Eclaims & Claim Submission Requirements

eClaims & Claim submission requirements

Member eClaims allows online claim submission for a variety of covered services. To use Member eClaims, plan members must be registered for GroupNet for Plan Members, and signed up for Direct Deposit and eDetails for email notification when the claims are processed. Plan members can also sign up to receive text messages on their mobile phone when their claims have been completed.

The “Submit a Claim” option can be seen upon signing in to GroupNet for Plan Members. Claims can be submitted online in six easy steps, as follows:

1. Selecting the Type of Claim – for example, prescription drugs or a chiropractic service
2. Selecting a Provider (when required) – for example, the plan member’s treating Physician, Optician or Chiropractor
3. Selecting a Patient – the plan member or a covered family member
4. Entering the Expense Details for the service received
5. Reading and Agreeing to the “Terms and Conditions” and the “Claim Summary and Consent”
6. Viewing or Printing the Confirmation and Summary of your Online Claim Submission

Refer to this table for guidance on how to submit your services and expenses:

Those highlighted in green require a prescription (this may cause certain expenses or service to be unavailable through Member eClaims).

*The initial placement of braces must be sent in the mail. However, subsequent orthodontic work can be submitted through Member eClaims.

The following limitations apply to the Member eClaims feature:

• Daily Limit: $1,000
• Weekly Limit: $1,500
• Monthly Limit: $2,500

The following daily limitations also apply to specific services and expenses:

• Paramedicals: $300 per practitioner
• Dental Orthodontics: $800
• Dental Routine: $800 per service
• Vision: $800 per expense
• Drugs: $600

Please keep in mind that all services must be provided within Canada and you may only submit claims going back to 6 months.

Audits

Great-West is committed to protecting you and your employer against fraud. Claims submitted online are therefore subject to random audits. To comply with these verifications, please make sure to keep your receipts for 12 months following your claim submission. If your claim is selected for a random audit, you will be asked to send Great-West the receipt(s) pertaining to the claim within the next 21 days, or risk losing Member eClaims access.

Prescription Drugs

Certain prescription drug claims need to be approved before Great-West Life can consider reimbursement. In order to be considered for coverage, please access GroupNet for Plan Members to retrieve the applicable Prior Authorization form in the Forms & Cards section. Have your physician complete the associated Request for Information form and mail it to Great-West Life for their consideration.

Major Dental

Before incurring any large dental expenses, or beginning any orthodontic treatment, ask your dental service provider to complete a treatment plan and submit it to Great-West Life. Great-West Life will calculate the benefits payable for the proposed treatment, so you will know in advance the approximate portion of the cost you will have to pay.

Orthopedic Shoes and Foot Orthotics

Your Group Policy includes coverage for the following:

Custom-made orthopedic shoes – footwear made specifically for one patient, from raw materials, using a variety of measurements and a three-dimensional cast of the patient’s feet.

Custom-fitted or modified orthopedic shoes – a shoe is considered to be modified when the orthopedic shoe is permanently changed, for example, adding a rocker sole, or leather patches to accommodate a foot deformity.

Custom-made foot orthotics – a device made from a cast of the foot that can be inserted into the shoe to support, align, prevent or accommodate foot abnormalities and improve how the foot functions.

The orthopedic shoes and orthotics described above are covered when they are considered to be reasonable treatment of disease or injury, and when prescribed by one of the following health care providers: Physician (MD), Chiropodist, Podiatrist, or Orthopedic surgeon.

The prescription must confirm the medical diagnosis necessitating the orthopedic shoe or orthotic. Prescriptions outlining symptoms rather than medical diagnosis will not be sufficient.

To ensure that claims for these expenses are assessed correctly and in a timely manner, a prescription as well as the following documents must be submitted with your completed claim form:

Custom-made orthopedic shoes – A laboratory bill that includes:

• Details of the casting techniques used
• A description of the process and material used to fabricate the shoes

Custom-fitted or modified orthopedic shoes:

• The brand-name and model of the shoes
• A description of each modification made to the shoes
• A breakdown of the cost of the shoes and each modification

Custom-made foot orthotics:

• A copy of a detailed biomechanical examination or gait analysis
• Details of the casting technique used
• A detailed description of the type of orthotic provided
• A breakdown of the charges for the orthotics

Great-West Life’s Toll-Free Number

To contact a customer service representative at Great-West Life for assistance with online services, claims or coverage, please call 1-800-957-9777.

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