Eligibility Manual www.claimsecure.com

Transcription

Eligibility Manual
www.claimsecure.com
Updated August 22, 2003
Table of Contents
Table of Contents
INTRODUCTION ............................................................................................................................................... 3
WHO TO CONTACT......................................................................................................................................... 3
GETTING STARTED ............................................................................................................................................. 4
ABOUT THE CLAIM SECURE SYSTEM ................................................................................................................. 4
PASSWORDS ........................................................................................................................................................ 4
WEB SITE UNAVAILABILITY .............................................................................................................................. 4
IMPORTANT GENERAL INFORMATION ................................................................................................. 5
SCRIPT PROMPT .................................................................................................................................................. 5
ENTERING AN IDENTIFICATION NUMBER OR SIN FOR A NEW MEMBER ........................................................... 5
UPPER CASE CHARACTERS ................................................................................................................................ 5
DATE FORMAT .................................................................................................................................................... 5
CHANGING SIN’ S OR IDENTIFICATION NUMBERS: ........................................................................................... 5
CHANGING MEMBER OR DEPENDENT EFFECTIVE DATES:.................................................................................. 5
COMMON BUTTONS ............................................................................................................................................ 6
LOG ON PROCEDURES .................................................................................................................................. 7
MAIN MENU ....................................................................................................................................................... 8
FEATURES AND BENEFITS OF ADMIN ELIGIBILITY ACCESS ............................................................................ 9
MEMBER FIELDS ...............................................................................................................................................10
MEMBER SEARCH .............................................................................................................................................12
MEMBER ELIGIBILITY ................................................................................................................................13
ADDING A NEW MEMBER .................................................................................................................................13
WAIVING WAITING PERIOD FOR NEW EMPLOYEES........................................................................................18
MEMBER ELIGIBILITY CHANGES .....................................................................................................................20
TERMINATING A MEMBER ...............................................................................................................................22
TO VIEW THE EFFECTIVE DATE OF THE TERMINATION: ...................................................................................23
REINSTATING A MEMBER WITHOUT A LAPSE IN COVERAGE.........................................................................25
REINSTATING A MEMBER WITH A LAPSE IN COVERAGE ................................................................................27
DEPENDENT ELIGIBILITY .........................................................................................................................29
ADDING OR CHANGING DEPENDENTS AND BENEFICIARIES ...........................................................................29
ADDING OR MODIFYING AN O VER-AGE DEPENDENT ....................................................................................31
ADDING OR MODIFYING COVERAGE FOR A DEPENDENT WITH A D ISABILITY..............................................33
ADDING A SPOUSE WITH COORDINATION OF BENEFITS INFORMATION (COB)............................................34
EHC & DENTAL COB FIELDS .........................................................................................................................34
COB EFFECTIVE D ATE ....................................................................................................................................34
COB EMPLOYER N AME ...................................................................................................................................34
REMOVING COORDINATION OF BENEFITS (COB) INFORMATION FOR A SPOUSE ..........................................35
CHANGING COORDINATION OF BENEFITS (COB) INFORMATION FOR A SPOUSE ..........................................36
TERMINATING A DEPENDENT ..........................................................................................................................37
REINSTATING A D EPENDENT ...........................................................................................................................38
ClaimSecure Web access
2
Introduction
Introduction
Welcome to the ClaimSecure web-based on-line access system!
This is a user-friendly system that provides access via the Web for you to:
• Update eligibility
• Query eligibility
The purpose of this manual is to provide you with a step by step guide on how to use this web
based system.
After reviewing this manual, if you have any questions, please contact your Client Service
Associate. ClaimSecure will make available ongoing support and work closely with you to
resolve any difficulties you may encounter.
Who to Contact
Questions
Who to
contact?
Telephone number
E-mail address
Eligibility inquiries (Changing
member I.D number, assistance
waiving waiting periods etc )
Logon issues (can’t connect to the
web, error message are displayed etc)
Group
Administration
888-513-4464
[email protected]
Helpdesk
888-513-4464 ext
2621
[email protected]
3
Getting Started
Getting Started
Our Website Address is
www.claimsecure.com
About the ClaimSecure System
The ClaimSecure system is a web-based application and is supported between 8:00 am and 5:00
pm Eastern Standard time. As a web based application, the ClaimSecure system makes use of the
navigational features commonly found on browsers. These features include the Back and
Forward buttons, which allow you to retrieve the pages you have recently used, and the Print
option (from the File menu), which allows you to print the information that you are currently
viewing. In addition to the Back, and Forward browser options, the ClaimSecure System offers its
own navigational buttons. Please refer to the descriptions of the Next, Previous, and Back buttons
in the section “Common Buttons” for additional information on these buttons.
Each ClaimSecure web session is timed so that if you leave a web session inactive for a certain
period, it will expire automatically. The length of inactive time before expiry can be modified on
the web server under the “Connection Timeout” property value. After a session has expired, you
must re-log into the application to regain connection and to request services.
All fields within the ClaimSecure system are case sensitive and require that you include the
appropriate upper case letters in the data that you enter. Mandatory fields must be entered as
outlined in this manual.
Passwords
Passwords in the ClaimSecure system are masked and encrypted. All new users are given an
initial default password, composed of User Name + 123, which must be replaced within two days
of the user creation date. If the default password is not replaced within two days, the system will
automatically set the user's status to inactive.
To ensure a high level of security, users must change their password every three months.
Web Site Unavailability
At the end of each month, we are required to run premium billings for all our accounts. During
the last 3 business days of each month, we ask that all clients refrain from adding,
changing or terminating member eligibility to help ensure accuracy in our billings.
4
Important General Information
Important General Information
Script prompt
Each time you press the save button when updating eligibility for members and dependents you
will receive the following script prompt. It is very important that you override this date and
enter the true effective date for each transaction.
Entering an Identification number or SIN for a new member
When adding a new member, all identification numbers must be 10 characters in length.
• SIN’s: Please remember to always key the leading zero. Example 0111222333
• Identification numbers: Identification numbers usually begin with the group number to
form a 10-digit number. For example if the group number is 1234, the identification
number may have the following format 1234001111.
Upper Case Characters
It is essential that you key all data in Upper Case characters (names, addresses etc).
Date Format
Our date format is Day/Month/Year. Example 23/05/2003. Please remember to key all 8 digits
for all dates.
Changing SIN’s or Identification Numbers:
•
SIN’s and identification numbers must be changed by our administrators in our Group
Administration office. Please contact us at 888-513-4464 and we will assist you with this
change.
Changing member or dependent effective dates:
•
If you are required to change an effective date, please do NOT change the dates on the web
screen. Please contact our Group Administration office and we will process the effective date
change for you.
5
Common Buttons
Common Buttons
The following is a description of the buttons commonly found on the ClaimSecure system:
Adds the information you have just entered to the database.
Returns to the previous page.
Returns you to the previous page .
Displays the next set of listings.
Returns to the previous page.
Saves the information you have just added or modified.
Searches for data that match the specified search criteria.
Software application:
A browser is a software application used to “surf” the net and works together with the operating
system (Windows, Unix etc.). We support Internet Explorer.
It is important to ensure that all “cookies” are enabled on your browser.
You do not download this application from a web site to your computer. Instead, the application
and data sits on our Web Server and your browser provides the access to the application and data.
Security:
Security is an extremely important issue when sharing information over a network. One of our
key components to this system is our security component. Multiple layers of security are
integrated into the system. Individual users will be provided with a unique identifier (username)
and a password.
ClaimSecure clients can access only the data that pertains to their own accounts.
6
Log On Procedures
Log On Procedures
To log on to ClaimSecure Web Eligibility Access, follow these procedures:
1.
Ensure that you are connected to the Internet.
2.
Using Internet Explorer, go to the ClaimSecure website at www.claimsecure.com
3.
Go to the English site.
4.
From the ClaimSecure homepage, click on Client Log on.
5.
You will now be prompted to enter a Client ID, User ID and Password; enter this and
click on “Log On”.
6.
After a successful log on, you will be presented with a main menu page. The list of
options on the menu may vary, dependent on the products and services purchased by the
client.
7
Main Menu
Main Menu
Once you have logged on, the Main Menu Page will be displayed. You can access all of the
functions available to you on the ClaimSecure website by way of the hyperlink options under the
headings Drug, Dental, Extended Health Care, Administration and Reports.
Note that the options displayed on this page depend on the privileges assigned to you by
ClaimSecure or Client Administrator. Options available to you are highlighted on the screen.
8
Main Menu
Features and Benefits of Admin Eligibility Access
The ClaimSecure Web Admin access allows you to:
•
Effectively maintain eligibility records by keying member, spouse and dependent additions,
changes and terminations in an on-line environment.
•
Query eligibility to ensure that all member, spouse and dependent records are on file,
accurate and up to date.
•
View individual premium calculations (if applicable)
•
View individual benefit volumes (if applicable).
9
Member Fields
Member Fields
Many of the fields that you see in this manual may not appear on your web page as this web
application is dynamic and fields may vary based on your plan design and setup. At the bottom
of this page, you will find a list of the member’s benefits, coverage, status, volumes and
premiums etc.
Field Help
Field help
The buttons on the top of this screen assist in maneuvering from one function to another.
•
M-Hist: Selection of this field will allow you to view member history such as changes to
health status and name changes. The history will also display the User ID who entered the
transaction, the date the change was entered, as well as the effective date.
•
B-Hist: Selection of this field will allow you to view Benefit History and will display benefit
changes such as increases of benefit volumes. The history will also display the User ID who
entered the transaction, the date the change was entered, the benefit volume before and after,
as well as the effective date.
•
Dep/Benef: Selection of this field will allow you to access dependents and beneficiaries.
• Billing (if applicable): Selection of this field displays current monthly premiums, net of
taxes, by employee. Retro charges and credits will also display along with the total premiums
calculated. This is especially useful where complex retroactive changes are involved to see
how they will affect the billing. It is always recommended that you view this screen each
time retroactive adds, changes and terminations are processed.
• Plan: Selection of this field will display a report which provides details such as plan design,
reductions, termination ages, maximum ages and benefit rates. You may print this report by
selecting the file “print” option within your browser.
• Next: Selection of this field will display the next member in the plan.
•
Prev: Selection of this field will display the previous member in the plan.
•
Add +: Selection of this field will allow you to add a new member. A blank eligibility
screen will appear allowing you to key a new member.
•
Save: Selection of this field will save the transaction just recorded. It should be used for
member and dependent additions, changes and termination. When reviewing a record and a
change is not being made, please do not use the save button. Please select “Log Out” or
select another eligibility record.
•
Calc (if applicable): Selection of this field forces a calculation of the current member’s
benefits. If the current month premium differs more than 15% from the previous month, a
warning will appear.
•
Srch NM: Selection of this field is used to search by member last name. Once the screen is
open, key in the surname and select OK.
•
Srch ID: Selection of this field is used to search by member ID. For Social Insurance
numbers and other 9 digit ID numbers, always enter a leading zero. Once the screen is open,
key in the certificate number and select OK.
11
Member Eligibility
Member Search
•
Access the website www.Claimsecure.com
•
Enter your client ID, User ID and password.
•
Select Eligibility Entry to add or modify member/dependent data.
•
Using the Srch Nm (Search Name) or Srch ID (Search ID/Certificate number) verify that the
member has not already been added to the system. When using the Srch ID function, you are
always required to enter a 10 digit ID number. For social insurance numbers, you are
required to enter a leading zero to form a 10 digit number. For example, enter the number as
0123123123.
Name Search
To switch to a new group, please enter the group number followed by the Surname. Example
1111/SMITH. If you are searching within the current group, enter the Surname only.
Example: SMITH.
ID Search
To switch to a new group, please enter the group number followed by the ID number.
Example: 1111/0123456789. If you are searching within the current group, enter the ID
number only. Example: 0123456789.
Member Eligibility
Member Eligibility
Adding a New member
•
To add a new member, click on the Add+ button on the screen.
Add button
•
A blank eligibility screen will appear. Here are some guidelines for completing the add
process and for updating eligibility on existing members.
•
Once the screen is completed, it is necessary to save the transaction by using the Save button
located at the top of the screen.
•
To move from field to field, always use the tab key on your keyboard. To update the
language and gender fields, you must click in each field with your mouse.
•
Given names and surnames must be entered in upper case characters.
•
All date fields are entered as Day/Month/Year – Example 23/04/2003.
13
Member Eligibility
Certificate Number: This is the member Identification number also known as “Certificate
Number”. This number must be keyed as you wish it to appear on the Pay-Direct Identification
cards, wallet certificate or eligibility reports. This certificate number is provided by the client or
assigned by ClaimSecure. The field is alphanumeric and consists of 10 characters. You may
search for members by this number. This is a mandatory field. For Social Insurance numbers
and other 9 digit ID numbers, always enter a leading zero.
Division/Unit: This is a 6 character numeric field. The division/unit is used to determine or
differentiate benefits or eligibility. This is a mandatory field and must be entered for each
member. It is used in the adjudication process and to sort billings and invoices. The pull down
menu on your screen will allow you to select the appropriate division and unit. Should you wish
to add new divisions and units to your existing plan, please contact your Client Service Associate.
Name: Given name. Enter the first name the way you would like it to appear on the pay-direct
card or wallet certificate. Name must be keyed in UPPER CASE (capital letters). This is a
mandatory field.
Surname: Family name (last). Enter the surname in UPPER CASE characters. This is a
mandatory field.
Address: This is an alphanumeric field that contains the street/mailing address of the member.
This is a mandatory field.
City: This is the city field and represents the city where the member resides. This is a mandatory
field.
Province: This is the province where the member resides and this field may be used in the
adjudication process on certain claims. A drop down list of all provinces is available. This is a
mandatory field and a province must be selected from the listing.
PC: This is the postal code associated with the address information. This is a mandatory field.
Telephone: This is the telephone field and represents the member’s home telephone number. This
field is optional.
Prov Empl: This is the province where the member works. This is a mandatory field. There is a
drop down list of province selections.
Hired: This is the date of hire. This is a mandatory field and together with any waiting periods,
will determine effective dates for benefits. Once you have finished adding a new member, please
review the effective dates of benefits to confirm that the dates are correct.
Terminated: This is the termination date and is used when a member terminates coverage. To
terminate a member, enter the date of termination (dd/mm/yyyy). This may be a future
termination date.
Language: This is the language field with a choice of either Eng (English) or Fr (French). Once
recorded, this allows for reports etc to be printed in the member’s choice of language. This is a
mandatory field.
D.O.B.: This is the date of birth field. This is a mandatory field (dd/mm/yyyy).
14
Member Eligibility
Gender: This is the gender field with a choice of either M (male) or F (female). This is used for
reporting and DUR (Drug Utilization Review) purposes. This is a mandatory field.
Smoker: This field may be required if your benefit package with ClaimSecure includes the
administration of Group Life and Optional Life benefits. This field is not required for
administration of Health and Dental benefits. If checked, this field indicates that the member is a
smoker and smoker rates will apply. If not checked, then non-smoker rates will apply.
Salary : This is a mandatory field if your benefit package with ClaimSecure includes risk benefits
(Life, AD&D, LTD). This is the primary salary. Salaries may be entered as annual, monthly, semimonthly, bi-weekly, weekly or hourly. The pay frequency is selected from the pull down box to
the right of the salary field. If you are entering an hourly rate, indicated the number of work hours
per week in the field “Hours”. This field is not required for administration of Health and Dental
benefits.
Health: This is the health coverage field and determines if the member has single or family
coverage. This is a mandatory field (Blank indicates no coverage).
Dental: This is the Dental coverage field and determines if the member has single or family
coverage. This is a mandatory field (Blank indicates no coverage).
Senior Claim ID: This is the Senior Claim Identifier used to record when a resident of the
province of Quebec has chosen to participate in the RAMQ plan, their private plan or both plans.
This field is mandatory for Quebec members and a selection is made from the following codes:
• R – means that the member has selected the RAMQ Plan
• P – means that the member has selected the Private Plan
• B – means that the member has selected Both plans.
• (Blank indicates – no coverage)
Spouse Claim ID: This is the Spouse Claim Identifier and as above is used to record whether a
spouse of a resident of the Province of Quebec has chosen to participate in the RAMQ plan, their
private plan or both plans. This field is mandatory for Quebec members and a selection is made
from the following codes:
• R – means that the member has selected the RAMQ Plan
• P – means that the member has selected the Private Plan
• B – means that the member has selected Both plans.
• (Blank indicates – no coverage)
It is very critical that any changes
ClaimSecure system.
in the senior claim status are updated in the
Location: This is an internal field used to sort card production.
15
Member Eligibility
•
Once the member data is entered, you must SAVE the member profile before entering the
dependent data.
Save
•
Press save. You will be prompted to enter the effective date. The effective date in the script
should be the same as the date of hire. If the date is different, please enter the date of hire in
the script prompt. Remember to always key the date of hire and allow the system to calculate
the effective date of benefits based on the waiting period in your plan design.
16
Member Eligibility
•
After the SAVE is complete, the lower portion of the screen allows you to view the benefits,
coverages, premiums, etc for the member. Always verify the effective dates of benefits at the
bottom of the screen for each transaction. If you were entering a retroactive add, you may be
generating retroactive premiums.
Verify effective dates
•
You can view the premiums by selecting the “Billing” option at the top of the member profile
screen. In this screen you can view retroactive credits and charges.
17
Waiving Waiting Periods
Waiving Waiting Period for New Employees
On occasion, you may need to waive waiting periods when key executives are hired. If your
benefit plan with Claimsecure includes the administration of risk benefits such as Group
Life and LTD, you CAN NOT WAIVE the waiting period without written approval from
the insurance carriers. Please contact our Group Administration department in our Sudbury
office at 888-513-4464 for assistance if this should occur.
If your benefit package does not include risk benefits, here are the steps required to waive a
waiting period.
•
•
•
To waive the waiting period for a new employee, begin with following the steps for entering
a new employee. Enter the employee’s true hire date and allow the system to calculate the
benefit effective dates based on your plan design.
Once the member has been added, benefits at the bottom of the screen may indicate “on
wait”.
Select each benefit at the bottom of the screen by selecting the square box to the left of each
benefit.
Once you have selected the benefit, a new screen will appear.
Change the effective date in this screen to the new effective date of coverage.
•
Press save and you will be prompted to enter the effective date once again.
•
•
Member Eligibility Changes
•
After the save is complete, you will return to the member profile screen.
•
Always verify the effective date at the bottom of the screen to ensure your effective date
change was successful. Follow these steps for each additional benefit.
19
•
•
•
Select Eligibility Entry to modify member data.
Select the member by using the Search Name or Search ID functions.
To edit eligibility for existing members, edit the required fields and save the transaction. In
this scenario we are changing the name from Bradley to Smith. Once you are situated in the
field you want to change (Surname), key Smith.
•
•
Select save.
You will be prompted to enter the effective date of the transaction. Please change the
effective date in the script prompt to the effective date of your change and press OK.
20
•
Verify the eligibility record to ensure that your transaction was successful. In this example,
the name has been changed from Bradley to Smith.
21
Terminating a Member
•
•
•
•
•
Select Eligibility Entry to terminate members.
Member information will appear on your screen. You must enter a date in the “Terminated”
field to terminate all benefits. In this example, we are entering the termination date of April
24, 2003.
Important Note: If your account has insured benefits such as the Out of Country travel
benefit, you can terminate a member retroactive to a maximum of 3 months. All
terminations with retroactive credits of more than 3 months need to be approved by the
carrier first. If this should occur, please contact our Group Administration department for
assistance.
Also, if you are extending coverage as part of a severance agreement, please contact your
client service for approval.
•
•
After the termination date is entered, you must SAVE the transaction.
You will be prompted to enter the effective date of the transaction.
•
•
Please change the date in the script prompt to the termination date.
Select OK.
22
•
Verify in the lower portion of the screen to ensure that all benefits are displayed as
terminated. The status will indicate Retro Term or Term.
To view the effective date of the termination:
•
•
•
Select each benefit at the bottom of the screen by selecting the square box to the left of each
benefit.
Once you have selected the benefit, a new screen will appear. You will now see the original
effective date as well as the termination date.
Select Back to return to the member profile screen.
23
Viewing Retroactive Credits and Charges
Viewing Retroactive Credits and Charges After Terminating or Adding a Member
•
After processing a retroactive termination or addition, you can view credits or charges
generated by selecting the “Billing” feature at the top of the member profile screen.
•
This screen will display the current month’s billing and will also display the calculated
amount of retroactive credits.
•
It is very important that you review this screen and ensure that premiums are correct.
24
Reinstating a Member Without a Lapse in Coverage
Reinstating a Member Without a Lapse in Coverage.
•
Select Eligibility Entry to reinstate a member.
•
•
Member information will appear on your screen. Remove the date in the TERMINATED
field to reinstate all benefits.
•
In this example, the member was terminated effective 01/04/2003.
coverage effective 01/04/2003.
25
We are reinstating
Reinstating a Member Without a Lapse in Coverage
After the termination date is removed, you must SAVE the transaction.
•
You will be prompted to enter the effective date of the reinstatement. Please change the date
in the script prompt to the reinstatement date. In this example, the reinstatement date is
01/04/2003.
•
Select OK.
•
Verify in the lower portion of the screen that all benefits are reinstated. Under the column
“Status” the word “term” should be removed.
26
Reinstating a Member With a Lapse in Coverage
An example of a reinstatement with a lapse in coverage is when a member is terminated April 1,
2003 and the member is re-activated June 1, 2003. Therefore, there is no coverage between the
period of April 1, 2003 and May 31, 2003. The process is similar to the reinstatement, however
there is one additional step required.
•
•
•
Select Eligibility Entry to reinstate a member.
Member information will appear on your screen. Remove the date in the TERMINATED
field to reinstate all benefits. In this example, the member was terminated January 1, 2003.
We are reinstating benefits effective March 1, 2003.
•
•
•
Remove the termination date and press save.
You will be prompted to enter the effective date.
In this example, the reinstatement date is March 1, 2003. Enter the reinstatement date in the
script prompt and press Save.
27
The system will automatically reinstate coverage back to the member’s original
effective date. Therefore, the following steps are required to ensure that benefits
have a lapse in coverage.
Benefit screen after the reinstatement
As you can see, the benefits have been reinstated back to the member’s original add
date of April 1/2002. Once the benefits have been reinstated, you need to change the
benefit effective date at the bottom of the member profile screen by doing the following:
•
•
•
•
•
•
•
•
Select each benefit and change the effective date to the reinstatement date. In this
example, we are changing the effective date to 01/03/2003.
Press Save.
You will receive a script prompt to enter the effective date again. Enter 01/03/2003.
Select OK.
You will return to the member profile screen.
At the bottom of the screen, you will notice the new effective date of 01/03/2003
Repeat these steps for each benefit.
Ensure that all benefits at the bottom of the member profile screen are displaying the
new effective date.
28
Dependent Eligibility
Adding or Changing Dependents and Beneficiaries
The dependent/beneficiary screen consists of basic dependent information (first name, last name,
date of birth, relationship, COB status, beneficiary designation, etc).
Field help: (Note: fields indicated as mandatory are compulsory on all add transactions.
• For a change to the dependent record, the effective date and the field to be changed are
mandatory.
• For dependent terminations, the field “terminated” is mandatory.
Dependent Check box: The dependent screens allows you to enter an individual as a dependent
for claims coverage, plus it also allows you to key beneficiary designations. For Health and
Dental claims adjudication, the “dep1” box must always be checked. If the individual is a
beneficiary and is not a covered dependent, the check box must be left blank. It is possible for a
dependent to be flagged as a dependent and a beneficiary in the same record.
Name: This field is the first name of the dependent. This is a mandatory field.
Surname: This field is the last name of the dependent. This is a mandatory field.
DOB: This field is the date of birth for the dependent. This is a mandatory field. The format of
this field is ddmmyyyy.
Rel: This field is the relationship code and provides a pull down list of available option.
Example: wife, son, daughter, husband, etc. This field is also required for beneficiaries. This is a
mandatory field.
Beneficiary Check Box: Beneficiary information is only required if your benefit package with
ClaimSecure includes Life benefits. If you are entering a beneficiary, this box must be checked.
Beneficiary Info: Beneficiary information is only required if your benefit package with
ClaimSecure includes Life benefits. These fields are used to designate a beneficiary. To flag a
dependent as a beneficiary, you must check the box Benef. In addition, you are required to
record the full or partial beneficiary designation by recording the applicable benefit and
percentage to be paid in the fields indicated.
Effective: This field is the original effective date of the dependent’s coverage. The format of this
field is ddmmyyyy. This is a mandatory field.
Term: This field is the date the dependent terminated coverage. The format of this field is
ddmmyyyy. This is a mandatory field for terminations.
School End: This field is the student end date. Coverage for a student would end as of this date.
The school end date is also used for dependents with disabilities. The format of this field is
dd/mm/yyyy. This is a mandatory field for students and disabled dependents.
Gender: This field is the gender of the dependent and can be coded with either M (male) or F
(female). This is a mandatory field.
Smoker: This field may be required if your benefit package with ClaimSecure includes the
administration of Spousal Optional Life benefits. This field is not required for administration of
Health and Dental benefits. If checked, this field indicates that the dependent is a smoker and
smoker rates will apply. If the field is not checked, then non-smoker rates will apply.
School/Employer: This field is used to record the name of the school that the dependent student
is attending. This field is also used to record the spouse’s employer. This is a mandatory field
for students and also for spouses who may be coordinating benefits with another carrier.
Status: This field is a code to determine if the dependent is a student or a disabled dependent.
This is a mandatory field.
EHC COB: This field indicates that a spouse is coordinating EHC coverage with a secondary
private payer. The spousal option is either S (single coverage elsewhere) or F (family coverage
elsewhere). If the spouse has family coverage elsewhere, then according to C.L.H.I.A. rules,
dependent children would be covered under the parent whose birth date is first in the year. This is
a mandatory field when the spouse is coordinating benefits with another carrier.
Dental COB: This field indicates that a spouse is coordinating Dental coverage with a secondary
private payer. The spousal option is either S (single coverage elsewhere) or F (family coverage
elsewhere). If the spouse has family coverage elsewhere then according to CLHIA rules, the
dependent children would be covered under the parent whose birth date is first in the year. This is
a mandatory field when the spouse is coordinating benefits with another carrier.
COB Eff: This field is the date the Spousal COB coverage became effective.
mandatory field when the spouse is coordinating benefits with another carrier.
•
•
•
•
This is a
Once these fields are entered for each dependent, save the transaction by selecting the SAVE
option located at the top of the screen.
You will receive a script prompt to enter the effective date again.
Select OK. You will return to the member profile screen.
To edit eligibility for existing dependents, edit the required fields and save the transactions.
30
Adding or Modifying an Over-Age Dependent
•
Select Eligibility Entry to add or modify a dependent.
•
•
Select Dep/Benef on top of the member profile screen and the dependent screen will appear.
•
Click on the box “Dep?”.
•
The mandatory fields for over-age dependents are: Dep?, Name, Surname, DOB, Rel,
Effective date, School End Dis Start, School/Employer and Stud.
•
Over-age students must be added with the status “stud”.
•
We require the school end date to be entered in the field “School End/Dis”. End dates are
usually entered as August 31st of the current year. Dependents who are indicated as
students must re-apply every year and their School End/Dis date must be updated
before August 31st of each year. If the student status is not updated by September 1st of
each year, we will reject claims. Once the school end date has been entered, coverage will
expire on that date.
•
Please remember to update existing children to student status once they reach the dependent
maximum age according to your plan design.
•
Children that have not reached the dependent maximum age should not be entered as
“stud” until they reach the dependent maximum age in your plan design. They should be in
the system as dependents even if they are in a post secondary school.
•
Enter the school name.
•
Press save once you are finished keying the dependent. You will be prompted to enter an
effective date. Change the date in the script prompt to the effective date of the add or
change. Select OK.
31
Once the dependent has been added and saved, you will return to the member profile screen.
Select Dep/Benef if you want to return to the dependent screen.
Over-Age student fields
Student field
School Name
School End date
32
Adding or Modifying a Dependent With a Disability
Adding or Modifying Coverage for a Dependent With a Disability
•
•
•
Select “Dep/Benef” on top of the member profile screen and the dependent screen will
appear. Click on the box “Dep?”.
•
The mandatory fields for over-age dependents are: Dep?, Name, Surname, DOB, Gender,
Rel, Effective date, School End Dis Start, School/Employer and Dis.
•
In the “School End/Dis” field you must enter the start date of disability. For example, if
you are adding a dependent with a disability effective 13/01/2003, you need to enter that date
in 2 fields: “Effective” and “School End Dis Start". This date does not need to be changed.
•
Press Save. You will be prompted to enter the effective date of the transaction. Change the
effective date to 13/01/2003. Select OK and you will return to the member profile screen.
Disability field
Start date of disability
33
Adding a Spouse with Coordination of Benefits Information (COB)
Adding a Spouse With Coordination of Benefits Information (COB)
If a spouse has coverage with another provider and your account is set-up as “Coordination of
benefits”. ClaimSecure maintains the other provider information in our system. Coordination of
benefit indicators should only be entered on a spouse record and not on a dependent record.
The following fields are mandatory in order to apply coordination of benefits and should never be
blank:
• School/Employer: Please enter the other provider’s name. If the name is unknown,
please enter “NA”.
• EHC COB: Indicate if the spouse has S “single” or F “family” coverage with the
other provider. If EHC COB does not apply, select the box N/A.
• Dental COB: Indicate if the spouse has S “single” or F “family” coverage with the
other provider. If DENTAL COB does not apply, select the box N/A.
• COB eff: Indicate the effective date of the coordination of benefits whether the S or
F or blank is elected.
Mandatory fields for adding a spouse with coordination of benefits are: Dep1, Surname, Name,
DOB, Rel, Spouse box, Effective Date, gender, EHC COB, Dental COB, School/Employer, COB
Effective Date.
EHC & Dental COB fields
COB Effective Date
COB Employer Name
34
Removing Coordination of Benefits (COB) Information for a Spouse
Removing Coordination of Benefits (COB) Information for a Spouse
•
The following fields remain mandatory when changing coordination of benefits information:
These fields should never be blank with the exception of School/Employer.
•
•
•
•
•
School/Employer: Should be removed.
EHC COB: Remove coverage by selecting N/A.
Dental COB: Remove coverage by selecting N/A.
COB eff: Enter the date the spouse has lost coverage with the other provider.
Press save and you will be prompted to enter an effective date of the transaction. In this
example, the spouse is removing coordination of benefits effective 23/05/2003.
Remove COB coverage for EHC and Dental by selecting N/A
Replace the effective date with the new effective date COB is being removed
Remove the employer name
35
Changing Coordination of Benefits for a Spouse
Changing Coordination of Benefits (COB) Information for a Spouse
•
The following fields remain mandatory when changing coordination of benefits information.
These fields should never be blank.
•
•
•
•
School/Employer: Change the name to the new provider or enter “N/A”.
EHC COB: Change coverage indicator or select N/A
Dental COB: Change coverage indicator or select N/A
COB eff: Change the date that coordination of benefit coverage is changing.
•
In this example, the spouse is changing the COB indicator from F to S for both EHC and
Dental with an effective date of 23/05/2003.
•
Press save and you will be prompted to enter an effective date.
23/05/2003.
Change the date to
Change the EHC & Dental COB fields
Change the COB Effective Date
Change the Employer Name if Required
36
Terminating a Dependent
Terminating a Dependent
•
If the member is also terminated, it is NOT necessary for you to also terminate
dependents.
•
•
•
Select Dep/Benef field. Find the dependent in the list of dependents and enter the termination
date in the TERM field. In this example, we are terminating the dependent effective
24/03/2003.
•
Save the transaction and the system will prompt you for the effective date. Change the
effective date of 24/03/2003 and select save.
•
You will return to the member profile screen.
•
If you wish to confirm that the transaction was successful, select Dep/Benef again and verify
that the dependent has a date in the TERM field.
Dependent Termination Date
37
Reinstating a Dependent
Reinstating a Dependent
•
•
•
Select Dep/Benef field. Find the dependent in the list of dependents and remove the
termination date in the TERM field. In this example we are reinstating the dependent
effective 24/03/2003.
•
Save the transaction and the system will prompt you for the effective date. Change the
effective date of 24/03/2003 and select save.
•
If you wish to confirm that the transaction was saved, select Dep/Benef again and verify that
the dependent has no date in the TERM field.
Remove date in the Term field
38

Eligibility Manual www.claimsecure.com

Transcription

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