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. Information may also be needed if patients have other health 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 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 is denied and will be reopened when all of the information is received.

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

Hours are reported by employers each month, and the Culinary Health Fund updates eligibility in 2-month periods.
You can schedule the surgery and then re-check the patient’s eligibility closer to the surgery date.

What prescription drugs are available at the Culinary Pharmacy?

Only certain drugs are available at the Culinary Pharmacy. These drugs are available to your Culinary Health Fund patients for free. That’s right, no copay for your Culinary Health Fund patients. Culinary Pharmacy Booklet

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

You can check on the website by clicking here, or you can call the Customer Service Office at 702-733-9938.

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 already paid more than
our allowable, we consider it 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 by the primary payor, we will pay the patient’s liability, up
to our allowable.

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

Yes, you may bill the patient for the co-pays, deductibles; and co-insurance when the Culinary Health Fund does not
pay anything as secondary.

What is age limit for mammograms?

Baseline Mammograms are covered 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 the claims are paid correctly.

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 – 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.

What should my patient do if they become totally disabled?

The Culinary Health Fund offers extended eligibility benefits for employees who become temporarily OR permanently totally disabled. The employee is credited with 120 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 the Culinary Health Fund does 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?

  • The Culinary Health Fund 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.