Contacts

 

 

 

 

 

This page provides you with easy access to all of theMCTWF's forms, along with a brief description of their use. Use these forms to print, fill out and mail to the MCTWF office at the address listed on the contacts page (note that these forms cannot be filled out and submitted electronically).  Adobe Acrobat Reader is required for viewing and printing and can be downloaded free of charge by clicking on the Acrobat Reader icon on this page.



Claim Forms

Medical - This form is used for reimbursement for allowed costs for non-network medical services.  

Dental -This form is used for reimbursement for allowed costs for non-network dental services.

Vision - This form is used for reimbursement for allowed costs for non-network vision services.

Prescription Drug Claims - This form is used by participants who seek  reimbursement for a prescription drug claim.

Mail Service Order Form- This Mail Service Order Form is used by participants to obtain mail order prescription drugs.

Death Benefit Claim Form- This form is used by beneficiaries who seek payment of a death benefit.

Accidental Death and Dismemberment Claim Form- This form is used by a participant for accidental dismemberment or by beneficiaries for accidental death who seek payment of an accidental death or dismemberment benefit.

COVID-19 Weekly Accident & Sickness Benefits Claim Form             

Participant's Report of Disability - These forms are required in order to apply for short-term disability benefits. One copy must be filled out by the participant and the employer and a separate form must be filled out by the physician.

MCTWF Extended Disability – Claimant’s Report of Disability  -This form is used by individuals that are applying for the Extended Disability benefit.

Total & Permanent Disability - These forms are required in order to apply for total and permanent disability benefits. One two-page copy must be filled out by  the claimant, one two-page copy must be filled out by the physician and one two-page copy must be filled out by the employer.

Total Disability Certification Form- This form, which must be provided annually to remain eligible, is used by those whose Total Disability Death Benefit has been reinstated.

Flexible Dependent Coverage Claims - This form is used by participants enrolled in the Program to receive reimbursement from their Medical Spending Account.

Blue Cross Blue Shield Global Core International Claim Form- This form is used by participants who seek reimbursement for a medical emergency claim where services were rendered outside of the United States.   


Appeal Forms

If your benefit claim is denied in whole or in part, you have the right to appeal. This Notice of Appeal Procedure benefit packages describes the MCTWF appeal process available to participants and providers.

Participant Benefit Claim Appeal - This form is used by participants to appeal an adverse benefit decision.


Provider Authorization Forms

These forms must be filled out by your provider and sent to MCTWF's Utilization Review Department for the appropriate service or medical equipment that requires prior authorization for -

Prior Authorization of Surgery Services

Prior Authorization of Radiology Services     
(Echocardiogram, MRI, MRA, CT Scan and Pet Scan)

Prior Authorization of In-Lab Sleep Study Services

Prior Authorization of Speech Therapy Services

Prior Authorization of Durable Medical Equipment Purchases

Prior Authorization of Colonoscopy Services

Prior Authorization of Home Health Care/Hospice


Participant/Family Information Forms

Enrollment Card- This form is used by new participants to provide MCTWF with the demographic, beneficiary and other insurance information information necessary to enroll in the plan. When filling out the form refer to the Required Beneficiary Documents to determine if additional information is needed.

Change of Beneficiary - This form is used by  participants to change the designated beneficiary(ies) listed on their enrollment card.

Contact Updates - This form is used by participants to provide address, telephone number and email address information updates.

Coordination of Benefits Information - This form is used by participants to modify information affecting dependent coordination of benefits.

Family Status Change - This form is used by participants to modify information affecting dependent eligibility.


Participant Application Forms

Non-Access Exemption - This application  is used to apply for in-network treatment coverage from an out-of-network primary care physician, medical specialist or general dentist, outside of the geographic area covered by the BCBS PPO or Delta Dental networks.

Assignment, Subrogation and Reimbursement Agreement (Work Related) - Execution of this agreement is required to obtain conditional coverage for a work-related illness or injury if the employer and/or the worker's compensation insurance carrier disputes the claim for benefits.

Assignment, Subrogation and Reimbursement Agreement (Non-Work Related) - Execution of this agreement is required to obtain coverage for a non-work related injury or illness caused by a third party.

Request for Continuation of Coverage Beyond Age 26 for Totally & Permanently Disabled Dependent - 
This form is used by adult children of a participant, age 26 or greater, who are totally and permanently disabled and need their coverage continued beyond age 26.

Flexible Dependent Coverage Program Election Form  This form is used by participants who wish to elect MCTWF's Flexible Dependent Coverage Program.

BCBSM Member Application for Payment Consideration- This application is used by participants for reimbursement of special formulas and medical foods.


Retirees Plan Application Forms

MCTWF Retirees Plan Enrollment Application - This application is used to apply for MCTWF's Retiree Medical Program.

Retiree Death Benefit - This application is used to apply for MCTWF's Retiree Death Benefit. 


HIPAA Privacy Forms

The full list of all MCTWF forms pertaining to The Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the HIPAA Privacy Rule, can be found HERE.


  

Get Acrobat Reader

Acrobat Reader required to view files.

Comments about this site should be directed to webmaster@mctwf.org
© contents and design, Michigan Conference of Teamsters Welfare Fund