- Claims Forms
- Other Forms
- Spanish Language Forms
Delta – Medical Reimbursement Form
- Anthem -
- Blue shield -
Member Reimbursement International Claim Form
- BlueCard -
Delta – Prescription Reimbursement Form
Delta – Dental Reimbursement Form
Delta – Vision Reimbursement Form
Flexible Spending Account (FSA)
Appeal for Benefits
Coordination of Benefits
Authorization for Disclosure of Health Information
Request to Access Protected Health Information
Third Party Liability (TPL) Questionaire
075076 Enrollment Form
Explanation of Benefits (EOB) Instructions
Continuity of Care Request Form
Medical Claim Form International: Formulario de Reclamo Medico Internacional
Member Claim Form: Formulario de Reclamo Medico
Drug Claim Form: Formulario de Reclamo de Medicmento (medication)
Dental Claim Form: Formulario de Reclamo de Dental
Vision Claim Form: Formulario de Reclamo de Vision
Coordination of Benefits (COB) Questionnaire: Cuestionaire de Coordination de Beneficios
Authorization for Disclosure of Health Information: Autorizacion Para la Revelacion de Informacion Medica
Request to Access Protected Health Information: Solicitud Para Acceder Informacion Medica Protegida
Third Party Liability (TPL) Questionnaire: Cuestionaire de Adeudo de Terceros
Explanation of Benefits Instructions: Instrucciones para su EOB
Workers Compensation Questionnaire: Cuestionario de Compensacion de Trabajadores
Continuity of Care Request Form: Continuidad de Atencion
United States Department of Labor
Glossary of Health Coverage and Medical Terms
- Mental Health Parity and Addiction Equity Act of 2008
- Patient Protection and Affordable Care Act
- genetic information non-discrimination act (GINA)
- newborns’ and mothers’ health protection act
- womens’ health and cancer rights act
- michelle’s law
- domestic partnership requirements in california
- children’s health insurance program reauthorization act
- SPD compliance issues (foreign language assistance & spd electronic distribution requirements)
- Your Rights and Protections Against Surprise Medical Bills
- Transparency in coverage
Mental Health Parity and Addiction Equity Act of 2008
Requires full parity between mental health/substance abuse benefits and medical/surgical benefits offered under a group health plan.
- Financial requirements and treatment exceptions
- Network requirements
- Cost sharing
- Medical necessity
Does not require plans to provide MH/SA benefits; applies to groups over 50.
Note: A health plan may opt-out if it meets the cost exemption in the Act and files necessary paperwork.
patient protection and affordable care act
Patient Protection and Affordable Care Act:
Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections
Interim final rules with request for comments.
genetic information non-discrimination act (GINA)
- Bans the use of genetic information for health insurance and employment purposes.
- Prohibits group health plans from discriminating on the basis of genetic information with respect to eligibility, premiums and contributions.
newborns’ and mothers’ health protection act
Medically necessary treatment and services for Pregnancy and Complications of Pregnancy are covered the same as any other illness for the employee and spouse only. In addition, the plan, in compliance with the Newborns’ and Mothers’ Health Protection Act of 1996, also provides that:
- Hospital stays will be covered for at least 48 hours following a normal vaginal delivery, or at least 96 hours following a Cesarean section,
- The attending physician does not need to obtain authorization from the plan to provide the mother and newborn with this length of hospital stay, and
- Shorter hospital stays are permitted if the attending health care provider, in consultation with the mother, determines that this is the best course of action.
womens’ health and cancer rights act
If you have had, or are going to have, a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and patient for:
- All stages of reconstruction of the breast on which a mastectomy has been performed,
- Surgery and reconstruction of the other breast to produce symmetrical appearance,
- Breast prostheses, and
- Treatment of physical complications of the mastectomy, including lymph edemas.
These benefits will be provided subject to the same deductible and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like additional information about WHCRA benefits, please contact the Human Resources Department.
Note: This benefit does not include any treatment or Surgery that is considered primarily cosmetic in nature. Breast implants are considered a Covered Expense only when following a Medically Necessary mastectomy. Breast reduction Surgery is not a Covered Expense.
Requires group health plans to continue coverage for dependent college students who take a medically necessary leave of absence for up to one year (without additional costs).
domestic partnership requirements in california
Currently, a couple that wishes to register must meet the following requirements:
- Both persons have a common residence.
- Neither person is married to someone else or is a member of another domestic partnership with someone else that has not been terminated, dissolved, or adjudged a nullity.
- The two persons are not related by blood in a way that would prevent them from being married to each other in California.
- Both persons are at least 18 years of age.
Either of the following:
- Both persons are members of the same sex.
- The partners are of the opposite sex, one or both of whom is above the age of 62, and one or both of whom meet specified eligibility requirements under the Social Security Act.
- Both persons are capable of consenting to the domestic partnership.
children’s health insurance program reauthorization act
Group health plans must permit employees and dependents who are “eligible but not enrolled for coverage” under an employer if:
- The employee’s or dependent’s Medicaid or CHIP coverage is terminated as a result of loss of eligibility, or
- The employee or dependent becomes eligible for a Medicaid or CHIP subsidy
Notice of the event is required within 60 days of special enrollment.
SPD compliance issues (foreign language assistance & spd electronic distribution requirements)
Foreign Language Assistance: Notice to Spanish Speaking Plan Participants
If a plan has participants who are literate only in a particular foreign language, the plan administrator may be required to provide a notice written in that language, along with the SPD, stating that assistance in understanding the SPD is available. (The employer need not provide an SPD written in that language.) The notice must include:
- The plan administrator’s phone number, and
- Information about where and when the assistance will be made available.
The foreign language requirement applies for plans with 100 or more participants if the lesser of 500 participants or 10% of the total number of participants are literate only in a particular language.
SAMPLE: This booklet contains a summary in English of your rights and benefits under the Plan. If you have difficulty understanding any part of this booklet, or if you have any questions regarding your benefits, rights or obligations under the Plan, please contact the Plan Sponsor and/or Contract Administrator at the following telephone numbers for assistance: List Employer and DHS’s Phone Numbers
SPD Electronic Distribution Requirements
Requirements for employees with work-related computer access:
Definition of work-related computer access: The employee has the ability to access documents at any location where they reasonably could be expected to perform employment duties. In addition, access to the employer’s electronic information system must be an integral part of their employment duties.
- Electronic materials must be prepared and delivered in accordance with otherwise applicable requirements (e.g., timing and format requirements for SPDs as outlined under ERISA.)
- A notice must be provided to each recipient, at the time that the electronic document is furnished, detailing the significance of the document.
- The notice must advise the participant of their rights to have the opportunity, at their work site, to access documents furnished electronically and to request and receive (free of charge) paper copies of any documents received electronically.
- The employer must take appropriate measures to ensure the electronic distribution will result in actual receipt of information by the participants (i.e. return-receipt).
- If the disclosure includes personal information relating to an individual’s accounts and benefits, the plan must take reasonable and appropriate steps to safeguard the confidentiality of the information.
Additional requirements for non-employees or employees with non-work related computer access:
Affirmative consent for electronic distribution must be obtained from the individual. Before consent can be obtained, a pre-consent statement must be furnished that explains:
- The types of documents that will be provided electronically;
- The individual’s right to withdraw consent at any time without charge;
- The procedures for withdrawing consent and updating information (e.g. updating the address for receiving electronic disclosure);
- The right to request a paper version and its cost (if any); and
- The hardware and software requirements needed to access the electronic document.
- The regulations permit the pre-consent statement to be provided electronically if the employer has a current and reliable e-mail address.
- If system hardware or software requirements change, a revised statement must be provided and renewed consent from each individual must be obtained.
- If the documents are to be provided via the Internet, the affirmative consent must be given in a manner that reasonably demonstrates the individual’s ability to access the information in electronic form, and the individual must have provided an address for the receipt of electronically distributed documents.
- The Employer must keep track of individual electronic delivery addresses, individual consents and the actual receipt of e-mailed documents by recipients.
- Steps 1, 2, 4, and 5 outlined above under requirements for employees with work-related computer access must also be followed.
To use electronic media to distribute plan-related materials, the plan administrator must also inform participants and beneficiaries that they have the right to receive paper copies of each document free of charge.
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment,coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
You’re protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have these protections:
- You’re only responsible for paying your share of the cost (like the copayments, coinsurance,and deductible that you would pay if the provider or facility was in-network). Your healthplan will pay any additional costs to out-of-network providers and facilities directly.
Generally, your health plan must:
- Cover emergency services without requiring you to get approval for services inadvance (also known as “prior authorization”).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network servicestoward your in-network deductible and out-of-pocket limit.
If you think you’ve been wrongly billed, contact: 1-800-985-3059.
Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
Transparency in Coverage
Important note: Machine readable files may be as large as in Gigabytes (GBs) or even one Terabyte (TB) in file size, which has significant system requirements for use. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download.
See Machine-readable JSON files for Provider, Prescription Drug Formularies and Plan information below. Delta Health Systems assumes no responsibility for how the information in these files is used or interpreted by third parties.
Provider information contained on this web page is updated on a monthly basis. Providers may join or leave the company's network at different points throughout the year. Also, not all providers participate in all networks.
Prescription Drug formulary information contained on this drug list is updated on a monthly basis. Prescription Drugs may be added to the formulary during a month, but Prescription Drugs are generally removed from the formulary on a quarterly basis.
The information available links below are provided in good faith to comply with the Machine-Readable Files (MRF) provision of the Transparency in Coverage Final Rule (TCFR). These files are extensive collections of data to be ingested and read by machines and are not intended for member use:
- 👉 Anthem BlueCross - Machine Readable Files
- 👉 Blue Shield of California - Machine Readable Files
- 👉 Cigna- Machine Readable Files
Beacon Health - Machine Readable Files
Multiplan - Machine Readable Files
- 👉 Aetna - Machine Readable Files
- 👉 Zelis - Machine Readable Files
To learn more about the TCFR and the MRF provision, refer to the Centers for Medicare & Medicaid Services (https://www.cms.gov/).Disclaimer:
These files are not designed as a consumer tool. These files are not a guarantee of coverage, nor a guarantee of the reimbursement rate that will be applied for any procedure. The claims reimbursement process is subject to a variety of factors that are not addressed in these files, including eligibility, medical necessity determinations, utilization management requirements, exclusions and other plan terms. These files also do not offer any information on a member's out-of-pocket charges. The information in these files is accurate as of the date noted for each file and is subject to change without notice.
The following list was developed by the National Quality Forum (NQF). Never events are medical errors that should never happen, but when they do, typically cause serious consequences for the patient. By excluding these events, the plan reduces unnecessary costs and eliminates payment for expenses which should not have been incurred. Never events include:
- Surgery performed on the wrong body part,
- Surgery performed on the wrong patient,
- Wrong surgical procedure on a patient,
- Retention of a foreign object in a patient after surgery or other procedure, or
- Intraoperative or immediately post-operative death in a normal, healthy patient (defined as a Class 1 patient for purposes of the American Society of Anesthesiologists patient safety initiative).
Product or Device Events:
- Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the health care facility,
- Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended, or
- Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a health care facility.
Patient Protection Events:
- Infant discharged to the wrong person,
- Patient death or serious disability associated with patient elopement (disappearance) for more than four hours, or
- Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a health care facility.
Care Management Events
- Patient death or serious disability associated with a medication error (e.g., error involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration),
- Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products,
- Maternal death or serious disability associated with labor or delivery on a low-risk pregnancy while being cared for in a health care facility,
- Patient death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates,
- Stage 3 or 4 pressure ulcers acquired after admission to a health care facility, or
- Patient death or serious disability due to spinal manipulative therapy.
- Patient death or serious disability associated with an electric shock while being cared for in a health care facility,
- Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances,
- Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility,
- Patient death associated with a fall while being cared for in a health care facility, or
- Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility.
- Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider,
- Abduction of a patient of any age,
- Sexual assault on a patient within or on the grounds of a health care facility, or
- Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a health care facility.
IRS Medical And Dental - eligible expenses
The following lists are examples of what medical expenses can/cannot be paid for out of your HSA/FSA account. For a complete list and detailed definitions, refer to:
IRS Publication 502 »
Can be paid out of your HSA/FSA account
- Alcoholism Treatment
- Artificial Limb/Prosthesis
- Artificial Teeth
- Autoette Wheelchair
- Breast Reconstruction
- Birth Control
- Brailed Books and Magazines
- Capital Expenses/Home Improvement (special equipment installed in a home to accommodate a disability)
- Christian Science Practitioner
- Contact Lenses
- Dental Treatment
- Diagnostic Devices
- Disabled Dependent Care Expenses
- Drug Addiction
- Eye Glasses
- Eye Surgery
- Fertility Enhancement
- Guide Dog or Other Animal
- Health Institute
- Health Maintenance Organization (HMO)
- Hearing Aids
- Home Care/Nursing Services
- Hospital Services
- Insurance Premiums (not paid for on a before-tax basis or by an employer)
- Laboratory Fees
- Lead-Based Paint Removal
- Learning Disabilities/Special Education
- Legal Fees
- Lodging/Meals (essential to medical care; not a part of inpatient care)
- Long-Term Care
- Medical Services (provided by a physician, surgeon, specialist or other medical practitioner)
- Nursing Home
- Organ Donors
- Psychiatric Care/Psychologist
- Special Education/Tuition
- Stop-Smoking Programs
- Telephone Equipment (specialized for hearing impaired, TTY and TDD)
- Transportation (essential to medical care)
- Vision Correction Surgery
- Weight Loss Program (for a specific disease diagnosed by a physician)
Cannot be paid out of your HSA/FSA account
- Nursing Services (for a normal, healthy baby)
- Controlled Substances
- Cosmetic Surgery
- Dancing Lessons
- Diaper Service
- Electrolysis or Hair Removal
- Flexible Spending Account
- Funeral Expenses
- Future Medical Care
- Hair Transplants
- Health Club Dues
- Health Coverage Tax Credit
- Health Savings Account
- Household Help
- Illegal Operations and Treatments
- Insurance Premiums (paid for on a before-tax basis or by the employer)
- Maternity Clothes
- Medical Savings Account
- Medicines and Drugs From Other Countries
- Non-prescription Drugs and Medicines (except insulin)
- Nutritional Supplements
- Personal Use Items
- Swimming Lessons
- Teeth Whitening
- Veterinary Fees
- Weight Loss Program (for improvement of appearance, general health, or sense of well-being)
Note: This list is subject to change in accordance with the Patient Protection and Affordable Care Act and Education Reconciliation Act of 2010.
changing coverage during the year
There are two sets of regulations, established by the Federal government, that control the types of coverage changes you can make during a plan year. The regulations classify the changes as follows:
Change in Status Events:
As provided by the Internal Revenue Code.
As a result of allowing you to pay for benefits on a before-tax basis, the government has established rules that control when you can change or enroll for coverage. Based on your situation, you may be able to:
- Change your coverage during the plan year (i.e., add or remove dependents to your existing coverage), or
- Late Enroll, which refers to enrolling yourself and/or your dependents for coverage during the plan year, even though you declined coverage when you were first eligible or during a previous open enrollment period.
Note: You must enroll for coverage in order to enroll your dependents.
- Special Enrollment Rights:
As provided by the Health Insurance Portability and Accountability Act—HIPAA
Under certain circumstances, even if you or your eligible dependents are not currently enrolled in a plan, the government requires that you and your eligible dependents be allowed to late enroll — enroll during the plan year even though you declined coverage when you were first eligible or during a previous open enrollment period.
Note: You must enroll for coverage in order to enroll your dependents.
During the Year
Change in Status Events:
As Provided by the Internal Revenue Code
You must change (enroll/drop) coverage within 31 days of the following events:
- Change in your legal marital, including marriage, death of your spouse, divorce, legal separation or annulment.
- Change in the number of your dependents, including birth, adoption, placement for adoption or death of your dependent.
- Change in your employment status, including termination or commencement of employment of you, your spouse or your dependent.
- Change in work schedule for you or your spouse, including an increase or decrease in the number of hours of employment, a switch between full-time and part-time status, a strike, lockout or commencement or return from an unpaid leave of absence.
- Your dependent satisfies or no longer meets the eligibility requirements for unmarried dependents, as described under Who Is Eligible, including age or other similar circumstances.
- A change in the place of residence or worksite of you or your spouse.
Note: This move must affect your coverage options.
- You, your spouse, or your dependents lose COBRA coverage.
- You, your spouse, or your dependents coverage under Medicare or Medicaid.
- If the plan receives a decree, judgment or court order, including a QMCSO pertaining to your dependent, you may add the child to the plan (if the decree, judgment or court order requires coverage) or drop the child from the plan (if the ex-spouse is required to provide coverage)
- A significant change in benefit or cost of coverage for you or your spouse. Your spouse’s employer provides the opportunity to enroll or change benefits during an open enrollment period.
Special Enrollment Rights:
As Provided by HIPAA
- You initially declined coverage under the plan because you had coverage under another plan, and subsequently incurred a loss of coverage under the other plan* Enrollment Requirements: You must change (enroll/drop) coverage within 31 days of the event.
- Occurrence of certain events such as birth, adoption, placement for adoption or marriage** Enrollment Requirements: You must change (enroll/drop) coverage within 31 days of the event.
- Eligibility for state premium subsidies under the Children’s Health Insurance Program or State Children’s Health Insurance Program (also known as Healthy Families in California) Enrollment Requirements: You must change (enroll/drop) coverage within 60 days of the event.
- Loss of coverage under Medicaid, the Children’s Health Insurance Program or State Children’s Health Insurance Program (also known as Healthy Families in California) Enrollment Requirements: You must change (enroll/drop) coverage within 60 days of the event.
*Loss of coverage means:
- COBRA coverage has been exhausted for reasons other than non-payment of premiums or fraud,
- Loss due to legal separation, divorce, death, termination of employment or reduction in the number of hours of employment, or
- Loss of coverage due to attaining a plan’s lifetime maximum for all benefits.
**There is no requirement that protected individuals in this category must have had other coverage prior to the existence of their special enrollment rights.
- PPO provider networks
- pharmacy benefit managers (PBMS)
- vision providers
- dental providers
- UM providers
- Health savings account providers
- other service providers
- government agencies
- legislation federal/state
PPO PROVIDER NETWORKS:
- Anthem Blue Cross (CA)
Must sign in as a participant on our homepage to access.
- Blue Shield of California
Must sign in as a participant on our homepage to access.
- Arizona Foundation for Medical Care
- Beech Street
- CFMCNET: Foundation for Medical Care
- First Health (Formerly CCN)
- Midlands Choice
- Networks By Design
PHARMACY BENEFIT MANAGERS (PBMs):
HEALTH SAVINGS ACCOUNT PROVIDERS:
- AHA: American Hospital Association
- HCAA: Health Care Administrators Association
- IFEBP: International Foundation of Employee Benefit Plans
- NHCAA: National Health Care Anti-Fraud Association
- SIIA: Self-Insurance Institute of America, Inc.
- SPBA: Society of Professional Benefit Administrators
- ECFC: Employers Council on Flexible Compensation
other service providers:
Experience the Delta Promise