Section 6: > Claims And Appeals Rules > Filing Claims In General
Filing Claims In General
How claims are processed depends on the type of claim. Who processes the claim
also depends on the type of claim.
Certain claims must be submitted to the applicable third-party claims administrator.
All other claims must be submitted to the Administrative Office. Each third-party
administrator, as well as the Administrative Office, is referred to as a "Claims
Administrator." This chart illustrates the Claims Administrator for each plan:
| Medical claims |
Administrative Office |
| Dental claims |
DeltaDental (PPO) or DeltaCare/PMI (DHMO) |
| Prescription Drug claims |
Outside Claims Administrator |
| Mental Health and Substance Abuse claims |
PacifiCare Behavioral Health (PBH) |
| Life and AD&D claims |
Administrative Office |
Generally, if you receive services from a network provider, the provider will
submit the claim to the applicable Claims Administrator directly. If you receive
services from a non-network provider, you or your provider will submit the claim
to the applicable Claims Administrator.
You may designate an authorized representative for assistance with respect to
your claim for benefits. For more information, contact the Claims Administrator.
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