Healthcare Providers

High Option
Healthcare Providers

Whether you regularly service NALC Health Benefit Plan members or you are seeing one for the first time. understanding our Plan policies and the benefits we offer is a top priority. Please select the members' plan type to learn about our Provider Networks. Eligibility, Member Benefits. Claim Submissions. Claim Status. Electronic Payment Information and Provider Resources.

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Provider Networks of the
High Option Plan

We strive to give our members the freedom to choose the providers they wish to see. We provide our members with In-Network medical providers through the Cigna OAP Network and In-Network mental health and substance use providers through Optum Health. 

If you do not participate in our networks, that is ok. We also offer out-of-network benefits to our members which are considered our standard benefits.

Medical Providers

The Plan’s provider network for medical services is through the Cigna Open Access Plus Network.

We encourage providers to register through the Cigna for Health Care Professionals website. It is a powerful tool to help you and your office staff conduct business with Cigna efficiently in real time.

There are many reasons to use the Cigna for Health Care Professionals website. First, it's easy to use and available at no cost to you. Second, you can view and access the following information and functions:

  • Cigna’s health care professional newsletters
  • Eligibility and benefits
  • Cigna claim editing procedures

Click here to get started.

If you are not participating in the Cigna OAP provider network but are interested in joining, please visit Cigna’s Health Care Provider Credentialing website.

Note – If Medicare is the primary payor, we follow Medicare guidelines while our Cigna OAP provider network is waived.

Mental Health and Substance Use Providers

The Plan's provider network for mental health and substance use providers is through Optum Health. We encourage providers to register for the Provider Express website through Optum Health. There are many reasons to use the Optum Health Provider Express website.

  • Optum’s Behavioral Health newsletters
  • Request Prior Authorization
  • Verify member benefits
  • Update provider demographics and more

If you are not participating in the Optum Health provider network but are interested in joining, please visit
www.providerexpress.com or call 877-468-1016.

Eligibility

Determining a member’s eligibility is an important step when it comes to giving them the care they need. Please see the information below to determine member eligibility.

Download Quick Start Guide

Detailed Benefits of the
NALC High Option Plan

Understanding a member’s plan benefits is an important step toward a satisfied patient. For benefit
information, please see the information below.

BENEFIT
MEMBERS PAY (IN-NETWORK)
MEMBERS PAY (NON-PPO)
Annual Routine Physical Exam (age 3 or older)
Nothing
35% after $300 deductible*
Adult Routine Immunizations & Tests
Nothing
35% after $300 deductible*
Well Child Care (through age 2)
Nothing
35% after $300 deductible*
Routine Immunizations (through age 21)
Nothing
35% after $300 deductible*
BENEFIT
MEMBERS PAY (IN-NETWORK)
MEMBERS PAY (NON-PPO)
Maternity
Nothing
35% after $450 per admission copay*
Medical/Surgery
Room and Board
Other Services and Supplies
$350 copayment per admission
35% after $450 per admission copay*
Mental Health/Substance Abuse
Room & Board Other Services and Supplies
$350 copayment per admission
35% after $450 per admission copay*
BENEFIT
MEMBERS PAY (IN-NETWORK PPO)
MEMBERS PAY (NON-PPO)
Medical/surgical
15% after $300 deductible
35% after $300 deductible*
Emergency Medical
15% after $300 deductible
15% after $300 deductible*
Observation Room
$350 copayment
35% after $300 deductible*
BENEFIT
MEMBERS PAY PPO
MEMBERS PAY NON-PPO
Initial office visit / Office visit on day of manipulation
$25 copayment per visit
35% after $300 deductible*
Manipulations (24 per calendar year)
$25 copayment per visit
35% after $300 deductible*
One set of spinal x-rays annually
15% after $350 deductible
35% after $300 deductible*
BENEFIT
MEMBERS PAY (IN-NETWORK PPO)
MEMBERS PAY (NON-PPO)
Office visits
$25 copayment per visit
35% after $300 deductible*
Telehealth virtual visit
$10 copayment per visit
-
X-rays, other diagnostic services
15% after $300 deductible
35% after $300 deductible*
BENEFIT DESCRIPTION
MEMBERS PAY (IN-NETWORK PPO)
MEMBERS PAY (NON-PPO)
LabCorp or Quest Diagnostics
Nothing
-
Other lab facility
15% after $300 deductible
35% after $300 deductible*
BENEFIT DESCRIPTION
MEMBERS PAY (IN-NETWORK PPO)
MEMBERS PAY (NON-PPO)
Office visit
$25 copayment per visit
35% after $300 deductible*
Telemental virtual visit
$10 copayment per visit
35% after $300 deductible*
Other diagnostic services
15% after $300 deductible
35% after $300 deductible*
LabCorp or Quest Diagnostics
Nothing
-
Other lab facility
15% after $300 deductible
35% after $300 deductible*
BENEFIT DESCRIPTION
MEMBERS PAY (IN-NETWORK PPO)
MEMBERS PAY (NON-PPO)
Accidental dental injury (to a sound natural tooth)
15% within 72 hours
35% after $300 deductible within 72 hours*
BENEFIT DESCRIPTION
A Generic Equivalent Will Be Dispensed If It Is Available, Unless Your Physician Specifically Requires A Brand Name
• Certain Drugs Require Prior Approval.
NETWORK
NON NETWORK
Retail Pharmacy
There is a 30-day plus one refill limit at local retail.
1st and 2nd fill:
Generic: 20% of Plan allowance 
(10% of Plan allowance for asthma, diabetes, & hypertension)
Formulary brand: 30% of Plan allowance
Non-Formulary brand: 50% of Plan allowance
Note: You may purchase up to a 90-day supply (84-day minimum) of covered drugs and supplies at a CVS/Caremark Pharmacy or through our Maintenance Choice Program. You will pay the applicable mail order copayment for each prescription purchased.
Retail: 50% of Plan allowance*
Mail Order Program
60-day supply: $10 generic / $60 Formulary brand / $84 Non-Formulary brand
90-day supply: $15 generic / $90 Formulary brand / $125 Non-Formulary brand
($8 generic / $50 Formulary brand / $70 Non-formulary brand for asthma, diabetes & hypertension)
Specialty drugs (requires prior approval)
We use the NALC's Advanced Control Specialty formulary
Caremark Specialty Pharmacy Mail Order:
  • 30-day supply: $200
  • 60-day supply: $300
  • 90-day supply: $400
Medical/Mental Health and Substance use disorder care
You pay nothing after deductible, coinsurance and copayment expenses total:
  • $3,500 per person or $7,000 family for services of PPO providers/facilities.
  • $5,000 per person or $10,000 per family for services of PPO/Non-PPO providers/facilities combined
Prescription
You pay nothing after coinsurance amounts for prescription drugs dispensed by a CVS National Network pharmacy and mail order copayment amounts total:
  • $3,100 per person or $5,000 family (SilverScript PDP, $2,000 per person).
BENEFIT
MEMBERS PAY (IN-NETWORK)
MEMBERS PAY (NON-PPO)
Annual Routine Physical Exam (age 3 or older)
Nothing
35% after $350 deductible*
Adult Routine Immunizations & Tests
Nothing
35% after $350 deductible*
Well Child Care (through age 2)
Nothing
35% after $350 deductible*
Routine Immunizations (through age 21)
Nothing
35% after $350 deductible*
BENEFIT
MEMBERS PAY (IN-NETWORK)
MEMBERS PAY (NON-PPO)
Maternity
Nothing
35% after $450 per admission copay*
Medical Room and Board
$350 copayment per admission
35% after $450 per admission copay*
Mental Health/Substance Use
Room and Board
$350 copayment per admission
35% after $450 per admission copay*
BENEFIT
MEMBERS PAY (IN-NETWORK PPO)
MEMBERS PAY (NON-PPO)
Medical/surgical
15% after $300 deductible
35% after $350 deductible*
Emergency Medical
15% after $300 deductible
15% after $350 deductible*
Observation Room
$350 copayment per admission
35% after $350 deductible*
BENEFIT
MEMBERS PAY PPO
MEMBERS PAY NON-PPO
Initial office visit / Office visit on day of manipulation
$25 copayment per visit
35% after $350 deductible*
Manipulations (24 per calendar year)
$25 copayment per visit
35% after $350 deductible*
One set of spinal x-rays annually
15% after $350 deductible
35% after $350 deductible*
BENEFIT
MEMBERS PAY (IN-NETWORK PPO)
MEMBERS PAY (NON-PPO)
Office visits
$25 copayment per visit
35% after $350 deductible*
NALCHBP Telehealth
$10 copayment per visit
-
X-rays, other diagnostic services
15% after $350 deductible
35% after $350 deductible*
BENEFIT DESCRIPTION
MEMBERS PAY (IN-NETWORK PPO)
MEMBERS PAY (NON-PPO)
LabCorp or Quest Diagnostics
Nothing
-
Other lab facility
15% after $350 deductible
35% after $350 deductible*
BENEFIT DESCRIPTION
MEMBERS PAY (IN-NETWORK PPO)
MEMBERS PAY (NON-PPO)
Office visit
$25 copayment per visit
35% after $350 deductible*
Telehealth virtual visit
$10 copayment per visit
35% after $350 deductible*
Other diagnostic services
15% after $300 deductible
35% after $350 deductible*
LabCorp or Quest Diagnostics
Nothing
-
Other lab facility
15% after $300 deductible
35% after $350 deductible*
BENEFIT DESCRIPTION
MEMBERS PAY (IN-NETWORK PPO)
MEMBERS PAY (NON-PPO)
Accidental dental injury (to a sound natural tooth)
15% within 72 hours
35% after $350 deductible within 72 hours*
BENEFIT DESCRIPTION
A Generic Equivalent Will Be Dispensed If It Is Available, Unless Your Physician Specifically Requires A Brand Name
  • Certain Drugs Require Prior Approval.
NETWORK
NON NETWORK
Retail Pharmacy
There is a 30-day plus one refill limit at local retail.
1st and 2nd fill:
Generic: 20% of Plan allowance 
(10% of Plan allowance for asthma, diabetes, & hypertension)
Formulary brand: 30% of Plan allowance
Non-Formulary brand: 50% of Plan allowance
Note: You may purchase up to a 90-day supply (84-day minimum) of covered drugs and supplies at a CVS/Caremark Pharmacy or through our Maintenance Choice Program. You will pay the applicable mail order copayment for each prescription purchased.
Retail: 50% of Plan allowance and any difference between our allowance and the billed amount
Mail Order Program
90-day supply:
Generic = 20% of the Plan allowance, maximum of $250 per prescription
Formulary brand = 30% of the Plan allowance, maximum of $350 per prescription
Non-Formulary brand = 50% of the plan allowance and any difference between our allowance and the charge, maximum of $500 per prescription
Specialty drugs (requires prior approval)
We use the NALC's Advanced Control Specialty formulary
Caremark Specialty Pharmacy Mail Order:
  • 30-day supply: $200
  • 60-day supply: $300
  • 90-day supply: $400
Medical/Mental Health and Substance use disorder care
You pay nothing after deductible, coinsurance and copayment expenses total:
  • $3,500 per person or $7,000 family for services of PPO providers/facilities.
  • $5,000 per person or $10,000 per family for services of PPO/Non-PPO providers/facilities combined
Prescription
You pay nothing after coinsurance amounts for prescription drugs dispensed by a CVS National Network pharmacy and mail order copayment amounts total:
  • $3,100 per person or $5,000 family (SilverScript PDP, $2,000 per person).

If you have questions, please contact our Customer Service Department at 888-636-NALC (6252), or download our Official Plan brochure.

** Note: When Medicare is the primary payor and covers services, we follow Medicare guidelines and coordinate with them by paying the patient deductible, copayments, coinsurance and lifetime reserve days at 100%.

If Medicare denies a service and it is a covered benefit of the Plan, we will pay 100% of the Plan allowance for services up to plan limitations/maximums.

Where Should You Submit Your Claims?

If you have claims to submit for NALC Health Benefit Plan members, please see below for the submission process that best fits your scenario. 

Medical Claim Submissions

If NALC or other non-Medicare coverage is primary:

  • Please submit claims electronically to: 
    Cigna/NALC HBP using electronic payor ID# 62308
  • If you are submitting claims by paper, please mail to: 
    NALC Health Benefit Plan, P.O. Box 188004, Chattanooga, TN 37422

If Medicare is primary:

  • Please submit claims electronically to Medicare. We participate in the CMS Coordination of Benefits Program and will obtain primary benefit information electronically. 
  • If you are submitting claims by paper, please include the Medicare remittance while mailing the claim to: 
    NALC Health Benefit Plan, 20547 Waverly Ct, Ashburn, VA 20149

Note: If you do not have electronic claim submission capabilities, please mail claims on a standard HCFA-1500 or UB-04 claim form.

Mental Health and Substance Use Claim Submissions

If NALC or other non-Medicare coverage is primary:

  • Please submit claims electronically to:
    OptumHealth using electronic payor ID# 87726
  • If you are submitting claims by paper, please mail to: 
    OptumHealth Behavioral Solutions, P.O. Box 30755, Salt Lake City, UT 84130-0755

If Medicare is primary:

  • Please submit claims electronically to Medicare. We participate in the CMS Coordination of Benefits Program and will obtain primary benefit information electronically. 
  • If you are submitting claims by paper, please include the Medicare remittance while mailing the claim to: 
    NALC Health Benefit Plan, 20547 Waverly Ct, Ashburn, VA 20149

Note: If you do not have electronic claim submission capabilities, please mail claims on a standard HCFA-1500 or UB-04 claim form.

Do You Need To Check The status of a claim?

If you previously submitted a claim and have yet to receive an explanation of benefits or payment, please see the following options.

For Medical Claim Status:

For Mental Health & Substance Use Claim Status:

  • Please contact OptumHealth Behavioral Solutions by calling
    877-468-1016.

Electronic Payment Information

The NALC Health Benefit Plan has partnered with Revenue Management Solutions (RMS) to implement its state-of-the-art provider platform for electronic payments and more.  

RMS gives eligible providers the ability to electronically receive payments for covered services from the NALC Health Benefit Plan. The RMS Platform offers expanded online visibility into claims submitted and member eligibility through its Claims Status and Eligibility modules. And best of all. its FREE.

If you have questions, please contact our Customer Service Department at 888-636-NALC (6252).
For more information on how to enroll, please view our quick start guide.

Download Quick Start Guide

Provider Resources

As a provider, having the resources needed can make your job a little easier.

Get Prior Authorization & Pre-Certification Support

Please visit our Prior Authorization Center and if you still have questions, please contact our Customer Service Department.

Visit Prior Authorization Center
Call Customer Service 888-636-NALC (6252)

Download the official NALC BHP Plan Brochure

Everything in one place - the Official NALC Plan Brochure.

The brochure is the go-to guide for plan benefits, coverage details and enrollments codes.
Keep it handy for your self and share it with members.

Download 2026 Brochure
Download 2025 Brochure

FAQs – High Option Providers

Need Help or
Have Questions?

We’re here to help you understand your health care options and make the most of your coverage.

Talk to a Plan Expert

Please contact our Customer Service Department between the hours of 8 a.m. to 6 p.m. Eastern, by calling 888-636-NALC (6252).

  • If you are an in-network medical provider in the Cigna OAP Network, please contact Cigna Provider Relations. 
  • If you are an in-network mental health/substance use provider in the Optum Network, please contact Optum Health Behavioral Solutions. 
  • If you are a non-participating provider, please contact the Plan’s Customer Service Department at 888-636-NALC (6252).

  • If you are an in-network medical provider in the Cigna OAP Network, please contact Cigna Provider Relations.

  • If you are an in-network mental health/substance use provider, please contact Optum Health Behavioral Solutions.

  • If you are a non-participating provider, please contact the Plan’s Customer Service Department at 888-636-NALC (6252).

View All FAQs