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SECTION 7 - HOW TO FILE A CLAIM

What this section includes:

· Claims mailing address
· How are Covered Health Care Services from a Network Provider Paid?
· How are Covered Health Care Services from an Out-of-Network Provider Paid?
· Notice of claim
· Claim forms
· Proof of loss
· Payment of claim
· Time of payment of claim
· Assignment of benefits

Claims Mailing Address
All Savers
P.O. Box 31375
Salt Lake City, UT 84131-0375

How Are Covered Health Care Services from Network Providers Paid?
We pay Network providers directly for your Covered Health Care Services. If a Network provider bills you for any
Covered Health Service, contact us. However, you are required to meet any applicable Annual Deductible and to
pay any required Copayments and Coinsurance to a Network provider.

Network providers must seek reimbursement from us and may charge you only for approved Copayments, Annual
Deductible, Coinsurance or non-Covered Health Care Services.
How Are Covered Health Care Services from an Out-of-Network Provider
Paid?

When you receive Covered Health Care Services from an out-of-Network provider, you or the out-of-Network
provider is responsible for requesting payment from us.

You or the out-of-Network provider should submit a request for payment of Benefits within 90 days after the date
of service. If you or the out-of-Network provider do not provide this information to us within 15 months of the date
of service, Benefits for that health service will be denied or reduced, as we determine. This time limit does not
apply if you are legally incapacitated or if extenuating circumstances apply. If your claim relates to an Inpatient
Stay, the date of service is the date your Inpatient Stay ends.
Notice of Claim

You must send us written notice of claim within 20 days from the date when you incur a claim. Failure to give
notice within the 20 days does not invalidate or reduce a claim, if you can show us that it was not reasonably
possible to give notice in that time, and you gave notice when reasonably possible.
We require the notice to include your name and address and the name of the person who incurred the claim.

Claim Forms

We do not require claim forms for medical coverage. However, we may require claim forms for other types of
insurance. We will provide you with any claim form we require within 15 days from the date we receive notice of
claim. If we do not provide a form in that time, you can meet the proof of loss requirement by sending us facts
about the nature and extent of the claim.

Proof of Loss

We require written proof of loss. A written proof of loss is a bill from a health care provider. We must receive the
proof within 90 days from the date of loss.

Failure to send the proof of loss to us in that time does not invalidate or reduce a claim if you can show us that it
was not reasonably possible to send us proof of loss in that time, and you sent it when reasonably possible.

Page 44 Section 7- How To File A Claim
PPO - 2017