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Questions and answers

Your questions are important to us. We want to ensure you have the information you need to provide care to our participants. These are the answers to some of the most common questions we get from providers.

If your question isn’t answered here, please call our Provider Services department at 702-892-7313.

Benefits and coverage

My patient needs surgery scheduled beyond the eligibility period shown on the website. How can I verify a patient’s future eligibility?

We update our participants’ eligibility in 2-month increments. Please schedule the surgery, and then re-check the patient’s eligibility closer to the surgery date.

What prescription drugs are available at the Culinary Pharmacies?

Your patients can get over 300 generic prescriptions for no copay at our Culinary Pharmacies.

When possible, please prescribe generic medications to help your patients get the medicine they need at the most affordable price.

What are the age limits for mammograms?

If your patients are 35 or older and have not had a mammogram in the past 11 months, they’re eligible for a mammogram. Patients can get their screening mammogram through an in-network free-standing radiology provider for no copay.

What if my patient becomes totally disabled?

The Culinary Health Fund offers extended eligibility benefits for patients who become temporarily or permanently totally disabled. This allows your patients who are disabled to keep their benefits for up to 24 months.

An Extended Eligibility applicationDownload PDF must be completed by the patient, their employer and you (if you’re the doctor disabling the patient). All three must complete this application correctly to avoid any delays in extending current eligibility.

Per our contract, do not charge patients to fill out extended eligibility forms.

In order for the patient to qualify:

  • The physician and employer must certify that the patient is temporarily or permanently totally disabled. (If temporarily totally disabled, please indicate expected time frame of disability, such as weeks, months, etc.)
  • The first 60-days of disability must be paid by the patient’s employer or the patient.
  • This benefit doesn’t entitle a patient any type of income.
  • The Culinary Health Fund doesn’t offer any long-term financial disability benefits.

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

The Culinary Health Fund offers Loss of Time benefits. This weekly benefit is for patients 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 (not dependents).
  • The amount of the weekly benefit is $150.00 (less FICA taxes).
  • The maximum benefit per period of disability is 13 weeks.
  • Benefits start on the:
    • 1st day of disability due to accident or injury
    • 8th day of disability due to an illness
  • To expedite the processing of this benefit, it is important that all of the questions on the Loss of time formDownload PDF are answered, including the date disability began and the expected return to work date (not the time frame).
  • This is a short-term benefit only.

Per our contract, do not charge patients to fill out loss of time forms.

Claims and billing

Why is my claim pending?

Claims are usually given pending status while we wait for more information from either you or your patient.

We may need more information from your patient if:

  • They were in an accident
  • They were hurt at work
  • They have other health insurance

We may need more information from you if it looks like the diagnosis/​information on the claim appears to show an injury that was work-related, caused by a motor vehicle accident, or caused by a third party.

In these cases, in order not to delay processing of the claim, it is important to send us any relevant information regarding the claim — such as the chart notes or injury forms.

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

How do I know if you received the claim(s) I submitted, or when you received it?

You can find out if a claim was received by:

My patient has two insurances, why did the Culinary Health Fund not pay anything on this claim?

The Culinary Health Fund coordinates benefits. If we are secondary, and the primary payor has already paid more than our allowable amount, we consider the claim paid, since you have already been paid at least what you would have received from the Culinary Health Fund if we were the only payor. If you are paid less than our allowable amount by the primary payor, we will pay the patient’s liability, up to our allowable.

May I bill the patient for the primary insurance copay, deductible, or coinsurance if the Culinary Health Fund pays zero?

Yes, you may bill the patient for the copays, deductibles, and co-insurance when the Culinary Health Fund doesn’t pay anything as secondary.

How long does it take to process a claim?

  • New claims: The standard filing period is 12 months unless the contract states otherwise.
  • Corrected claims: Must note on the claim “Corrected Claim” or it will be denied as a duplicate.
  • Clean claims: Those that have all the information needed to process the claim are processed within 30 business days of receipt (equal to 45 calendar days).
  • Claims requiring additional information: Claims are pended for 45 days and a letter is sent to the provider and/or patient for the necessary information. If the information is not received within the 45 days, the claim is closed.

How does the Culinary Health Fund pay a work-related claim?

Any work-related claims must be denied by Workers Compensation before the Culinary Health Fund will consider payment. If the claim was denied by Workers Compensation, all we need is a copy of the denial letter for the 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 the Culinary Health Fund.