Provider Manual

Member Eligibility

Identifying an 1199SEIU Benefit Funds Member

Because a member’s eligibility with the 1199SEIU Benefit Funds is determined by their wages and hours, it may change from month to month. It is important for providers to verify eligibility before providing non-emergency covered services.

To verify eligibility:

  1. Ask the member for their 1199SEIU Health Benefits ID card and
  2. Obtain verification by checking NaviNet or calling our automated Interactive Voice Response (IVR) system as indicated in Automatic Eligibility Verification (below).

All members are issued an 1199SEIU Health Benefits ID card that includes the names of their eligible dependents, the name of the member’s specific Benefit Fund (1199SEIU National Benefit Fund for Health and Human Service Employees, 1199SEIU Greater New York Benefit Fund or 1199SEIU National Benefit Fund for Home Care Employees) and the claim filing information.

Automatic Eligibility Verification—NaviNet and Interactive Voice Response (IVR) System

Online: Providers may access the 1199SEIU Benefit Funds’ provider portal NaviNet after completing a free registration process.

You will need the following information to access claim status:

  • Claim ID number
  • Servicing provider NPI
  • Billed claim amount
  • Member’s ID number
  • Patient’s date of birth

By phone: Providers may call the IVR system to verify a member’s eligibility 24 hours a day, 7 days a week. Using the IVR system, providers may verify eligibility for an unlimited number of members at one time and verify members’ eligibility for medical, hospital and vision services. To use the IVR system:

  1. Call (888) 819-1199.
  2. Enter your provider tax identification number (TIN).
  3. Enter the member’s 10-digit identification number and the patient’s date of birth.

Eligibility Verification for Emergency Services

If a member requires emergency services, the provider must verify eligibility as soon as practical under the circumstances.

Retroactive Eligibility

If the 1199SEIU Benefit Funds verify a member’s eligibility but subsequently learn that the member was not eligible at the time of service, the member will be retroactively ineligible for services provided and the Benefit Funds will not be liable for any services rendered to that ineligible member.

Coordination Benefits

When a member, spouse or child is covered by more than one group health plan, the two plans share the cost of the member’s family health coverage by “coordinating” benefits.

The primary plan makes the first payment on a claim and the secondary plan pays an additional amount according to its terms. Members are routinely sent Coordination of Benefits forms in order to establish whether the 1199SEIU Benefit Funds are their primary payer or their secondary payer.

If the Benefit Funds are unable to establish if they are the primary or secondary payer, the claim may be denied until additional information is received. Please remind members to complete all requested forms promptly to avoid claim and payment delays.

If the Benefit Funds are the primary payer, payments will be made according to the Benefit Funds’ Schedule of Allowances. The Benefit Funds should be billed first for these charges.

If the Benefit Funds are the secondary payer, the Benefit Funds will supplement the primary payer’s coverage according to the agreed-upon Schedule of Allowances. The primary payer should be billed first for charges. Please note that the total amount paid by both health plans combined cannot exceed the Benefit Funds’ Schedule of Allowances or 100 percent of the actual charges, whichever is less. The Benefit Funds will reimburse the member for the primary payer’s co-payments.

If the member and their spouse both have dependent coverage, the primary payer for any children will be the plan of the parent whose birthday is earlier in the year. The other parent’s plan is the secondary payer.

For spousal care, the spouse’s plan is the primary payer. The Benefit Funds are the member’s primary payer and the spouse’s secondary payer.

HMO, Paid-in-Full or Prepaid Plan Coverage

If the member’s spouse and/or children are enrolled in a Health Maintenance Organization (HMO) plan, or any other similar or paid-in-full plan, they must use the benefits provided by that plan. The 1199SEIU Benefit Funds will provide coverage only for those benefits that are not provided by that plan.

Medicare Eligibility

The 1199SEIU Benefit Funds are the primary payer for working members and their spouses age 65 and over who may be covered by Medicare. They are eligible for the same coverage as any other working member or spouse. Members may elect Medicare Part A and Part B, and in such cases, Medicare will become the secondary payer.

Once a member retires and becomes Medicare-eligible, they are no longer covered by the Benefit Funds’ Plans for working members, but they may be covered by the 1199SEIU Medicare Advantage Program administered by another carrier.

If a working member is entitled to Medicare benefits for end stage renal disease (ESRD), the Benefit Funds will be the primary payer of benefits only for the period required by law. Thereafter, the Benefit Funds will be secondary to Medicare.