What To Do If You Receive a Bill For Your WTC-Related Care

Billing in the healthcare industry can be complex. It can also be difficult for medical staff to understand our role and how to process claims for WTC-related medical care. This is especially true if they do not work with the WTC Health Program often. Remember, the WTC Health Program is not insurance. The process of paying claims for care received in the Program is a bit different than other claims.

Here are just some of the things that make Program billing complex:

• The Clinical Centers of Excellence may refer some members to outside providers for specialized care. Also, the Nationwide Provider Network is made up entirely of outside providers. These outside providers and their offices may not work with Program members often.
• Services for Survivors in the WTC Health Program are required by law to be billed differently than services for Responders. Survivor claims must follow a Coordination of Benefits process, while Responder claims are only sent directly to the Program. This is another wrinkle that all these providers need to know.
• After benefits are coordinated, a Survivor’s primary insurance or provider may send what is called an Explanation of Benefits for care you receive through the Program. This looks very much like a bill but is not.

With all of this in mind, it is not surprising that billing can cause confusion for the Program’s providers and members. We do our best to educate providers and to remind them how to process Program-related claims. However, you may still mistakenly receive a bill for this WTC-related care. You might also be mistakenly asked to pay a copay at the Program-affiliated provider’s office.

Remember: Do not pay! The Program is very limited in its ability to reimburse you if you do. So, when in doubt, please contact us.

In addition to the complex nature of medical billing, the claims process can take some time to complete.

This is the general path that a medical claim can take, though there are often exceptions:

1. The provider must complete the necessary claim paperwork. This can take some time depending on the volume of patients they see. Plus, for Survivors, the provider must coordinate the benefits—this means they must first submit the claim to primary health insurance for initial payment. That can make the process take a bit longer.
2. The provider sends the claim to the WTC Health Program. Sometimes this is done electronically. Sometimes it is done by mail or fax.
3. Once the WTC Health Program receives the claim, the Program processes it in the order it is received. Nationwide Provider Network claims are processed by Managed Care Advisors-Sedgwick, the Nationwide Provider Network administrator. Certain things can affect the time it takes to process the claim. For example, if information is missing or incomplete, we must get back in touch with the provider to get the info we need.
4. Once the claim is processed, the claim can be paid if all requirements are met. Claims may be denied for various reasons. For example, the service may be for a condition not certified as WTC-related by the Program, or the claim may have been submitted incorrectly. If the claim is denied, you may receive a bill from the provider. Call the WTC Health Program call center or the Nationwide Provider Network if this happens.
5. If the claim is approved for payment, most providers use electronic billing, but not all. We may need to send the payment by mail. This can add to the timeline.

We try to process and pay claims as soon as possible. However, the many steps involved mean it may take some time. Depending on the situation, enough time may pass between your visit and the final payment that the provider may mistakenly send you a bill.

Again, if this happens, do not pay this bill and contact us. We will help straighten things out.

As with medical care, you should not be charged for prescriptions needed to treat your certified WTC-related health condition(s), including copays or deductibles. If a pharmacy asks you to pay for a WTC-related prescription, show them your WTC Health Program Express Scripts pharmacy card. They should contact Express Scripts directly. That information is on your card.

If you are a Survivor, coordination of benefits also applies to pharmacy benefits. Be sure to give the pharmacy both your primary health insurance information and your WTC Health Program Express Scripts pharmacy card. Learn more on the Coordination of Benefits page.

If the issue is unable to be resolved at the pharmacy, you might choose to pay out-of-pocket so that you can get your prescription prescribed by a Program provider as soon as possible. Only do this as a last resort. If you do pay, you can request reimbursement from Express Scripts through their Express Scripts Direct Claims form (also available en Español ). For questions about this process, please contact Express Scripts directly at 1-800-935-7179.

Please note: the WTC Health Program cannot guarantee reimbursement. The Program also does not have the legal authority to reimburse you directly.

If you are a Survivor member in the Program, you might receive a document known as an Explanation of Benefits. This is because of the required Coordination of Benefits process where your primary health insurance company pays first for WTC-related care received through the Program.

An Explanation of Benefits is a statement from your primary insurance company that details what a medical service cost, what they paid, and what is left over. IT IS NOT A BILL. It will often say that somewhere on it. It breaks down the cost of the medical services. It might also show a balance remaining. It might even say something like “your responsibility” or “patient’s responsibility.” Because it can look like a bill, this can be very confusing.

For WTC-related claims for approved services, remember that you are not responsible for the remaining amount shown on an Explanation of Benefits or a bill. The Program pays that remaining cost.

Unfortunately, the Program cannot control if your primary insurer or provider sends you an Explanation of Benefits or a bill. That is why it is important for you to call us immediately if you DO get a bill. If you are not sure it is a bill, do not worry. Call us and we will help.

Explanation of Benefits from different insurers may look very different from each other. Here is a sample Explanation of Benefits from the Centers for Medicare & Medicaid Services that may help you identify what you received: Reading Your Explanation of Benefits (EOB)

Just remember that for approved WTC-related services received through the Program, “your responsibility” really means “the Program’s responsibility.” We cover that cost.