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Depending on the type of claim you have (death or dismemberment, medical, dental, vision, etc.), there are different requirements for filing a claim. This section provides more detail regarding how to file a claim.

If you need copies of your claim for your records, you should make them before submitting your claim. The Fund Office does not provide copying services. You are responsible for maintaining your own records. The following claim forms can be downloaded below.

Death Benefit or Accidental Death and Dismemberment Benefit Claims

To receive the Death Benefit or Accidental Death and Dismemberment Benefits, you or your Beneficiary must contact the Fund Office and follow the claim procedures in effect at the time of your claim. No claim form is required, but for:

  • Death Benefits, your Beneficiary must submit a death certificate; and 
     
  • Dismemberment Benefits, you must submit a letter from your Doctor.  

You must submit the required information within two years of the date of death or date of loss. 

Death Benefit or Accidental Death and Dismemberment Benefit Claims

To receive the Death Benefit or Accidental Death and Dismemberment Benefits, you or your Beneficiary must contact the Fund Office and follow the claim procedures in effect at the time of your claim. No claim form is required, but for:

  • Death Benefits, your Beneficiary must submit a death certificate; and
     
  • Dismemberment Benefits, you must submit a letter from your Doctor.  

You must submit the required information within two years of the date of death or date of loss.

The Fund will notify you of its decision on your claim within 60 days of the date it receives your claim. This timeframe may be extended if the Fund Office needs additional information to process your claim. In that case, the Fund Office will notify you of the additional information that is needed and you will be given 45 days to provide the information. If you do not provide the information, the Fund Office will decide your claim on the basis of the information that has been provided and your claim may be denied.

If the claim is approved, the Fund Office will send a check in the applicable amount to you or to your Beneficiary.

Prescription Drug Benefits Claims

The Prescription Drug Benefits cover your short-term prescription needs through a Retail Pharmacy Network and long-term prescription needs through a Mail Order Prescription Drug Service.

Retail Pharmacy Network

The Retail Pharmacy Network is offered through OptumRx. If an acute medication (immediate treatment) has been prescribed for you, you should have the prescription filled at a participating network pharmacy.  You must present the Prescription Drug card or other form of identification to the pharmacist and pay the applicable co-payment and deductible to the pharmacy.  You will receive the prescription and no paperwork will be required.  OptumRx will pay the balance of the cost of the prescription directly to the pharmacy.

If you do not use a participating network pharmacy, you are responsible to pay the entire cost of the prescription. You must complete a claim form and submit it to OptumRx in order to be reimbursed for covered Prescription Drugs obtained through a non-network pharmacy. Your reimbursement will be equal to the amount the Fund would have been charged for the prescription by the network pharmacy at the negotiated pharmacy rate, less the co-payment and deductible (if applicable).

The claim form should be sent to:

OptumRx
Direct Member Reimbursement
P.O. Box 968022
Schaumburg, Illinois 60196-8022

You may obtain an OptumRx Claim Form by contacting OptumRx at 1-800-880-1188, visiting their website at www.optum.com/optumrx.html,or by contacting the Fund Office.

Mail Order Prescription Drug Service

The mail order Prescription Drug service is administered by OptumRx.  If a maintenance medication (long-term treatment) has been prescribed for you, you should have the prescription filled through the mail order program. To order a prescription from the OptumRx Mail Order Prescription Drug Service, complete an OptumRx  mail order form, enclose the prescription prepared by your Doctor, and send it to OptumRx. See Mail Order Prescription Drug Service for more  information about the mail order prescription drug service administered by OptumRx.

Wellness Expense Benefit Claims

To receive the Wellness Expense Benefit, your Physician must submit a claim to Blue Cross Blue Shield of Illinois with a diagnosis code indicating the need for a general or routine physical exam and related expenses including certain diagnostic testing covered by the Plan.

If you are Medicare eligible you must submit the following information to the Fund Office in order to obtain benefits under the Wellness Expense Benefit, if available:

  • A completed Major Medical Claim Form, with Wellness Benefit indicated in Section #5,
     
  • An itemized bill on which your Physician or Provider has used a diagnosis code that qualifies for reimbursement under the Fund,
     
  • The matching Medicare Summary Notice (MSN, or Medicare explanation of benefits),
     
  • The matching Explanation of Benefits (EOB) from the SMW+ Plan.

If Medicare denied the charge because it is a non-covered wellness claim, you do not need to submit the bill to SMW+. If Medicare has denied the charge, you must submit only the claim form, itemized bill, and the matching Medicare Summary Notice (MSN, or Medicare explanation of benefits) to the Fund Office.

Dental Benefit Claims

If you go to a Delta Dental participating Dentist, the Dentist will submit a claim form directly to Delta Dental and you will only be responsible for any deductibles, copayments, and non-covered charges. If you go to a non-participating Dentist, you may be required to pay the Dentist his or her fees, and then file a claim with Delta Dental for reimbursement under the Dental Plan. You must include any information or proof necessary to process the claim.

Contact Delta Dental for the appropriate dental claim form. Complete the section of the claim form Member information.

You must complete a separate claim form for each member of your family who is filing for benefits – even if two people are filing for the same type of benefits. In addition, you must complete and file a new claim form each and every time a non-network claim is submitted. Be sure to give all information requested on the form and check all appropriate boxes. Delta Dental does not require their own claim form; the standard ADA (American Dental Association) claim form is acceptable.

Optical Expense Benefit Claims

To receive the Optical Expense Benefit, you do not have to submit a vision claim form, but you will be required to pay the EyeMed Provider for any cost over your maximum when you pick up your glasses or contact lenses. Contact EyeMed for details at 1-866-723-0514 or access the web site at www.eyemedvisioncare.com. If you use an out-of-network Provider, you are required to pay the entire cost up-front to the Provider. You must submit a vision claim form to Eyemed. EyeMed will process the claim and remit payment, up to the applicable maximum, directly to you.

Hearing Aid Expense Benefit Claims

To receive the Hearing Aid Expense Benefit, you must file a claim form with the Fund Office. If you use  an Amplifon Hearing Health Care Provider, your Provider will file your claim for you. If you need a claim form, contact the Fund Office for the appropriate claim form. Complete the claim form section entitled This Part of Form to be Completed by Member.

You must complete and file a separate claim form for each member of your family who is filing for benefits – even if two people are filing for the same type of benefits. In addition, you must complete and file a new claim form each and every time a claim is submitted. Be sure to give all information requested on the form and check all appropriate boxes.

You must send an itemized bill with your claim or any information or proof requested that is reasonably required to process such claims. You must pay the bill in full before the Fund will reimburse you for the Hearing Aid Expense Benefit. Have your doctor or audiologist complete the appropriate portion of the claim form and return the completed claim form to the Fund Office. Once approved, a check for the appropriate amount will be forwarded to you.