Services requiring Pre-Certification include:
Inpatient admissions, outpatient surgeries, rehabilitative physical therapy, occupational therapy, speech and language therapy, CAT Scans and MRIs.
All of the above services must be pre-certified in advance by calling (866) 832-1410.
For Procedures, Durable Medical Equipment, Devices and Other Services, please complete the online Prior Approval Form and fax to 440-249-4251 along with documentation of medical necessity for the procedure.
This form may be mailed to the following address:
1900 Crocker Road #560
Westlake, OH 44145
The patient, physician, or hospital must telephone at least 3 business days prior to the planned admission.
If you do not secure Pre-Certification for the above mentioned services, your covered medical expenses will be subject to an out-of-network penalty.
Pre-certification does not guarantee the payment of benefits. Each claim is subject to medical plan review in accordance with the exclusions and limitations contained in the Plan, as well as a review of eligibility, adherence to notification guidelines, and coverage under the Student Health Plan.
If you do not secure Pre-certification for non-emergency inpatient admissions or provide notification for emergency admissions, your covered medical expenses will be subject to an out-of-network penalty.
Notification of Emergency Admissions
The patient, patient’s representative, physician, or hospital must telephone SEBT at 440-249-4251 within 1 business day following admission.
Pre-Certification simply means calling SEBT prior to treatment to obtain approval for a medical procedure or service.
Pre-Certification may be done by you, your doctor, a hospital administrator, or one of your relatives.
How To File A Claim
Benefits under this Plan shall be paid only if the Plan Administrator decides in its discretion that a Covered Person is entitled to them. When a Covered Person has a Claim to submit for payment that person must:
(1) Complete a claim form.
(2) Complete the Student portion of the form.
(3) For Plan reimbursements, attach bills for services rendered.
(4) If you don't have a copy of the bills to attach with the claim form, then you will need to have the Physician complete the provider's portion of the form.
(5) Send the above to the Claims Administrator at this address:
CareFirst Providers Submit Electronically To:
Payer EDI #: Prof 580/Inst 190
Or mail claims and correspondence to:
PO Box 981610
El Paso, Texas 79998
Please review the Pre-Certification Requirement for prior claims approval on in-patient hospital admissions, surgery, physical therapy, CAT Scans, MRIs, High-Cost Procedures, Durable Medical Equipment and Other Devices.
When Claims Should Be Filed
Claims should be filed with the Claims Administrator within 180 days of the date charges for the service were incurred. Benefits are based on the Plan's provisions at the time the charges were incurred. Claims filed later than that date may be declined or reduced unless:
(a) it's not reasonably possible to submit the claim in that time; and
(b) the claim is submitted within one year from the date incurred. This one year period will not apply when the person is not legally capable of submitting the claim.
The Claims Administrator will determine if enough information has been submitted to enable proper consideration of the claim. If not, more information may be requested from the claimant. The Plan reserves the right to have a Plan Participant seek a second medical opinion.
Student Educational Benefit Trust (SEBT)
For coverage and claim questions, call (866) 662-4097
Email us at firstname.lastname@example.org
STUDENT HEALTH PLAN
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