Claim Process

1. Timing of Claims Submission. Bills or invoices for Covered Services, and requests for reimbursement for payments made directly by a Group Member for such Covered Services, must be forwarded to Primary Health within twelve (12) months from the date of service for which charges were incurred. (See Section II.A.9., "How to Submit a Claim for Benefits").
2. Proof of Payment For Services Directly Paid By The Group Member. Proof of payment for Out-of-Network Services paid by a Group Member will be required for reimbursement. Failure to provide proof of payment within the required time shall not invalidate or reduce any Claim if it was not reasonably possible to provide such proof within the time required.
3. Additional Records. Primary Health may require Group Member to provide additional medical and other documentation to substantiate that the services rendered were Covered Services before paying providers or reimbursing the Group Member.

Recovery of Overpayment

If the payments by Primary Health for Covered Services provided under the Plan plus the coverage provided by the other Payors exceed the total amount of benefits which should have been paid under this Section, Primary Health has the right to recover the amount of that excess payment if it is the Secondary Plan, from any:

• person to whom such payments were made; or
• other Payors; or
• any other entity to which such payments were made.

How to Submit a Claim For Benefits

1. In the event a non-Participating Provider does not bill Primary Health directly and the Group Member is required to pay for part or all of the care, it will be necessary for the Group Member to submit a claim to Primary Health as outlined directly below.
2. To submit a claim for Benefits, a Group Member should obtain an itemized statement or bill from the Provider who furnished the health care services.
3. Write Group Member number on the itemized statement or bill if the information does not already appear.
4. Make a photocopy of the itemized statement or bill for your records.
5. If Emergency services are received outside the United States, Group Members are required to provide Primary Health with an itemized copy of the paid bill. The bill and other relevant information must be submitted with English translation and charges converted to U.S. currency.
6. Send the original itemized statement or bill to:
   
   Primary Health Network, Inc.
   Attn: Claims Department
   Box 5679
   Boise, ID 83705
   

In no event shall Primary Health pay Claims or reimbursement requests that are reported more than twelve (12) months following the date of service.

If a Group Member has any questions concerning this procedure or the status of a claim, he/she may call Primary Health�s Customer Service Department.