How to submit an Extended Health Claim

If your policy has a pay direct drug plan, these claims will be electronically adjudicated right at your pharmacy, and the employee will be responsible to pay any outstanding amount. However, some extended health plans require Employees to complete a form and submit directly to the insurance carrier.

Employees can coordinate benefits with their Spouse. Both must be covered under an employer’s health plan and at least one (Employee or Spouse) must have couple or family coverage.

  • An Employee can never receive a refund of more than 100% of eligible expenses.
  • Employees must submit claims for their expenses to their benefits program first. If the refund is less than 100% of costs, the Employee can then submit a claim for the difference to their Spouse’s plan.
  • The Spouse must always submit claims for expenses incurred for himself or herself to his or her own plan first. If the Spouse’s refund is less than 100% of the expense, then the Spouse can submit a claim for the difference to the Employee’s benefits program.
  • Claims for dependent children must go first to the plan of the parent whose birthday comes first in the calendar year. If the parents have the same birthday, submit the child’s claims to the plan of the parent whose first name comes first in the alphabet. If the parents are separated or divorced, the child’s claim must go first to the plan of the parent who has custody of the child.

 

Typically dentists can submit a dental claim electronically directly to the insurer. If not, the Employee can mail the claim form to the insurer for reimbursement of costs as per the group policy.

Employees can coordinate benefits with their Spouse. Both must be covered under their employer’s dental plan and at least one (Employee or Spouse) must have couple or family coverage.

  • An Employee can never receive a refund of more than 100% of eligible expenses.
  • Employees must submit claims for their expenses to their benefits program first. If the refund is less than 100% of costs, the Employee can then submit a claim for the difference to their Spouse’s plan.
  • The Spouse must always submit claims for expenses incurred for himself or herself to his or her own plan first. If the Spouse’s refund is less than 100% of the expense, then the Spouse can submit a claim for the difference to the Employee’s benefits program.
  • Claims for dependent children must go first to the plan of the parent whose birthday comes first in the calendar year. If the parents have the same birthday, submit the child’s claims to the plan of the parent whose first name comes first in the alphabet. If the parents are separated or divorced, the child’s claim must go first to the plan of the parent who has custody of the child.

An HSA is a type of flexible spending account, an individual employee account funded by employer contributions to provide reimbursement for a wide range of health-related expenses for themselves and their dependents. An HSA may be over and above, or in place of a group extended health and/or dental plan.

Submission Deadlines:

  • Deadlines will vary depending on the time period chosen of 30, 60 or 90 days after the end of the HSA plan year.
  • HSA amounts are credited to the employee’s HSA account periodically as directed by the plan. Some plans credit amounts monthly and others credit them once per year.

Employees must complete an Emergency Out-of-Province Claim form and forward to the insurance carrier with attached itemized bills outlining the services for which charges were incurred.

The Insurer will coordinate the claim with the applicable provincial health plan directly.

  • Ensure that claims are made promptly as the MSP claiming deadline is 90 days from the date of service (other provincial health plans may have alternate deadlines).
  • Employees must sign the Members Statement and Patient’s/Guardian’s Authorization for Release of Information in the space provided regardless of whether the Employee incurred the expense.
  • If the Spouse incurred the expense and is claiming under the Employee’s plan as per Coordination of Benefits guidelines, both the Employee and Spouse must sign in the spaces provided.
  • If the Employee incurred the expense, they must sign both spaces “Member’s signature” and “Patient’s signature or parent/guardian if patient is a minor”.

Please contact Johnstone’s Benefits directly if an employee incurs a Life, AD&D or Critical Illness claim.

Please contact Johnstone’s Benefits directly if an employee incurs a Short Term (WI/STD) or Long Term (LTD) disability claim.

Tips for Claim Forms

Click on the type of form title to expand the section.

Then, select the appropriate form to link to the actual electronic form or the forms directory on the insurer’s website.

Each form will have specific instructions on how to complete the claim form.

Contact Johnstone’s Benefits if you require further information or guidance, if you are unable to access the required form, or if the desired form is not listed.