Claims and Providers Q&A

This information is intended to provide general guidance for members’ common questions about MUST. The Summary Plan Description document, related amendments, and Schedule of Medical Benefits supersede this general information for specific eligibility and benefit questions.

1. Who processes my claims?
MUST claims are administered by First Choice Health in Seattle, WA.

2. Do I have to submit my own medical claims?
Most medical providers will submit claims for you. However, if the provider requires you to submit your own claim, his or her office should supply you with a copy of an itemized bill which can be submitted to the claims office. All of the following information is required:

The date of service
The participant’s name
The name and birth date of the patient receiving the treatment or service and his/her relationship to the participant
The diagnosis code of the condition being treated
The code for the treatment or service performed
The amount charged by the provider for the treatment or service
Notes or documentation supporting the medical necessity of the treatment or service.

The address for submitting medical claims is:

First Choice Health
P.O. Box 12659
Seattle, WA 98111-4659

Generally, claims must be submitted to MUST within 12 months after the date of service. However, if the employer group has terminated its MUST coverage, claims must be submitted within three months of the termination date.

3. Can I view my claims information online?
Yes. On the MUST home page, look in the "Quick Links" box for a link to the Claims Web site. You will need a password to access your information. If you have never accessed the Claims Web site, click the Register New User icon on the login page.

Participants can review information about their own claims, deductible information, etc., as well as for covered dependents under age 18. Spouses and dependents age 18 and older must obtain their own password.

4. What number should I call if I have a question about a claim?
Call the Claims Administration office (First Choice Health) at 1-877-714-5556.

5. I called the Claims Administration office, but I need additional help understanding how my claim was processed. What should I do?
Call the Customer Service representatives in the MUST Administration office (1-800-845-7283) or call the MUST marketing representative in your region (click here for their names and numbers). They are happy to help you understand your benefits or to help explore any claims questions you may have.

6. How do I appeal a claim determination?
If a claim is denied in whole or in part, the participant will receive a claim Explanation of Benefits (EOB) form showing the reason for denial. If the participant does not understand the reason for the denial and wishes to appeal the decision, he/she must submit a written request to the address below within 180 days of the denial:

First Choice Health Administrators
Attn: Appeals Specialist
600 University Street, Suite 1400
Seattle, WA 98101

The MUST Plan Supervisor will research the information initially received and determine if the initial determination was appropriate based on the terms and conditions of the MUST plan and other relevant information. Notice of the decision will be sent to the participant within 60 days after receiving the request. If the denial is upheld, the participant may request a second review. Refer to the Summary Plan Description for more details.

7. Can I see any doctor I want?
You can see any licensed provider you wish. However, it is to your advantage to use providers who are network members, because claims payment is based on the reduced rates negotiated with the networks. If your provider happens to be out-of-network, he/she is not obligated to accept the amount that MUST will pay for a given service and may “balance-bill” you for any charge exceeding this amount (although this is rare).

To prevent this, MUST and First Choice Health offer a Preferred Provider Network arrangement with Health InfoNet in MT, ND, SD, & CO; First Choice Health Network for WA, OR, ID & AK; and First Health for the rest of the United States.

More information is available using the "Providers" button on the main menu or you can call 1-877-714-5556 for assistance with questions about providers and networks.

8. Can I see providers outside the U.S.?
If you plan to travel outside the U.S., contact the Claims Administration office before you leave. A staff member will provide a letter that outlines the requirements for submitting and processing foreign claims (see sample letter). It is likely that you will need to pay for services at the time they are rendered and submit the claim yourself to MUST for review.

9. What does MEE stand for?
This stands for “Maximum Eligible Expense." When you obtain services from an out-of-network provider, MUST pays claims according to established MEE allowable charges. See the Providers section of this Web site for more information.

10. My claim for a preventive visit was not processed correctly. Why?
The most common reason is that the provider’s office did not code it as a preventive visit, which means it was paid according to the medical portion of your benefit rather than the preventive benefit. You should ask your provider whether the claim will be submitted using a preventive code. However, keep in mind that the appropriate coding is your provider’s decision, based on your health status, prior test results, and other factors.

If the service was submitted with a preventive code but it was denied, it may have exceeded the limits of the plan’s preventive benefit, such as receiving the same test twice within the same benefit period. Call the Claims Administration office at 1-877-714-5556 if you have questions.

11. Does MUST reimburse for mileage to my healthcare provider?
No. Travel expenses are specifically excluded under the plan.

12. I have other coverage in addition to MUST. How does MUST determine which plan pays first?
If you are enrolled in MUST as the participant, then that plan is primary (i.e., it pays first). If you are enrolled in another plan as a spouse or dependent, that plan is secondary. When dependent children are covered by their parents under two plans, the primary plan is determined by the parent whose birthday occurs first in the year. Other factors may come into play for dependents; see the Summary Plan Description document under “Coordination of Benefits.”

13. How do I read my Explanation of Benefits (EOB)?
This example should answer all of your questions. If it does not, please call MUST customer service at 1-800-845-7283.