Here is a list of frequently asked questions by benefit type. If your question is not addressed here, contact the Administrative Office at 714-898-2200 or 1-800-499-8121.
FAQs For Active Employees
Why is it necessary to provide a statement about accident details when the accident was not work related?
Although the services may not be work related, there are still other instances where there is a “Third Party Liability (TPL)”. Some examples are automobile accidents, slip and falls, etc. If services are not a result of a TPL, simply provide the details on the questionnaire, sign, date and return it to the Trust Fund office. This information cannot be taken over the phone through the Customer Service line.
If services are a result of a TPL and benefits are payable, the Fund, as a condition for furnishing benefits, requires a statement acknowledging that reimbursement is due to the Fund for monies collected.
Why do you delay claims asking if my dependents have other insurance coverage? Why can't this be handled during open enrollment?
Each year, questionnaires are sent when the first claim is filed. Although your dependent did not have other coverage in the past, it is still necessary to document the file for the current claim year. Obtaining this information during the open enrollment period may not be applicable to the period when the charges are incurred.
If there is other insurance coverage for your dependent children, the Fund uses the “Birthday Rule” for the coordination of benefits. This means the plan of the parent whose birthday falls earlier in the calendar year (regardless of birth year) will be primary.
How long do newly eligible people have to stay in the HMO and prepaid dental plan?
You will be able to make different plan selections during the first open enrollment (held in November) after your benefits start, for coverage starting the January 1 after that open enrollment.
How can I find out whether I live in an HMO’s or prepaid dental plan’s service area?
Service areas are determined by zip code. You can get a list of HMO service area zip codes from the Administrative Office.
FAQs For Retirees
How can I find out what doctors and dentists are in the networks?
The Administrative Office can provide you with copies of the most recent provider directories free of charge. You can also visit the websites shown in the Resources section.
What if I’m eligible for Medicare but my spouse isn’t?
In that case, your spouse will be enrolled in the closest counterpart for participants not eligible for Medicare (for example, the Kaiser HMO if you enroll in Kaiser Senior Advantage, the PacifiCare (UHC) HMO if you enroll in PacifiCare Secure Horizons). You and your spouse can choose either the high or the low option under your program.
Can I enroll myself in Kaiser and my spouse in Blue Shield?
No, you must either both be in Kaiser or both be in Blue Shield.
If I decide to get dental care through my HMO, can I enroll my spouse separately in United Concordia?
No, you may enroll your spouse in United Concordia only if you enroll yourself.