Bricklayers of PA & DE

Claims address for Bricklayers #1 claims:

Allied Trades Assistance Program, Attn: billing department
4170 Woodhaven Road
Philadelphia, PA 19154

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Common Medical Event	Services You May Need	Your Cost If You Use a Network Provider	What Will be Covered if You Use an Out of Network Provider	Limitations & Exceptions
If you have mental health, behavioral health, or substance abuse needs	Mental/Behavioral health outpatient services	$20 copay per visit	50% of allowance per visit, after $1500 deductible *	Out of pocket maximum
	Mental/Behavioral health intensive outpatient services	$20 copay per visit	50% of allowance per visit, after $1500 deductible *	Out of pocket maximum
	Mental/Behavioral health partial services	$20 copay per visit	50% of allowance per visit, after $1500 deductible *	Out of pocket maximum
	Mental/Behavioral health inpatient services	No Charge	50% of allowance per visit, after $1500 deductible *
	Mental/Behavioral health inpatient miscellaneous facility charges	Included in room and board facility charges	50% of allowance per visit, after $1500 deductible *	Out of pocket maximum
	Substance use disorder outpatient services	$20 copay per visit	50% of allowance per visit, after $1500 deductible *	Out of pocket maximum
	Substance use disorder intensive outpatient services	$20 copay per visit	50% of allowance per visit, after $1500 deductible *	Out of pocket maximum
	Substance use disorder partial services	$20 copay per visit	50% of allowance per visit, after $1500 deductible *	Out of pocket maximum
	Substance use disorder inpatient services	No Charge	50% of allowance per visit, after $1500 deductible *
	Substance use disorder miscellaneous facility charges	Included in room and board facility charges	50% of allowance per visit, after $1500 deductible *	Out of pocket maximum

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* 50% of allowance refers to 50% of ATAP’s usual and customary charges. As a member, if the provider does not accept this as full payment, you can be balance billed anything above this and what you pay will not count toward your out of pocket maximum.

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Important Questions	Answers	Why this Matters:
What is the plan year?	The plan year is calendar year, January 1 – December 31.	The plan year impacts the way your benefit plan will cover your treatment costs.
What is the overall deductible?	For each calendar year: Network: Individual $0/ Family $0. Out of Network: Individual $1500/ Family $4500	You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use.
What is the overall lifetime maximum?	Unlimited except where otherwise indicated for network and out of network	The lifetime maximum refers to the total amount of money you can put out over the time you are covered by these benefits.
Is there an out of pocket maximum on my expenses?	No for in-Network Out of Network: Individual $10,000 / Family $20,000	The out of pocket maximum is the most you could pay during a coverage period for your share of the cost of covered services. This limit helps you plan for health care expenses.
Does this plan use a network of providers?	Yes. For a list of network providers, see www.alliedtrades-online.com or call 1-800-258-6376	If you use an in network provider, this plan will pay some or all of the costs of covered services. Be aware, your in network doctor or hospital may use an out of network provider for some services. Plans use the term in network, preferred, or participating for providers in the network.
Do I need authorization/pre-certification to see a Mental/Behavioral health or Substance use provider?	Authorization is required for inpatient services. An authorization form is required for all Levels of Care for Substance Use Disorder. An outpatient referral form is required for those seeking outpatient mental health services.	Authorization is required for all Inpatient Mental/Behavioral health and Substance use treatment services. Authorization can be obtained by calling ATAP at 1-800-258-6376. (Typically, the provider calls for this information).

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Provider Frequently Asked Questions	Answers	Additional Information
What is the effective date of the policy?	SPDs are effective the 1st of each year & benefits are based on a calendar year	N/A
Is there any pre-existing?	No	N/A
Are the mental health and substance abuse benefits combined?	No	N/A
Is accreditation required?	Yes	Both state license and JACHO accreditation are required
Are prescriptions covered by this plan?	No	Prescription medications are covered by the client’s prescription plan
Do intensive outpatient programs and partial hospitalization programs come from the inpatient or outpatient benefit?	Outpatient	N/A
What type of plan is this (PPO, HMO, etc.)?	Self funded	N/A
Are all levels of care authorized based on medical necessity?	Yes	N/A
Where do providers send claims?	Claims address will be provided when pre-certification is requested	Eligibility and potential benefit term date will also be explained at this time. Provider can call 800-258-6376 at the time of pre-certification to obtain this information
Is there an electronic payer ID?	Not at this time	N/A
Are there any limitations on this policy?	Yes	See above SPD for information about deductibles, out-of-pocket maximums, and other benefit limitations

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