74 Types of Claims Health benefit claims can be filed for medical, mental health, substance use disorder, and prescription drug, benefits. Th ere are four categories of health claims as described below: Pre - Service Claim means a claim for a benefit for which the Plan requires approval before health care is obtained, or approval is required in order to receive the maximum benefit provided by the Plan. Urgent Claim means a claim for health care or treatment that if normal pre - service standards were applied, would seriously jeopardize the life or health of the Covered Person or the ability of the Covered Person to regain maximum function or, in the opinion of a physician with knowledge of the covered person’s medical condition, subject the covered person to severe pain that could not be adequately managed without the care or treatment that is the subject of the claim. However, the Plan will not deny benefits for these procedures or services if it is not possible for the claimant to obtain the pre - approval, or the pre - approval process would jeopardize the claimant’s life or health. Concurrent Claim means a claim that is reconsidered after an initial ap proval is made, resulting in a reduction, termination or extension of a benefit. (An example of this type of claim would be an inpatient hospital stay originally certified for five days that is reviewed at three days to determine if the full five calendar days stay is still appropriate. In this situation, a decision to reduce, terminate or extend the hospital stay is made concurrently with the period of hospitalization.) Post - Service Claim means a claim for benefits that is not a pre - service, concurrent or urgent claim. Specifically, a claim submitted for payment after health services or treatment have been obtained. Claim Elements A claim must include the following elements to trigger the Plan’s internal claims process : • Be written or electronically submitt ed (oral communication is acceptable for authorization of services only for Urgent Care Claims); • Be received by the Plan Administrator or Claims Administrator (as applicable); • Name a specific individual participant and his/her Social Security Number or oth er assigned unique identification number; • Name a specific claimant and his/her date of birth; • Name a specific medical condition or symptom; • Provide a description and date of a specific treatment, service or product for which approval or payment is requeste d (must include an itemized detail of charges and applicable service codes); • Identify the provider’s name, address, phone number, professional degree or license, and federal tax identification number (TIN); and • When another plan is primary payer, include a copy of the other Plan’s Explanation of Benefits (EOB) statement along with the submitted claim. A request is not a claim if it is: • Not made in accordance with the Plan’s benefit claims filing procedures described in this section; • Made by someone other th an you, your covered dependent, or your (or your covered dependent’s) authorized representative; • Made by a person who will not identify himself or herself (anonymous); • A casual inquiry about benefits such as verification of whether a service/item is a cove red benefit or the estimated allowed cost for a service;