire member submitted a claim for reimbursement without providing an Explanation of Benefits (EOB), which is required according to the LEOFF 1 Policies and Procedures guidelines outlined below. The member asked the board to review and consider changing the policies and procedures and not require members to submit EOB's for claims. The member has now provided written documentation indicating orthotics are not covered for LEOFF 1 fire members by both Medicare and United American.
According to the current RCW 41.26.150 and LEOFF 1 Policies and Procedures, Section III, Procedures to receive benefits, subsection J, paragraph 5, LEOFF 1 claims reimbursements are offset by any reduced amount received through insurance or other sources first and members must submit an EOB indicating the amount paid by insurance if any or if there is denial of coverage.
The LEOFF board must determine whether or not to pay reimbursement for orthotics in the amount of $85 and whether or not to revise the Policies and Procedures language to add the following language:
"Staff may process reimbursements for claims without an explanation of benefits (EOB) as long as the member provides written substantiation that a prescribed treatment or medical item is not covered under the member's current insurance plans".
Attachments:
Application for payment, Medicare policy, email from NWFFT, and RCW 41.26.150
Reference:
LEOFF Disability Board Policies and Procedures (2009) Medical Servi...
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