How to Submit Claims
What information should I include when I submit a claim?
When filing a claim for covered services, bills and receipts should be itemized and show:
- Patient name, date of birth, address, phone number, and relationship to enrollee.
- Patient’s Plan identification number.
- Name, address, and tax identification number of the person or company providing the services or supplies. We do not need the tax ID number for providers outside the U.S.
- Date(s) of service, or date(s) supplies were furnished.
- Diagnosis or a description of your symptoms (not required for prescription medicine receipts).
- Charge for each service or supply.
- A brief description of each service or supply.
- If you have another health plan as your primary payor, you must send a copy of the explanation of benefits (EOB) you received from that payor (for example, the Medicare Summary Notice).
- Bills for private duty nursing care must show that the nurse is a Registered Nurse (R.N.) or Licensed Practical Nurse (L.P.N.). You also should include the initial history and physical, treatment plan indicating expected duration and frequency from your attending physician or other health care professional, and notes from the nurse.
- Claims for rental or purchase of durable medical equipment must include the purchase price, a prescription, and a statement of medical necessity including the diagnosis and estimated length of time needed.
- Claims for dental services submitted to FSBP must include a copy of the dentist’s itemized bill (including the required information listed above) and the dentist’s Federal Tax ID Number. We do not have separate dental claim forms.
The process to submit a claim online is simple: login to the Member Portal with your username and password. Once inside the portal, under the Secure Forms tab, select “Submit A Claim.” Follow the screen prompts to upload your PDF claim documents. You have the option to include questions or comments, or to send your claim to a specific Health Benefits Officer. Please ensure your name and member ID number appear on the claim.
If you are serving overseas, note that using State Department mail (Pouch Mail) will significantly delay your claim’s processing.
Visit the FSBP provider search page. Enter your search terms and click “Search.” Choose the appropriate network option: either the “Foreign Service Benefit Plan - Aetna Choice POS II”; or the “NetCare-Guam.”
The provider should call 202-833-5751.
- For Self Only (401) enrollment, the deductible is $300 for in-network providers (including Guam) and providers outside the U.S., and $400 for out-of-network providers (including Guam).
- For Self Plus One (403) enrollment, the deductible is $600 for in-network providers (including Guam) and providers outside the U.S., and $800 for out-of-network providers (including Guam).
- Under a Self and Family (402) enrollment, the deductible is $600 for in-network providers (including Guam) and providers outside the U.S., and $800 for out-of-network providers (including Guam).
Login to Aetna Navigator Select “ID card” at the top of the page, and then choose to print/download additional ID cards or view your ID card. To order a replacement ID card, you can call 202-833-4910.
You can update your address in the Member Portal. Login, or register if you are a first-time user. Go to Member Profile and select the “click to update” button. Then enter the desired information and click save.
FSBP has a special arrangement with the e-Cleveland Clinic to provide our members with the option of a second opinion for certain diagnoses received from a foreign provider. The Overseas Second Opinion benefit provides access to nationally-recognized specialists for a second opinion via the e-Cleveland Clinic. Once you obtain the second opinion, you choose whether to proceed with the original course of treatment, seek out another opinion, or arrange care with an alternate physician. To determine if you are eligible to participate, e-mail the Plan at [email protected].
If you would like to see a second provider of your choice while serving overseas, the consultation and any medically necessary tests or services will be covered in the same way as any overseas provider. See Overseas.
FSBP provides access to Aetna’s Aexcel specialists network. Aexcel is a designation for doctors and doctor groups in 12 medical specialty areas:
- Obstetrics and gynecology
- Cardiothoracic surgery
- General surgery
- Plastic surgery
- Vascular surgery
Doctors with the Aexcel designation will have a blue star next to their listing in the provider search results. The Evaluation Standards are:
- Volume: In order to compare like practices, Aetna first evaluates volume by identifying doctors who have managed at least 20 episodes of care for Aetna members over the past three years.
- Clinical Performance: Doctors must meet standards in one of five categories. Those categories are (1) use of technology; (2) alignment with Institutes of Quality®; (3) certification by an external entity such as the National Committee for Quality Assurance; (4) performance-based improvement model; or (5) claim-based measures.
- Efficiency: Aetna examines what these doctors charge Aetna members for services and how many and what types of services they perform. Aetna considers all costs of care, the number of patients served with chronic or complex conditions, and risk-adjustment factors like age, gender, and disease risk.
We have a list of participating pharmacies here.
For the complete drug formulary and to compare drug prices please visit the co-branded website. By clicking on the “Go” button in the middle box under Open Enrollment Information, both current members and prospective members can find out information on the Plan’s prescription benefits (retail, home delivery and specialty), search for a nearby participating pharmacy, compare prescription costs, review the Plan’s formulary and utilize the Savings Advisor tool.
For more information, please see the video below that explains generics and formularies.
Express Scripts can be contacted directly by phone for any questions you may have:
- Member Services – 800-818-6717
- If the 800 number does not work for you from outside the 50 United States, call Express Scripts collect at 724-765-3077 or 724-765-3074.
- TTY – (800) 899-2114
- Accredo, an Express Scripts Specialty Pharmacy – 800-922-8279
There are two options you can explore: The Price a Medication tool, and the Extended Payment Plan.
Price a Medication is part of the co-branded website and app. You simply enter the medication you were prescribed and read about lower-cost alternatives for the same drug. Use this information to discuss lower-cost medications that might be appropriate for your condition with your prescriber.
The Extended Payment Plan allows you to pay for your home delivery medications over three installments, via credit or debit card. There’s no waiting – medications are shipped as soon as the first payment is received. When you enroll in EPP, it applies to every home delivery prescription for you and your eligible dependents. To enroll or learn more, you can call Express Scripts at 800-818-6717, or enroll at the website or app. Here’s how:
- Under “My Account,” select “Edit Payment Information” from the drop-down menu.
- Under “Your Information” select “Payment Information.”
- Then, click on “Edit Information.”
- Next to “Extended Payment Program,” you will see a link to “Learn More.”
Several medications are now available with no cost-sharing for you. They are not technically “free” because the Plan pays full cost for them; thus, for members there is no out-of-pocket cost.
These medications include:
- FDA-approved women’s contraceptives, including oral and injectable contraceptives, cervical caps, diaphragms, IUDs, vaginal rings, and hormonal patches.
- FDA-approved tobacco cessation drugs, both prescription-only and over-the-counter (a prescription from your provider is required for reimbursement).
- Medicines to promote better health recommended under the Affordable Care Act and that have an “A” or a “B” rating from the U.S. Preventive Services Task Force
Certain non-covered prescription drugs can be obtained at a discounted price through the Express Scripts Pharmacy. These may include Renova, a dermatological drug; Propecia, a cosmetic drug; and erectile dysfunction agents.
If you use a non-covered prescription drug and you want to learn whether it falls into this category, as well its discounted price, call Express Scripts at 800-818-6717. To order an eligible medication, you need to submit the prescription with a home delivery order form and payment for the full discounted price.
As a non-FEHB benefit, you cannot file an FEHB disputed claim about any drugs obtained via this program. Further, the price you pay for any drug in this program is separate and apart from your FSBP premium, deductible, copayments, or catastrophic protection out-of-pocket maximums.
Your safety is the top concern of both Express Scripts and FSBP. We require prior authorization of certain medications as a safety measure for you to establish the medical necessity of your use of the drug. Examples of drug categories requiring prior authorization include, but are not limited to, growth hormones, certain hormone therapies, interferons, erythroid stimulants, anti-narcoleptics, sleep aids, migraine medication, weight loss medications, opioids, and oncologic agents. The review of your prior authorization request uses Plan rules based on FDA-approved prescribing and safety information, clinical guidelines, and uses that are considered reasonable, safe, and effective. Additionally, there are some medications that may be covered with limits (for example, only for a certain amount or for certain uses) unless you receive approval through a coverage review.
Contact Express Scripts Member Services directly if you have questions about, or need to obtain, prior authorization for a medication: 800-818-6717.
Your prescription drug coverage includes the Personalized Medicine Program, which incorporates pharmacogenetics testing to optimize drug therapies for certain conditions. The program is available – at no extra cost - to patients taking Plavix or Warfarin. It requires no action on your part.
The FDA recommends pharmacogenetics tests to help doctors prescribe the most appropriate drug and dosage for each patient. First, a pharmacist from Express Scripts contacts your doctor to see if it is appropriate for you to participate in the testing. If your doctor agrees, the pharmacist will contact you to let you know that testing is available and, if you agree to it, arrange to complete the test. Results will be sent directly to your doctor and to a specially trained Express Scripts pharmacist. Ultimately, your doctor decides which drug and dose is best for you.
FSBP was designed to make it easy for our members to receive the healthcare they need while overseas - anywhere in the world. Simply see the healthcare provider of your choice, pay your bill, and send us an itemized receipt along with the contact information of the provider. No translation or currency exchange information is necessary (See Claims for more detailed instruction).
For those benefits where copayments, coinsurance or deductibles apply, we pay 100% of the Plan allowance for the rest of the calendar year after your expenses total to:
- For Self Only enrollment $5,000 and for Self Plus One or Self and Family enrollment $7,000 for in-network providers (including Guam) and providers outside the 50 United States and when you use the Plan’s network retail pharmacy through Express Scripts (ESI), or home delivery (mail order) through the Express Scripts PharmacySM, or purchase prescriptions outside the 50 United States from a retail pharmacy or Military Treatment Facility (including Guam);
- For Self Only enrollment $7,000 and for Self Plus One or Self and Family enrollment $9,000 for in- and out-of-network providers combined (including Guam) and when you use the Plan’s network retail pharmacy through Express Scripts or home delivery (mail order) through the Express Scripts PharmacySM or purchase prescriptions outside the 50 United States from a retail pharmacy or Military Treatment Facility (including Guam).
For Self Plus One and Self and Family enrollments, once any individual family member reaches the Self Only catastrophic protection out-of-pocket maximum during the calendar year, that member’s claims will no longer be subject to associated cost-sharing amounts for the rest of the year. All other family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.
Any expenses incurred that apply toward the catastrophic out-of-pocket maximum for in-network or out-of-network apply toward both in and out-of-network limits.
This catastrophic protection out-of-pocket maximum is combined for medical/surgical, mental health/substance misuse disorder, and pharmacy. There are some expenses that do not fall under this provision; see your FSBP FSBP Brochure, Section 4, Your Costs for Covered Services.
This does not mean the doctor does not provide quality services. It could be that Aetna does not have enough information available to evaluate a particular doctor or the doctor’s specialty is not one of the 12 specialty categories. An Aexcel designation is not a guarantee of service quality or treatment outcome. Therefore, the Aexcel designation should not be the only reason for choosing a specialty doctor. The Aexcel designation is only a guide, and all ratings have a chance for error.