ASEA AFSCME Local 52 Health Benefits Trust is in Alaska

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linkavailable These forms can be completed and processed online as long as you are registered and have logged on to the site.

  • If you are not registered, click on “Not Registered” at the top of the page and follow the registration instructions.
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  • Once you are logged in, the form will prefill with your personal information on file (i.e. name, Health Plan ID, etc.)
  • Complete the form online, attach any required document(s) and submit for processing.

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  • Download the form.
  • You can then print and fax or mail it to the ASEA Health Trust Administrator for processing.
Form Description Process Online Display
Request for Reimbursement-Medical/Dental Benefits If the provider does not bill directly, complete a Request for Reimbursement-Medical/Dental Benefits form, attach an itemized bill (super bill). Make sure your claim is submitted within 90 days after treatment began, or within 30 days after treatment ends, whichever is later.

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Explanation of Accident/Injury Use this form, as directed by the ASEA Health Trust Administrator, to describe the details relating to an accident or injury for which benefit claims have been submitted.

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Authorization to Release Protected Health Information When you sign and submit this form, you authorize the Trust to release your protected health information to the individual(s) you designate.   linkavailable
Incentive Request The Trust will pay an incentive to participants who live in the Mat-Su Borough and choose to receive treatment at Alaska Regional Hospital instead of Mat-Su Regional Medical Center. You must complete an Incentive Request form and submit it within 365 days of the date of service. The incentive amount is 10% of the amount the Trust pays Alaska Regional Hospital, up to $500 for outpatient services and $1,000 for inpatient services.   linkavailable
Medical PreTreatment Estimate This form may be useful to help you determine the costs of an upcoming treatment or procedure. After your provider completes this form, the Health Trust Administrator can help you determine what coverage will be provided, and what your out-of-pocket costs may be.   linkavailable
Other Coverage Statement Use this form when a qualified beneficiary becomes covered under another group health plan, becomes entitled to Medicare, or is determined to be no longer disabled.

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Travel PreAuthorization Travel benefits must be preauthorized to be eligible for reimbursement. Submit this form to the claims administration office before you travel.   linkavailable
VSP Out-Of-Network Reimbursement Use this form to submit claims for vision care reimbursement when the care was received by a provider outside the VSP network.   linkavailable
Aetna Provider Nomination Form Use this form to nominate a health care provider to Aetna’s PPO network. It does not guarantee a provider’s participation. Providers must successfully complete Aetna’s credentialing process and sign an agreement (a contract) before becoming part of the Aetna network.   linkavailable
Patient Auditor Program Form This program allows you to share in the savings if you find an error on your health care provider’s bill. If the error is greater than $100 on a single bill, you would be eligible for one-half of the total savings up to a maximum of $400.   linkavailable

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