Why is my claim pending? 
Claims are usually pended for more information from either you or your patient. 

• Patients – information is usually needed if their care is for an accident that may have been caused at work, or may need to be subrogated.  To print the accident form, click here.  Information may also be needed if patients have other insurance. 
• Providers – claims may be held when the diagnosis/information on the claim appears to show an injury that could be work related, due to a MVA, or caused/from a third party. In these cases, in order not to delay processing of the claim, it is important to send in any relevant information regarding the claim – such as the chart notes or injury forms.

Once the needed information is provided, the claim is processed.  If the information is not received within 45 days, the claim is denied, and will be reopened when the information is received. 

My patient needs surgery scheduled beyond the eligibility period shown on the website.  How can I verify a patients’ future eligibility?
Hours are reported by employers each month, and the Fund updates eligibility in 2-month periods.  You can schedule the surgery, then re-check eligibility closer to the surgery date. 

My patients ask me if their prescription is available at the Culinary Free Pharmacy?
Only certain drugs are available at the Culinary Free Pharmacy.  These drugs are available to your Culinary patients for free.  That’s right, no copay for your Culinary patients.  Click here to print the Culinary “Free Drug List”.

How do I know if you received the claim(s) I submitted, or when you received it?
First, you can check the website.  If it is not listed there, you can call customer service. 

My patients have two insurances, why did Culinary did not pay anything on this claim?
Culinary coordinates benefits – if we are secondary, and the primary payor already paid more than our allowable, the Fund considers it paid, since you have already been paid at least what you would have received from the Fund if we were the only payor.  If you are paid less than our allowable by the primary payor, the Fund will pay the difference. 

May I bill the patient for primary’s copay, deductible, or coinsurance if the Fund pay zero? 
Yes, you may bill the member for the co-pays, deductibles; and co-insurance when Culinary does not pay anything as secondary.

Does the Fund pay for childhood vaccinations?

• We pay for vaccine serum for hepatitis A and Prevnar – these are not provided by the State of Nevada. 
• Other serums are provided by the State of Nevada, so we currently do not pay for these serums. 
• We pay an administrative fee for immunizations to ensure children receive their vaccinations.

What is the mammogram age limits?
Baseline Mammograms - are covered only once between the ages of 35-39 and every 12 months after the age of 40.  Please make sure you provide screenings on time to ensure claims are paid. 

What are the limits and timelines for adults and children Well Care? 

• Adults – one preventive routine physical exam is covered every 12 month period. 
• Children – exams are covered in accordance with the guidelines of the American Academy of Pediatrics

How long does it take to process a claim?

• New Claims – standard filing period is 12 months unless contract notes otherwise. 
• Corrected Claims – must note on claim “CORRECTED CLAIM” or it will deny as a duplicate
• “Clean” claims  - those that have all the information needed to process the claim - are processed within 30 working days of receipt (equals 45 calendar days)
• Claims requiring additional information are pended for 45 days and a letter sent to the provider/member for the necessary information.  If the information is not received within the 45 days, the claim is closed.

How does Culinary pay a work related claim?

• Any work related claims must be denied by workers comp before Culinary will consider payment.
• If claim was denied by workers comp, all we need is a copy of the denial letter for claim to be considered for payment.
• If the patient never reported the injury to their employer and it is work related, the claim will be denied by Culinary.

What should my patient do if they become totally disabled?

• Culinary offers extended eligibility benefits for employees who become temporarily OR permanently TOTALLY disabled.
• The employee is credited with 112 hours for each month of disability (this is called disability credits), beginning on the 61st day of continuous disability. These credits replace work hours to keep them eligible for benefits up to a maximum of 24 months. 
• An "Extended Eligibility" application must be completed by the employee, the employer, and the doctor disabling the employee. All must complete this application correctly to avoid any delays in extending current eligibility.
• In order for the employee to qualify:
  • The physician and employer must certify that they are temporarily OR permanently TOTALLY disabled ( If temporarily totally disabled, please indicate expected time frame of disability, such as weeks, months, etc.) and
  • The first 60-days of disability must be paid by the employer or the employee.
• This benefit does NOT entitle an employee to any type of income and Culinary doe s not offer any long-term financial disability benefits. Considering this, completing these forms at minimal or no cost at all is a big financial help for the patient.

What happens if my patient becomes disabled and unable to perform their regular job duties?

• Culinary offers Weekly Loss of Time benefits for employees who become disabled while employed and are prevented by such disability from performing their regular job duties.
• Documentation of disability is required from the physician and employer before benefits are paid.
• This benefit is only available to the employee.
• The amount of weekly benefit is $150.00 (less FICA taxes).
• The maximum benefit per period of disability is 13 weeks.
• Benefits start on the 1st day for disability due to accident or injury and on the 8th day of disability due to an illness.
• To expedite the processing of this benefit it is important that all questions on the form are answered including, the date disability began and the expected return to work date (not time frame.
• This is a short-term benefit only therefore, completing these forms at minimal or no cost at all is a big financial help for the patient.