IUPAT LOCAL 177 HEALTH
AND PENSION TRUST FUNDS
Consent to Release Version 1.0
Electronic Funds Transfer (EFT) Authorization for Claim Payments Version 1.0
Guide to Applying for Freezing of Hours Version 1.0
Guide to Applying for Weekly Disability Benefits Version 2020
Health Spending Account Claim Form Version 1.0
Pre-Determination - Hospital Bed Assessment Form Version 2017
Pre-Determination - Knee Brace Version 2017
Pre-Determination - Nursing Care Assessment Form Version 2017
Pre-Determination - Oxygen Concentrator Assessment Form Version 2017
Pre-Determination - Wheelchair Assessment Form Version 2017
Prescription Drug Special Authorization Request Form Version 1.0
Consent to Release Version 1.0
Electronic Funds Transfer (EFT) Authorization for Claim Payments Version 1.0
Guide to Applying for Freezing of Hours Version 1.0
Guide to Applying for Weekly Disability Benefits Version 2020
Health Spending Account Claim Form Version 1.0
Pre-Determination - Hospital Bed Assessment Form Version 2017
Pre-Determination - Knee Brace Version 2017
Pre-Determination - Nursing Care Assessment Form Version 2017
Pre-Determination - Oxygen Concentrator Assessment Form Version 2017
Pre-Determination - Wheelchair Assessment Form Version 2017
Prescription Drug Special Authorization Request Form Version 1.0
Submit claims in the Ellement app (web)
Ellement app
Discover how the Ellement Online Claims web app allows you to submit and check your claim status on your computer.
Submit a claim
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Log in to the member portal using your username and password.
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Click Submit a Claim in the top right corner of the screen.
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A drop-down menu with options to submit a Health, Drug or Dental claim will appear. Select the appropriate claim type.
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Select the patient you will submit the claim for by clicking on their name.
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Select a service provider from your recent health providers listed below the search bar, or enter the following service provider's details:
a. name,
b. address,
c. phone number,
d. and license or registration number. -
On the next page, enter the claim details as they appear on your receipt:
a. Search for the service code by typing in the Name (Health), Procedure Code (Dental) or DIN (Drug) of the service provided.
b. Enter the service date and the total cost of the service. -
If any other insurance has paid a portion of your claimed amount, check the box for additional coverage and enter the amount paid by the primary plan.
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To apply any unpaid balance to your healthcare spending account, activate the Apply Balance to HCSA on the left side of the screen by clicking the toggle button.
Step 3 - services menu
Step 4 - selecting a patient
Step 5- selecting a service provider
Step 6 - claim details
Claim multiple services
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Click Add another service and complete the claim details for each additional claim item.
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You'll see the services added to your claim listed at the bottom of the screen.
Step 1 - add another service
Step 2 - add another service
Finalize submitting your claim(s)
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After entering your claim details, click Next to add receipts and other supporting documents to your claim. If a Primary Plan has paid any amount, add the additional coverage statement to your submission.
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Once you have attached your documents, click next and review your submission. Make sure that all information is correct. To make any adjustments, select the Cancel button.
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Click Submit at the bottom of the screen to submit your claim for processing.
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Review the acknowledgments and check I agree.
Step 1 - add supporting documents
Step 2 - reviewing your submission
Finalize submitting your claim(s)
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Once your claim is submitted, you can check your claim status on your dashboard under Recent Claims or History.
Step 1 - dashboard
Step 2 - recent claims