Group Administrator`s Manual

Transcription

Group Administrator’s Manual
for
Groups with 51 or More Eligible Employees
Form No. 3-402 (10-01)
The enclosed Group Administrator’s Manual is a general resource that answers questions
insureds may have regarding their coverage. It covers parts of the policy in general terms.
Please refer to your Master Group Policy for complete details.
Table
of
Contents
Phone Numbers and Addresses . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Who is Eligible for Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Enrollment Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Enrollment Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Causes of Ineligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Consolidated Omnibus Budget Reconciliation Act . . . . . . . . . . . . 9
Billing Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
How to File Health Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
How to File Prescription Drug Claims . . . . . . . . . . . . . . . . . . . . 21
How to File a Dental Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
How the Vision Service Plan Works . . . . . . . . . . . . . . . . . . . . . . . 27
Preview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Group Administrator’s Manual – Large Group
Phone Numbers
and
Addresses
To Submit Health Claims:
Blue Cross of Idaho
Claims Department
or PO Box 7408
Boise, ID 83707-1408
Blue Cross of Idaho
Claims Department
3000 E. Pine Avenue
Meridian, ID 83642-5995
For Customer Service:
Blue Cross of Idaho
Customer Services Dept.
or
PO Box 7408
Boise, ID 83707-1408
Blue Cross of Idaho
Customer Services Dept.
3000 E. Pine Avenue
For Traditional Group:
Toll-free:
Boise calling area:
1-800-627-1188
(208) 331-7347
For Preferred Provider Organization (PPO):
Toll-free:
Boise calling area:
1-800-627-1006
(208) 331-7699
To Submit Dental Claims or for Customer Service:
Blue Cross of Idaho
Dental Services
or
PO Box 7408
Boise, ID 83707-1408
Blue Cross of Idaho
Dental Services
3000 E. Pine Avenue
Toll Free:
Boise Calling Area:
1-800-289-7929
(208) 363-8755
For Preview:
Preadmission Review:
Toll-Free:
Boise Calling Area:
1-800-627-1187
(208) 345-2576
Customer Services:
Toll-Free:
Boise Calling Area:
1-800-627-1188
(208) 331-7347
Blue Cross of Idaho’s website: www.bcidaho.com
1
Who
is
Eligible
for
Coverage
Refer to your Master Group Policy for details.
Who Qualifies for Health Care Coverage
All eligible employees and their dependents qualify for health care coverage when eligibility and
enrollment criteria are met.
Who is an Eligible Employee
An eligible employee is a full-time, regular employee who works 20 hours or more a week.
The definition of eligible employee may also include public officers and public employees without
regard to the number of hours worked, at the discretion of the employer.
Newly hired employees qualify for coverage for themselves and their dependents after completing
your group’s designated probationary period, if any.
Who is an Eligible Dependent
An eligible employee’s lawful spouse qualifies for coverage. A dependent, never-married child
(natural, stepchild, adopted, or legally placed with the employee for adoption) is eligible for
coverage:
1.
Until the end of the month in which the child turns age 23, if finacially dependent upon the
employee for support; or
2.
Until the age specified in your group policy; or
3.
If medically certified as disabled due to mental disability, retardation, or physical disability
(subject to periodic recertification) and financially dependent upon the employee for
support, regardless of age.
2
Enrollment Information
Benefit Summary
The Benefit Summary describes your employees’ coverage based on your group policy. Blue
Cross of Idaho provides your group with a current Benefit Summary to distribute to each of your
enrolled employees.
Identification Cards
Each enrolled employee will receive two Blue Cross of Idaho identification cards for his or her use
and for the use of any insured family members. Both cards list the employee’s name as the
enrollee and include the enrollee identification number. Covered members should show the
identification card to the health care provider at the time services are received. If your group
provides prescription drug coverage, the identification card should be shown to the pharmacist at
the time prescription drugs are purchased.
Leave of Absence
An employee with an approved leave of absence may continue to receive your group’s benefits at
your rates for up to 90 days, unless your group policy specifies otherwise. The Family and
Medical Leave Act (FMLA) of 1993 (applies to groups of 50 or more) requires continued coverage
for up to 12 weeks, if eligible. Please make a notation on your billing in the “Explanation” column
on the Roster page that the employee is on an approved leave of absence and submit the
appropriate payment (employee and employer contributions) with the billing. To ensure
continued coverage for the employee, your group must continue making its regular payment for
the employee’s coverage during the approved leave of absence. We will not accept payments
made directly by an employee.
Retirement
Enrollees who retire at age 65, have both Medicare Part A and Part B, and are Idaho residents
qualify for Blue Cross of Idaho Medicare supplement coverage. They may enroll in any of our
Medicare supplement programs without health statement approval during the six-month open
enrollment period following the 65th birthday or with enrollment in Part B of Medicare. Medicare
supplement policyholders can pay by bank withdrawal or will be billed directly.
If the retiree has covered dependents, eligible family members under age 65 may have two options
for continuous coverage:
1.
If the dependent resides in Idaho, the dependent may be eligible to transfer to a Blue Cross of
Idaho individual program, if a properly completed application is received by Blue Cross of
Idaho within 30 days from when group coverage was terminated; or
2.
If your group qualifies, the dependent may be eligible for COBRA continuation coverage
(please refer to the Consolidated Omnibus Budget Reconciliation Act section).
Name or Address Change
To make a name or address change, the employee should complete a Member Name or Address
Change Card, then mail the self-addressed card to Blue Cross of Idaho. When an employee has a
name change, the Group Administrator should cross off the former name, then write in the new
name on the Roster page of the group billing. See the example in the Forms section of the
Resource Handbook.
3
Transfer of Enrollment
An enrolled employee or insured dependent may be eligible to transfer coverage, without lapse of
coverage or health statement approval for new coverage, when the insured individual:
Is no longer eligible for enrollment with the group, has no other health coverage,
and still resides in Idaho—The insured individual living in Idaho may be eligible to
transfer to a Blue Cross of Idaho individual program, if a completed application is submitted
to Blue Cross of Idaho within 30 days from when group coverage was terminated; or
Lives or moves out of state—The insured individual may transfer enrollment to the Blue
Cross and Blue Shield Plan that serves the state to which he or she is moving. The insured
individual should check with that Plan for confirmation. Credit for waiting periods already
satisfied in the original state may apply in the new state. If the insured individual who moves
out of state elects new coverage from an insurance company other than the Blue Cross and
Blue Shield Plan that serves the state to which he or she is moving, transfer of enrollment
with no lapse of coverage is not guaranteed.
Transfer of enrollment gives employees continuous health care protection with credit for waiting
periods for preexisting conditions. Please explain to the employee or insured dependents that the
benefits and rates for the new coverage may differ from those offered by your group.
4
Enrollment Procedures
To see how to adjust your billings for new employees and new dependents, please refer to the Billing
Adjustments section.
How to Enroll Newly Hired Eligible Employees
Each newly hired eligible employee requesting coverage must complete an application and apply
for coverage within a 30-day period of becoming eligible or 30 days prior to completion of their
probationary period, which we refer to as the “initial enrollment period.” The Group Administrator
should send the employee’s application with the billing prior to their requested effective date. The
employee’s effective date will be the first day of the month following receipt of a completed
application, provided the employee has or will have completed any probationary periods as stated
in your group’s Master Group Policy. Failure to submit a completed application during the initial
enrollment period may qualify the eligible employee as a late enrollee. (Please refer to the Who
Qualifies as a Late Enrollee section for more information.)
How to Determine the Effective Date of Coverage
If the application for coverage is properly completed and submitted, a new employee’s coverage
will become effective the first day of the month following Blue Cross of Idaho’s receipt of
application, provided the eligible person has completed the probationary period, if any. Blue Cross
of Idaho will bill for the employee on the next billing statement.
How to Add a New Eligible Dependent
To add an eligible dependent, the employee must complete an application and apply for coverage
for such eligible dependent within a 30-day period of the dependent becoming eligible for
coverage. This is referred to as the “initial enrollment period”. If a dependent is a newborn natural
child, adopted, or is eligible because of marriage, the initial enrollment period is 60 days (see
paragraph below). Failure to submit a completed application during the initial enrollment period
may qualify the eligible dependent as a late enrollee. (Please refer to the Who Qualifies as a Late
Enrollee section below for more information.) Incomplete applications, including applications
unsigned or undated, will be returned for completion.
If the application is properly completed and submitted within 30 days of the eligibility date,
coverage for a new dependent will become effective the first day of the month following Blue
Cross of Idaho’s receipt of the application.
To add a newborn natural or adopted child or a dependent who is eligible because of marriage,
the employee must complete an application and apply for coverage within a 60-day period of the
dependent becoming eligible. In the case of a newborn dependent who is the enrollee’s natural
child, the date of birth will be the effective date. If the eligible dependent has been placed with
the enrollee for adoption, the completed application should be submitted within 60 days after the
date of placement. The date of birth will be the effective date of coverage for an enrolled adopted
eligible dependent placed within 60 days of the date of birth. The date of placement will be the
effective date of coverage for an enrolled adopted eligible dependent placed after 60 days of the
date of birth.
How to Enroll Late Enrollees
Enrollment procedures are the same regardless of when an eligible employee or dependent
applies for coverage, whether during or after the initial enrollment period. Ask the employee to
5
complete an application, then submit it immediately. If approved, coverage will be effective the
first day of the month following receipt of the application.
Effective on or after January 1, 2000, coverage for late enrollees will be effective on the
anniversary date of the group’s policy, if approved.
Who Qualifies as a Late Enrollee
A late enrollee is an eligible employee or dependent who requests enrollment in your group’s
health care coverage after the initial 30-day enrollment period. Full waiting periods will be
applied to coverage for all late enrollees.
If an individual does not qualify as a late enrollee when applying for coverage after the initial
enrollment period, credit for qualifying previous coverage will be applied to preexisting condition
waiting periods.
An eligible employee or dependent shall not be considered a late enrollee if:
1.
The individual meets each of the following criteria:
a.
The individual was covered under qualifying previous coverage at the time of initial
enrollment;
b. The individual lost the qualifying previous coverage as a result of termination of
employment or eligibility, the involuntary termination of the qualifying previous
coverage, or the death or divorce of a spouse; and
c.
The individual requests enrollment within 30 days after termination of the qualifying
previous coverage; or
2.
Your group offers multiple health benefit plans and the individual elects a different plan
during an open enrollment period; or
3.
A court has ordered coverage be provided for a spouse, minor, or dependent child under a
covered employee’s health benefit plan, and request for enrollment is made within 30 days
after issuance of the court order.
6
Causes
of Ineligibility
To see how to adjust your billings for any of the examples listed below, please refer to the Billing
Adjustments section.
Group Termination
Group coverage terminates on the last day of the month for which the group made payment for
the terminating employee or the day specified in your group policy.
Divorce or Death of a Covered Dependent
In the event of a divorce or death of an insured dependent, the employee should complete the
front of an enrollment application (which is also used as an enrollment change form), indicating
the date of divorce or death, and list any covered dependents who should remain insured. The
Group Administrator should mail the enrolled employee’s application immediately to Blue Cross of
Idaho.
A newly divorced ex-spouse who is a resident of Idaho, and with no other health coverage, may be
eligible to transfer to a Blue Cross of Idaho individual program if a properly completed application
is received by Blue Cross of Idaho within 30 days from the date group coverage was terminated.
Group coverage for the ex-spouse terminates on the date of divorce. A newly divorced ex-spouse
may be eligible for COBRA continuation coverage. (Please refer to the Consolidated Omnibus
Budget Reconciliation Act section.)
“Dependent Child” Status Ends
An insured child becomes ineligible for coverage as the employee’s dependent:
•
On the date he or she marries; or
•
On the last day of the month in which he or she attains age 23, if financially dependent upon
the employee for support, or the age specified in your group policy; or
•
When the child attains financial independence; or
•
Upon divorce, stepchildren on the date of the divorce.
Coverage may be extended for a dependent child who is medically certified as disabled due to
mental disability or retardation or physical disability and financially dependent upon the employee
for support. Request a Certification for Mentally Disabled or Retarded or Physically Disabled
Dependent form from Blue Cross of Idaho. The employee and current attending physician must
complete and return the form to Blue Cross of Idaho within 31 days of the child’s 23rd birthday if
the child has extended coverage as a student. Eligibility is subject to periodic recertification.
It is the employee’s legal responsibility to notify the Group Administrator or Blue Cross of Idaho
when a dependent child is no longer eligible for coverage. When a child no longer qualifies for
coverage, the employee should complete the Change Request section on the front of an
enrollment application. The covered employee should include the child’s name, date of marriage,
or the date the child ceased to be an eligible dependent under the terms of the group policy.
The insured dependent child who is terminating does have choices for continuing insurance
coverage. Refer to the next section, “Termination of Employment and Death of Employee.”
7
Termination of Employment and Death of Employee
Coverage for surviving covered family members ends on the last day of the month following the
employee’s death.
A terminated employee and his or her dependents and surviving insured dependents of a deceased
employee who live in Idaho may:
•
Transfer to a Blue Cross of Idaho individual program, if they have no other health coverage in
force, and if a properly completed application is received by Blue Cross of Idaho within 30
days from the date group coverage was terminated; or
•
Be eligible for COBRA continuation coverage if your group qualifies (please refer to the
Consolidated Omnibus Budget Reconciliation Act section).
A terminated employee and his and her dependents and surviving insured dependents of a
deceased employee who are either moving or are already residing out of Idaho may:
•
Transfer enrollment to the Blue Cross and Blue Shield Plan that serves the state to which they
are moving after checking with that Plan for confirmation; or
•
Elect new coverage from an insurance company other than the Blue Cross and Blue Shield
Plan that serves the state to which they are moving; in which case, there is no guarantee of
continuous coverage; or
•
Be eligible for COBRA continuation coverage if your group qualifies (please refer to the
Consolidated Omnibus Budget Reconciliation Act section).
8
Consolidated Omnibus Budget Reconciliation Act
What is COBRA?
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) applies only to certain
employers who sponsor group health care programs for their employees and who have employed
20 or more employees on a typical day (at least 50% of the time) in the previous year. If your
group meets these criteria, we strongly recommend that you seek advice from your company’s
legal counsel about how COBRA provisions may apply to your group.
Title X of COBRA amends the Internal Revenue Code, the Public Health Service Act, and Title I of
the Employee Retirement Income Security Act (ERISA) to require certain employers to provide
continuation of health care coverage, at the employee’s expense, to certain employees and their
eligible dependents who would otherwise have become ineligible for coverage because of certain
“qualifying events” listed below.
Employers are required by law to notify new employees and their spouses of COBRA continuation
when health care coverage begins and to send notice to any employee at the time of the event
that qualifies the employee or dependents for COBRA continuation. (See Information
Concerning Group Health Coverage Continuation sample form at the end of this section.)
Qualifying Events and Periods of Continued Coverage
COBRA health coverage continuation is available to employees and/or eligible dependents who
are covered by their group’s health care program at the time of a qualifying event that would
otherwise result in the loss of group coverage. Qualifying events and applicable periods of
continuation for eligible employees and/or dependents are listed below:
•
Employment terminates (other than for gross misconduct)
Term: up to 18 months1 for employee and eligible dependents; or
•
Work hours are reduced
Term: up to 18 months1 for employee and eligible dependents; or
•
Death of employee
Term: up to 36 months for eligible dependents; or
•
Employee becomes eligible for Medicare2
•
Employee and spouse divorce or legally separate
•
Dependent child ceases to be a “dependent child” under the terms of the group health
program; i.e., child turns age 23, child marries, or child provides the majority of his or her
own support.
Term: up to 36 months for that child.
1Qualified beneficiaries who are or have been determined to be disabled by the Social Security Administration at any time during
the first 60 days of continuation coverage may be entitled to coverage for up to 29 months instead of 18 months. This extension is
dependent upon when Medicare coverage begins.
2Please note that a person who retires before reaching age 65, elects COBRA continuation, and then turns age 65 and is eligible for
Medicare, becomes ineligible for COBRA, even if he or she has not completed the COBRA continuation period.
9
Administration of COBRA
When the Group Administrator receives notice of a qualifying event, the following steps should be
taken:
Provide the employee and/or eligible dependents with a notice and election form. (See Group
Health Coverage Continuation Notice and Election sample form at the end of this section.)
1.
If COBRA continuation has not been elected nor COBRA payment received before the
expiration of existing coverage, process billing forms according to instructions under the
Causes of Ineligibility section. The employee and/or dependents will be considered
terminated from group coverage until they have enrolled in the COBRA continuation
program. The option to elect COBRA continuation expires 60 days after the employer
notifies the employee of COBRA continuation eligibility.
2.
Submit the Blue Cross of Idaho Group Coverage Continuation Application for COBRA along
with necessary payment when an individual elects COBRA continuation. Be sure to keep a
record of the continuation notice and election form in your files.
3.
Collect payment for coverage from the COBRA beneficiaries and submit it on their behalf
within 45 days of election. Payment must be retroactive to the date of expiration of the
coverage that was in effect at the time of the qualifying event. Please note that Blue Cross of
Idaho will not accept COBRA continuation payment directly from the COBRA beneficiary
or apart from the group’s payment. COBRA continuation payment must be included in
the group’s regular payment.
Important note: Within six months prior to the end of the COBRA continuation term, the Group
Administrator is required by federal law to notify the beneficiaries living in Idaho, who have no
other health coverage, that upon completion of the full term of COBRA continuation they may be
eligible for continuous coverage under a Blue Cross of Idaho individual program. A properly
completed application must be received by Blue Cross of Idaho within 30 days from the
termination date of COBRA health coverage to ensure continuous coverage. (See “Transfer of
Enrollment” under the Enrollment Information section.)
Group billings will list all COBRA beneficiaries separately from active employees.
When COBRA Continuation Ends
When a COBRA beneficiary loses eligibility because, for example, payment was not made or the
continuation period expired, please line out that beneficiary’s name on the group billing. Note in
the “Explanation” column of the Roster page the reason for terminating COBRA continuation and
deduct the amount for the terminating COBRA beneficiary.
10
INFORM ATION CONCERNING GROUP HEALTH COVERAGE CONTINUATION
SENT: April 19, 2000
NAME: ˙N ame¨
GROUP #: ˙G rpNo¨
IMPORTANT NOTICE
I.D.#: ˙Id No¨
As used in this Notice, ˙G rpName¨ will be referred to as the "Group Health Plan"; ˙G rpName¨ will be referred to as the "Employer";
and _____________________________________, an agent or employee of the Employer, will be referred to as the "Plan
Administrator." (If no Plan Administrator has been designated here, then the Employer shall be the Plan Administrator.)
The Federal law commonly referred to as COBRA requires most employers sponsoring group health plans to offer employees and their
covered family members the opportunity for a temporary extension of health coverage (called "continuation coverage" or COBRA
coverage ) in certain instances where coverage under the plan would otherwise end. This notice is intended to inform you, in a
summary fashion, of your rights and obligations under the continuation coverage provisions of COBRA.
Both you (the employee) and your spouse should read this summary carefully and keep it with your records.
Qualifying Events
If you are an employee covered by the Group Health Plan, you have the right to elect this continuation coverage if you lose your group
health coverage because of one of the following two qualifying events:
(1) Termination of your employment (for reasons other than gross misconduct on your part); or
(2) Reduction in your hours of employment.
If you are the spouse of an employee covered by the Group Health Plan, you have the right to elect continuation coverage for yourself if
you lose group health coverage under the Group Health Plan for any of the following four qualifying events:
(1) The death of your spouse;
(2) A termination of your spouse’s employment (for reasons other than gross misconduct) or reduction in your spouse’s hours of
employment;
(3) Divorce or legal separation from your spouse; or
(4) Your spouse becomes eligible for Medicare.
The dependent child of an employee covered by the Group Health Plan has the right to elect continuation coverage if group health
coverage under the Group Health Plan is lost for any of the following five qualifying events:
(1) The death of a parent;
(2) The termination of a parent’s employment (for reasons other than gross misconduct) or reduction in a parent’s hours of employment
with the Employer;
(3) Parents’ divorce or legal separation;
(4) A parent becomes eligible for Medicare; or
(5) The dependent ceases to be a "dependent child" under the Group Health Plan.
Maximum Coverage Period
If you (the employee) lose coverage because of termination of employment (other than for gross misconduct) or reduction in hours, the
maximum continuation coverage period for you and any covered family members is 18 months from the date of termination or reduction
in hours. There are two exceptions:
(1) If you (the employee) or a covered family member is disabled at any time during the first 60 days of continuation coverage
(beginning with the date of termination or reduction in hours), the continuation coverage period for all qualified beneficiaries under the
qualifying event is 29 months from the date of the termination or reduction in hours. The Social Security Administration must formally
determine under Title II (Old Age, Survivors, and Disability Insurance) or Title XVI (Supplemental Security Income) of the Social
Security Act that the disability exists and when it began. For the 29-month continuation coverage period to apply, notice of the
determination of disability under the Social Security Act must be provided by the disabled individual to the Employer within the 18month coverage period and within 60 days after the date of the determination.
(2) If a second qualifying event occurs (e.g., the employee dies or becomes divorced) within the 18-month or the 29-month coverage
period, the maximum coverage period becomes 36 months from the date of the initial termination or reduction of hours.
If you (the employee s spouse or dependent child) lose group coverage because of the employee s death, divorce, legal separation, or the
employee s entitlement to Medicare, or because you l ose your dependent status under the Group Health Plan, the maximum coverage
period for the spouse and dependent child is 36 months from the date of the qualifying event.
Form No. 4-152 (9/97)
11
If you (the employee s spouse or dependent child) are on continuation coverage and (1) the original qualifying event was either
termination of the employee s employment or reduction in the employee s hours of employment and (2) the employee becomes entitled
to Medicare within 18 months of the original qualifying event, your maximum coverage period ends 36 months from the date the
employee became entitled to Medicare.
Notices and Election
Under this law, you (the employee or a covered family member) have the responsibility to inform the Plan Administrator of a divorce,
legal separation or a child losing dependent status under the Group Health Plan within 60 days of the divorce, legal separation or child
losing dependent status. If you fail to notify the Plan Administrator during the 60-day notice period, any family member who loses
coverage will not be eligible to elect continuation coverage.
The Employer has the responsibility to notify the Plan Administrator of the employee’s death, termination of employment, reduction in
hours or Medicare eligibility within 30 days of the death, termination, reduction in hours or Medicare eligibility.
When the Plan Administrator is notified as described in the previous paragraph, the Plan Administrator will in turn notify you (the
employee or a covered family member) that you have the right to elect continuation coverage. You have 60 days from the date you
would lose coverage because of one of the events described in the previous paragraph or 60 days after receiving notice from the Plan
Administrator, whichever is later, to inform the Plan Administrator that you are electing continuation coverage. The employee or
covered spouse may elect continuation coverage for all covered family members. In addition, the employee, and his or her covered
spouse and covered dependent children each have an independent right to elect continuation coverage. Therefore, a covered spouse or a
covered dependent child may elect continuation coverage even if the employee does not elect continuation coverage.
If continuation coverage is elected, the Employer must provide coverage that is identical to the coverage provided under the Group
Health Plan to similarly situated employees or family members. If the coverage for similarly situated employees or family members is
modified, continuation coverage will be modified the same way.
If you do not elect continuation coverage, your group health insurance coverage will end.
Newborn, Placed or Adopted Children With the Covered Employee after the Qualifying Event
If a child is born to, placed for adoption with, or adopted by a covered employee during the period of continuation coverage, the
employee may apply to enroll the child for coverage according to the eligibility and enrollment provisions of the Group Health Plan.
There are specified time limits for submitting applications. Please refer to your Benefit Summary, Member Certificate, or Group Health
Plan for details.
Te rmination Before the End of Maximum Coverage Period
Continuation coverage may be cut short for any of the following five reasons:
(1) The Employer no longer provides group health coverage to any of its employees;
(2) The premium for your continuation coverage is not paid;
(3) You (employee or any covered family member) become covered under another group health plan that does not contain any exclusion
or limitation with respect to any preexisting condition that you or any other covered family member has;
(4) You (employee or any covered family member) become eligible for Medicare;
(5) You (employee or any covered family member) were entitled to a 29-month maximum coverage period due to a disability, and you
receive a final determination under Title II or XVI of the Social Security Act that you are no longer disabled.
If you (employee or a covered family member) have any questions about COBRA continuation coverage, please contact the Plan
Administrator. Also, please notify the Plan Administrator immediately if you become covered under another group health plan that
does not contain any exclusions or limitations with respect to any preexisting conditions you may have, or if you or your spouse has
changed addresses.
Form No. 4-152 (9-97)
12
GROUP HEALTH COVERAGE CONTINUATION NOTICE AND ELECTION
TO: ˙N ame¨
Group Number: ˙G rpNo¨
Date of Notice: April 19, 2000
Identification Number: ˙I dNo¨
IMPORTANT NOTICE
As used in this Notice, ˙G rpName¨ will be referred to as the "Group Health Plan"; ˙G rpName¨ will be referred to as the "Employer";
and ______________________________________________, an agent or employee of the Employer, will be referred to as the "Plan
Administrator." (If no Plan Administrator has been designated here, then the Employer shall be the Plan Administrator.)
Your eligibility for group health coverage terminated or will terminate on ˙T rmDate¨.
On April 7, 1986, a new Federal law was enacted (Public Law 99-272, Title X) requiring that most employers sponsoring group health
plans offer employees and their covered family members the opportunity for a temporary extension of health coverage (called
"continuation coverage") at group rates in certain instances where coverage under the plan would otherwise end. This notice is intended
to inform you, in a summary fashion, of your rights and obligations under the continuation coverage provisions of this law.
(Both you and your spouse should take the time to read this notice carefully. )
If you are an employee covered by the Group Health Plan, you have the right to choose this continuation coverage if you lose your group
health coverage because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross
misconduct on your part).
If you are the spouse of an employee covered by the Group Health Plan, you have the right to choose continuation coverage for yourself
if you lose group health coverage under the Group Health Plan for any of the following four reasons:
(1) The death of your spouse;
(2) A termination of your spouse’s employment (for reasons other than gross misconduct) or reduction in your spouse’s
hours of employment;
(3) Divorce or legal separation from your spouse; or
(4) Your spouse becomes eligible for Medicare.
In the case of a dependent child of an employee covered by the Group Health Plan, he or she has the right to continuation coverage if
group health coverage under the Group Health Plan is lost for any of the following five reasons:
(1) The death of a parent;
(2) The termination of a parent’s employment (for reasons other than gross misconduct) or reduction in a parent’s hours
of employment with the Employer;
(3) Parents’ divorce or legal separation
(4) A parent becomes eligible for Medicare; or
(5) The dependent ceases to be a "dependent child" under the Group Health Plan.
Under this law, the employee or a family member has the responsibility to inform the Plan Administrator of a divorce, legal separation,
or a child losing dependent status under the Group Health Plan within 60 days of the event. The Employer has the responsibility to
notify the Plan Administrator of the employee’s death, termination of employment or reduction in hours, or Medicare eligibility within
30 days of the event.
When the Plan Administrator is notified that one of the events has happened, the Plan Administrator will in turn notify you that you
have the right to choose continuation coverage. Under this law, you have at least 60 days from the date you would lose coverage because
of one of the events described above or 60 days after receiving notice from the Plan Administrator, whichever is later, to inform the Plan
Administrator that you want continuation coverage.
If you do not choose continuation coverage, your group health insurance coverage will end.
If you choose continuation coverage, the Employer is required to make available to you coverage which is, as of the time the coverage is
available, identical to the coverage provided under the Group Health Plan to similarly situated employees or family members. This law
requires that you be afforded the opportunity to maintain continuation coverage for 3 years unless you lost group health coverage because
of a termination of employment or reduction in hours. In that case, the required continuation coverage period is 18 months; however, if
you are determined to be disabled under the Social Security Act (Title II, OASDI or Title XVI, SSI) at the time you become eligible for
continuation coverage, you are entitled to 29 months of coverage or until you are no longer disabled, whichever occurs first. This law
also provides that continuation coverage may be cut short for any of the following four reasons:
(1) The Employer no longer provides group health coverage to any of its employees;
(2) The premium for your continuation coverage is not paid;
(3) You or any other covered family member becomes covered under another group health plan that does not contain any
exclusion or limitation with respect to any preexisting condition that you or any other covered family member has; or
(4) You or any other covered family member becomes eligible for Medicare benefits.
Form No. 4-153 (5-96)
(Continued, Over)
CC: ˙G rpNo¨
13
You do not have to show that you are insurable to choose continuation coverage. However, under this law you may have to pay all or
part of the premium for your continuation coverage. This law also says that, in certain circumstances, at the end of the 18 month or 3
year continuation coverage period, you must be allowed to enroll in an individual conversion health program under the Group Hea lth
Plan if a conversion option is available to similarly situated active employees. If you choose to enroll in an individual conversion
health program, you must comply with all requirements for conversion as set forth in your employer s Group Health Plan Policy.
If you have any questions about this law, please contact the Plan Administrator. Also, if you have become covered under another
group health plan that does not contain any exclusions or limitations with respect to any preexisting conditions, or you or your
spouse have changed addresses, please notify the Plan Administrator.
ELECTION
I hereby acknowledge that I have read the foregoing Group Coverage Continuation Notice and elect as follows:
�
I DO elect to continue coverage under the Group Contract and agree to the conditions and requirements outlined above. I
understand that my first premium payment for continuation coverage must be received within 45 days of the date of this
election and that all subsequent monthly premiums must be received by the first day of each month.
�
I DO NOT elect to continue coverage under the Group Contract.
___________________________
Date
_________________________________________________________________
Signature of Employee / Spouse / Child
Form No. 4-153 (5-96)
14
15
Billing Adjustments
For your reference, an example of a billing statement, including sample detail, is included in the
Sample Billing at the end of the Billing Adjustments section.
Due Date
Payment is due to Blue Cross of Idaho on or before the first day of the month.
Benefits will not be provided to insureds whose current payment has not been made, and
coverage will be terminated for nonpayment for the entire group as of the last day for which
payment has been made. By promptly paying the amount due, delays in claims processing and/or
payment may be avoided.
Billing Changes
Include all changes to your group’s enrollment with your bill.
1.
2.
3.
4.
Enter rates to be added to your bill next to the “Add Total Additions” for:
• new enrollees
• new eligible dependents, if addition(s) changes rates
When a newborn is added to a single, two-party or two-party no spouse contract, please
submit a full month’s premium for the child if his or her date of birth falls on or
between the 1st and 15th day of the month. No premium is required for the first partial
month if the child’s date of birth falls on or between the 16th and 31st day of the
month.
Enter rates to be subtracted from your bill (for a terminating or deceased enrollee) next to
“Subtract Total Deductions.” These rates would include:
• divorce
• death of a covered dependent
• when dependent child status ends because “child married,”“child turned 23,” or “child
independent”
• termination of employment
• death of employee
• reduction in hours worked
Adjust the amount for the total due on page one of the bill.
Use the “Explanation” column on the Roster page of your bill to explain why the change was
made (birth, death, divorce, or termination) and the date of the event.
Billing Reconciliation
After you make all necessary changes for the month, recheck the billing for accuracy using the
payment reconciliation section on page one of the bill:
“Add Total Additions”—This is the total of all your additions for the month.
“Subtotal”—This is the sum of the “Ending Balance” and “Add Total Additions”.
“Subtract Total Deductions”—This is the total of all deductions for the month.
“Please Pay This Amount”—This is your revised total.
When you send your payment, please include:
1.
2.
3.
All pages of the white copy of the original billing showing your reconciliation; and
Any applications for dependent changes; and
Your check for the amount due.
le
Health Claims
16
17
ANY CORPORATION
ANY CORPORATION
8989 W 4TH ST
ANYTOWN, ID 83700
ROSTER NUMBER -- 9925992599
REASON--
OVER/SHORT
PAYMENT ACTIVITY SINCE LAST STATEMENT
BEGINNING BALANCE FROM 09/08/99
35,000.00
-----------------------
35,000.00
THIS AMOUNT
PLEASE PAY
TOTAL DEDUCTIONS
SUBTRACT
SUBTOTALS
TOTAL ADDITIONS
ADD
10/01/99 THRU 10/31/99
BILLING STATEMENT
CR
GROUP NUMBER
STATEMENT NUMBER
AUDITOR NAME
PHONE EXT
STATEMENT DATE
DUE DATE
=================
-----------------------------
-----------------------------
-----------------------------
32,000.00
32,000.00
-----------------------------
0.00
9999-001
1999090017.00
R. SMITH
8885
9/9/1999
10/01/99
payment to help ensure accurate processing.
PAGE 1
VERY IMPORTANT : Please be sure to return all applications with WHITE copy of this billing and your
18
DOE, MARK
DOE, JAMES
DOE, JILL
DOE, TIMOTHY
111-11-1111
121-21-2121
323-12-9955
414-83-5641
03
03
03
03
03
2PARTY
SINGLE
FAMILY
SINGLE
FAMILY
FAMILY
10/01/99
DUE DATE
8885
R. SMITH
1999090017.00
9999-001
258.15
131.40
333.20
131.40
333.20
333.20
131.40
258.15
146.25
131.40
131.40
9/9/1999
258.15
131.40
333.20
131.40
333.20
333.20
131.40
258.15
146.25
131.40
333.20
TOTAL DUE
STATEMENT DATE
PHONE EXT
DOE, LEWIS
222-22-2222
03
SINGLE
AUDITOR NAME
DOE, JAMES
333-33-3333
03
2PARTY
ANYTOWN, ID 83700
DOE, VICTORIA
444-44-4444
03
2PTYNS
8989 W 4TH ST
DOE, STACY
555-55-5555
03
SINGLE
131.40
333.20
AMOUNT
EMPLOYER
STATEMENT NUMBER
DOE, JANE
663-66-6645
03
SINGLE
FAMILY
RATE STRUCTURE
GROUP NUMBER
DOE, REBECCA
777-77-7777
03
03
OPT LOB
ANY CORPORATION
DOE, BELINDA
888-88-8888
NAME
FROM 10/01/99 THRU 10/31/99
ANY CORPORATION
DOE, JOHN S.
999-99-9999
ID
BILLING
DEPARTMENT -- 0001 -- ACTIVE
ROSTER - 9925992599
payment to help ensure accurate processing.
EXPLANATION
PAGE 2
VERY IMPORTANT : Please be sure to return all applications with WHITE copy of this billing and your
To receive benefits for covered services, a claim must be submitted. There are two ways to submit a
claim:
Claim Filing by Provider
The health care provider (physician, specialist, hospital, or other professional facility) will file the
claim and will work closely with Blue Cross of Idaho to help insureds obtain their benefits.
1.
For services supplied by an Idaho provider, the insured should present his or her Blue Cross
of Idaho identification card and ask that the claim be submitted to Blue Cross of Idaho.
2.
For services supplied by a provider outside of Idaho, the insured should present his or her
Blue Cross of Idaho identification card and ask that the claim be submitted to the local Blue
Cross and Blue Shield Plan. This procedure allows the insured to take advantage of any
discount arrangement the provider might have with the local Blue Cross and Blue Shield Plan.
Claim Filing by Insured
Insureds can send in their own claims. They should follow these steps:
1.
Ask the physician, specialist, hospital, or other professional facility for an itemized billing. An
itemized billing indicates each service received and its procedure code, the date the service
was furnished, the diagnosis code and the charge for each service. Blue Cross of Idaho
cannot accept billings that only say “Balance Due,”“Payment Received,” or similar billing
notations.
2.
Obtain a Patient Questionnaire (see example in the Forms section of the Resource
Handbook) from the health care provider or from any Blue Cross of Idaho office. Follow the
instructions at the top of the questionnaire. Complete one form for each patient. Group
Administrators may order a supply of Patient Questionnaires to keep on hand for their
employees.
3.
Send the Patient Questionnaire and itemized billing to:
Claims Department
Blue Cross of Idaho
or
PO Box 7408
Boise, ID 83707-1408
Claims Department
Blue Cross of Idaho
3000 E. Pine Avenue
4.
Blue Cross of Idaho will process the Idaho provider claims and forward the claims for
services furnished by a provider outside Idaho to the local Blue Cross and Blue Shield Plan.
5.
Claims must be filed within 12 months of the date of service to be eligible for benefits.
Notification of Payment
As soon as the claim is processed, the insured will receive an Explanation of Benefits (EOB) from
Blue Cross of Idaho. The EOB (see example at the end of this section) will list each patient, the
provider of service, date of service, type of service, charge and an explanation of how the claim
was processed. The EOB will indicate whether payment was sent to the provider or insured.
EOBs do not contain prescription drug claim information.
This section applies only if your group coverage includes prescription benefits. For complete details
19
20
®
®
®
Form No. 225P (Rev. 08/98)
1-800-682-9095
Help us protect your health care dollars.
Improper billing and submission of fraudulent
claims drive up the cost of health care.
If you suspect insurance fraud,
please call Blue Cross of Idaho’s confidential
Fraud Hotline at
or write to:
Blue Cross of Idaho Customer Service
PO Box 7408, Boise, ID 83707
For Customer Service please call:
159
Group No.
599-33-4444
Enrollee ID No.
Enrollee Name
Jane L. Smith
BlueCross
of Idaho
This claim was denied because the service is not a benefit of your contract/policy.
50.30
50.30
.00
.00
c.
12.58
12.58
Amount
Your Plan
Pays
This amount was paid to you because you received services from a noncontracting
provider. It is your responsibility to reimburse this provider.
3.32
1.66
1.66
Amount
Applied to Copayment/
Deductible Coinsurance
b
b
b
Remarks
Code
80% a
80% c
80% c
%
Your
Plan
Pays
10/04/99
b.
66.20
62.88
1.66
1.66
Amount
Noncovered
Page 1 of 1
The amount your plan pays is included in the enclosed check.
You may owe all or a portion to you provider.
TOTALS:
Medical Equipment
Medical Equipment
Medical Equipment
Blue Cross
of Idaho
Contractual
Savings
Patient s Responsibility
This is not a bill.
a.
REMARKS:
08/14/99
08/14/99
08/14/99
Provider s
Submitted
Fee
EXPLANATION OF BENEFITS
Description of Service
Jane L. Smith
Patient
Billing Provider
Service Provider
Service Date
Claim No.
of your group’s prescription coverage, please refer to your Master Group Policy.
Benefits through Blue Cross of Idaho Network Pharmacies
Your group’s prescription drug benefit is provided through the Blue Cross of Idaho Pharmacy
Network administered by WellPoint Pharmacy Management. Blue Cross of Idaho has contracted
with WellPoint Pharmacy Management to process claims for prescription drugs. They use a
computerized system to automatically provide the insured’s benefit information to Blue Cross of
Idaho Pharmacy Network pharmacists. Network pharmacies are listed in the pharmacy directory.
The Blue Cross of Idaho enrollee identification card contains the data necessary to verify
enrollment in the pharmacy program. After the network pharmacist has entered this information
into the system, he or she will have immediate access to:
1.
Enrollment status;
2.
Whether the prescription drug is covered; and
3.
The amount of deductible and/or copayment to collect from the insured.
Enrollment status and benefits can be verified while the insured is at the pharmacy. Immediate
access to current information prevents the use of expired cards or payment of benefits for
ineligible prescription drugs.
Prescription drug benefits include utilization review of prescription drug usage for the insured’s
health and safety. If there are patterns of over-utilization or misuse of drugs, the insured’s personal
physician and pharmacist will be notified. Blue Cross of Idaho reserves the right to limit benefits
to prevent over-utilization or misuse of prescription drugs.
Certain prescription drugs may require preauthorization. If the insured’s physician or other
provider prescribes a drug which requires preauthorization, either the provider or the pharmacist
will inform the insured that preauthorization is required. To obtain preauthorization the insured
or the insured’s physician must call Blue Cross of Idaho.
How to Use the Blue Cross of Idaho Pharmacy Network Prescription Drug Benefit
Each enrolled employee will be issued a Blue Cross of Idaho enrollee identification card that
includes enrollment information for the Blue Cross of Idaho Pharmacy Network and will receive a
pharmacy directory listing all network pharmacies. When an employee or covered dependent
goes to a network pharmacy for covered prescription drugs, these steps should be followed:
1.
Inform the pharmacist that he or she is a Blue Cross of Idaho insured. Present the enrollee
identification card along with the prescription, whether the prescription is new or a refill;
2.
After the pharmacist enters the enrollee identification number in the computer, the WellPoint
Pharmacy Management system will identify the correct deductible and/or copayment that the
insured owes the pharmacist; and
3.
The pharmacist will ask the insured to sign a form verifying receipt of the prescription.
To obtain covered prescription drugs outside of Idaho, the employee should call WellPoint
Pharmacy Management’s toll-free number, 1-800-962-7378, to obtain a listing of WellPoint network
pharmacies. After selecting a WellPoint network pharmacy, the insured must present his or her
identification card to the WellPoint pharmacist, and pay the appropriate deductible and/or
copayment.
If the pharmacist is paid in full at the time of purchase, the insured must file a claim to collect
benefits. The prescription claim filing procedure is explained below.
21
How to Collect Benefits When a Non-Network Pharmacy is Chosen
When an employee or dependent goes to an Idaho pharmacist who is not a Blue Cross of Idaho
participating pharmacist or to an out-of-state pharmacy that is not in the WellPoint Pharmacy
Network, the employee must pay the pharmacist the full cost of the prescription drugs at the time
of purchase and file a claim. (See Prescription Drug Claim Form in the Forms section of the
Resource Handbook.)
To file a claim, an insured should:
1.
Get a prescription drug claim form from the Group Administrator or any Blue Cross of Idaho
office. The Group Administrator may order an additional supply of prescription drug claim
forms from Blue Cross of Idaho; and
2.
Complete the employee’s section of the claim form and ask the pharmacist to complete the
balance of the form; and
3.
Attach the original paid pharmacy receipt, including the required drug information, to the
claim form.
4.
Send the claim to the address on the back of the form. For your reference, the address is:
Blue Cross of Idaho
Prescription Drug Program
PO Box 9083
Oxnard, CA 93031-9083
Reimbursement is based on the pharmacy network formula, less the deductible and/or
copayment, rather than on the retail price.
Certifax
Certifax benefits apply only if your group coverage includes this benefit.
Certifax Pharmacy Services is a mail service prescription program that is offered by Blue Cross of
Idaho. This program provides an inexpensive and convenient way to order medications regularly
taken on a long-term basis (maintenance medications) and have them delivered directly to the
insured’s home.
The Certifax mail order program:
•
Saves Time
Medications are delivered via UPS or First Class U.S. Mail. With a larger supply delivered, the
insured won’t have to order as often.
•
Saves Paperwork
No claim forms to fill out, no receipts to save, and no waiting for reimbursment.
Generic Drugs
Most prescription drugs have two names: the brand name (or trademark) and the generic (or
chemical name). By law, both brand name and generic drugs must meet the same standards for
safety, purity, quality, and strength. Generic drugs can save money for the insured and the Health
Plan. Have the physician prescribe them whenever possible. Certifax substitutes only the highest
rated generic drugs available.
22
Transferring Prescriptions
If maintenance medications are being taken, Certifax can transfer existing prescriptions from your
present pharmacy if there are any refills remaining. Also, a new prescription can be written for
faster service.
Ordering Refills
Order refills three weeks before you expect to run out. This allows sufficient time to receive,
process, fill, and deliver the order.
Questions
Call Certifax Customer Service or a Certifax pharmacist toll-free between 7:00 am and 5:00 pm
(Pacific Time) Monday through Friday.
1-800-635-3070
Fax 503-526-0580
Or write to:
Certifax
PO Box 188
Beaverton, OR 97075-0188
.
23
How
to
File
a
Dental Claim
This section applies only if your group coverage includes dental benefits. For complete details of
your group’s dental coverage, please refer to your Master Group Policy.
All dental coverage provided by Blue Cross of Idaho offers cost savings based on our Contracting
Dentist Program. Contracting dentists agree to recognize the maximum allowance as their
maximum fee for eligible services furnished to Blue Cross of Idaho insureds. Insureds are
responsible only for any deductible (if applicable), coinsurance, and non-covered amounts. They
never pay amounts that exceed the maximum allowance when the eligible service is furnished by
a contracting dentist.
When insureds receive covered dental services from a noncontracting dentist (a dentist who has
not signed an agreement with Blue Cross of Idaho), they will be responsible for any deductible (if
applicable), coinsurance amount, noncovered amounts, and amounts above the maximum
allowance.
Blue Cross of Idaho’s dental program provides coverage up to $1,000 ($1,000 or $1,250 for
Preferred Blue® Dental, depending on your group coverage) in dental care services per insured
per calendar year. Refer to your Master Group Policy to determine which dental option your
group has selected, if applicable.
Deductible Dental Option
Your group may choose from two deductible options—either $25 per insured per calendar year or
$50 per insured per calendar year.
The Deductible Dental Option pays 100% of the maximum allowance for routine dental care,
including exams, x-rays, cleanings, palliative treatments, oral tissue biopsies, fluoride (to age 23),
and space maintainers and sealants for certain teeth (for enrolled dependent children to age 16).
Benefits are available for two oral exams per insured per calendar year. Preventive care benefits
are not subject to the deductible.
The Deductible Dental Option pays 80% of the maximum allowance after the calendar year
deductible is met for frequently used services such as diagnostic casts, fillings and pin retentions,
simple extractions, oral surgery, root canal therapy, occlusal adjustments, and periodontal
maintenance.
The Deductible Dental Option pays 50% of the maximum allowance after the calendar year
deductible is met for prosthetic and restorative treatments, including crowns and repair of crowns;
bridgework and repair of bridgework; dentures and the repair, adjustment, and relining of dentures;
gold inlays and onlays; and cast porcelain restorations.
Incentive Dental Option
Preventive Care services include routine dental care, such as exams, x-rays, cleanings, palliative
treatments, oral tissue biopsies, fluoride (to age 23), and space maintainers and sealants for certain
teeth (for enrolled dependent children to age 16). Benefits are available for two oral exams per
insured per calendar year.
Basic care services include frequently used services such as diagnostic casts, fillings and pin
retentions, simple extractions, oral surgery, root canal therapy, occlusal adjustments, and
periodontal maintenance.
24
The Incentive Dental Option pays for basic and preventive care according to the following:
•
Benefit payments begin at 70% of the maximum allowance.
•
The benefit payment increases 10% each calendar year of enrollment up to 100% of the
maximum allowance provided the insured receives covered services each consecutive
calendar year. If an insured does not receive covered services in a given calendar year, the
benefit payment decreases 10% for the next calendar year.
•
Payment for covered Preventive and Basic services is never less than 70% of the maximum
allowance. Benefit payments will never be more than the maximum allowance.
The Incentive Dental Option pays 50% of the maximum allowance for major care covered services,
regardless of the “incentive level” the insured has attained. Services include prosthetic and
restorative treatments, including crowns and repair of crowns; bridgework and repair of
bridgework; dentures and the repair, adjustment, and relining of dentures; gold inlays and onlays;
and cast porcelain restorations.
Preferred Blue Dental Option—a Preferred Provider Organization (PPO) Dental Plan
There is an annual deductible of $25 or $50 per person per year, depending upon your employer’s
selected plan. This deductible applies to in-network and out-of-network services for Basic and
Major care benefits and preventive care benefits for out-of-network services. When three insured
family members have satisfied their deductibles, all other insured family members are immediately
eligible for benefits.
This plan pays a designated percentage of the maximum allowance for routine dental care benefits.
Available benefits include two annual oral exams, x-rays, cleanings, fluoride treatments, treatmentrelated sealants for certain teeth, space maintainers, and oral tissue biopsies. Certain benefits are
only available to dependent children with age maximums.
Basic care benefits cover frequently used services such as diagnostic casts, fillings, and pin
retentions, simple extractions, oral surgery, root canal therapy, occlusal adjustments, and
periodontal maintenance. After the calendar year deductible is met, the program pays a designated
percentage of the maximum allowance, depending upon your employer’s plan.
Major care benefits of this plan include prosthetic and restorative treatments such as crowns and
crown repair, bridgework and repair of bridgework, dentures (repair, adjustment, relining), inlays
and onlays, and cast porcelain restorations. A designated percentage of the maximum allowance is
covered, depending upon your employer’s plan, after the calendar year deductible is met.
Orthodontic Benefits
Orthodontic benefits apply only if your group coverage includes this benefit.
Orthodontic benefits are available to groups that have 35 or more enrolled employees and are an
option with both the Deductible, Incentive, and Preferred Blue Dental Programs. Benefits for
orthodontic services are available only to insured dependent children, with age maximums that
depend upon your employer’s plan.
The orthodontic option pays 50% of the maximum allowance for covered services up to a $1,000
lifetime benefit limit per dependent child. Benefits are provided for installation of appliances to
straighten teeth and to correct abnormally positioned teeth.
25
Dental Program Exclusions & Limitations
•
Your Master Group Policy’s extensive list of dental services includes all services for which
benefits will be paid by the program. No benefits are available for services not included in
the list.
•
If alternate procedures produce professionally satisfactory results, payment of benefits is
based on the procedure with the lesser charge.
•
If an insured changes dentists during a treatment program or if more than one dentist
performs the same procedure, Blue Cross of Idaho pays benefits as if only one dentist has
performed the services.
•
Benefits for construction of dentures are based on charges for standard services.
To submit a claim, write or call us at:
Blue Cross of Idaho Dental Services
or
PO Box 7408
Boise, ID 83707-1408
Blue Cross of Idaho
Dental Services
3000 E. Pine Avenue
or
Toll Free:
Boise Calling Area:
1-800-289-7929
(208) 363-8755
26
How
the
Vision Service Plan Works
This section applies only if your group coverage includes vision benefits. For complete details of
your group’s vision coverage, please refer to your Master Group Policy.
Benefits Available through VSP
Blue Cross of Idaho provides vision benefits through Vision Service Plan (VSP). The Vision Care
Plan brochure provides benefit information specific to your group policy, including copayments
and reimbursement schedules.
Before an appointment is made for a member or a covered dependent, your employees should find
a VSP doctor by using the VSP directory, calling VSP at 1-800-877-7195, or using VSP’s on-line
doctor directory service at www.vsp.com.
Once they have found a doctor, they may call the office for an appointment and provide the
following information:
1.
Indicate they are a VSP member
2.
VSP member group or employer
3.
Social Security number or other identification number
4.
Date of birth
Eye examinations are allowed once during a period specified in your Master Group Policy. Contact
lenses or glasses (with a frame and lenses) may also be allowed in accordance with your Master
Group Policy. Please check your Policy for benefit coverage.
VSP provides no benefits for medical or surgical treatment of the eyes, including but not limited to
radial keratotomy.
When a VSP Member Doctor is Used
When your enrolled employees choose a VSP member doctor, they simply pay the appropriate
copayments to the doctor. Your employees’ copayments are specified in your group policy. In
addition to the copayments, they will be responsible for optional items selected that are not
covered by the plan.
When a VSP Nonmember Doctor is Used
An employee may choose not to see a VSP member doctor, in which case reimbursement is
allowed at specific levels detailed in your group policy. VSP will reimburse your employees for
services received from any licensed optometrist, ophthalmologist, or optician. Employees must
pay the nonmember doctor in full, and submit an itemized bill to VSP.
The reimbursement schedule does not guarantee full payment nor can VSP guarantee patient
satisfaction when services are received from a nonmember doctor.
27
Preview
Preview is an innovative program from Blue Cross of Idaho designed to help moderate the
increasing costs of health care without impairing the quality of the care you receive. Preview
provides alternatives in how health care is delivered. For example, Preview encourages the use of
outpatient surgical facilities rather than inpatient care. This type of approach to health care
benefits helps lower costs while maintaining a high level of care.
Please photocopy the Preview section and distribute it to your employees; this information is also
available in your Master Group Policy. It is important to call Blue Cross of Idaho before a hospital
admission to be eligible to receive full benefits.
Elements of Preview
Preadmission Review—After the physician or insured notifies Blue Cross of Idaho of a planned
hospitalization, our Preadmission Review nurse or Medical Director may confer with the physician
to discuss the treatment and possible alternatives. The physician and the insured may discuss any
alternatives, then determine whether inpatient or outpatient treatment is appropriate. To reach a
member of the Preadmission Review team, please call:
Toll-free:
Boise calling area:
1-800-627-1187
(208) 345-2576
These telephone numbers are also located on the back of the identification cards.
Emergency Admission Review—Please call the next working day or within 24 hours of an
emergency or maternity admission. Blue Cross of Idaho will begin monitoring the insured’s stay in
the hospital.
Continued Stay Review—The Preadmission Review nurse will confer with the physician or the
hospital staff to determine if continued hospitalization is medically necessary.
Benefit Information—The Customer Services Department is available to answer questions about
any of the insured’s benefits. A one-on-one consultation with a Customer Services Representative
may help the insured understand how Preview really works. To reach the Customer Services
Department, call:
For Traditional Small Groups:
Toll-free:
Boise calling area:
1-800-627-1188
(208) 331-7347
For Preferred Provider Organization (PPO) Groups:
Toll-free:
Boise calling area:
1-800-627-1006
(208) 331-7699
Individual Benefits Management—This is an individual approach to the insured’s treatment. In
some cases, Blue Cross of Idaho may allow coverage for alternative services that are not usually
covered under the group’s health care plan. Blue Cross of Idaho may terminate coverage for
alternative service at any time.
When the Preadmission or Emergency Admission Review process is followed correctly, Blue Cross
of Idaho will pay claims for eligible expenses at the full benefit level selected by your group. It is
important to follow the Preview procedures to ensure eligibility in collecting full benefits.
28
When Preview is Not Used
When Blue Cross of Idaho does not receive a request for Preadmission or Emergency Admission
Review, or if the insured chooses not to follow the treatment agreed upon by the physician and
the Preadmission Review team, the claims for that admission will be handled in the following
manner: The insured will be responsible for paying an “admission deductible,” which will be
50% of the eligible expenses incurred during that admission, or $500, whichever is less. After
the admission deductible and the Major Medical annual deductible (if any) are met, Blue Cross
of Idaho will pay policy benefits for your remaining eligible expenses.
29
Conclusion
Help Avoid Delays
Filing a claim and receiving payment should be a simple process for your employees. Our ongoing
performance studies show that we process about 90% of our claims within two weeks of the day
we receive them. However, delays occasionally do occur. Here are some common reasons for
delays and how you and your employees can help us avoid them:
1.
Payment may be delayed because the insured forgets to ask the provider to submit a claim.
Insureds should present their Blue Cross of Idaho identification card each time they visit a
health care provider, and they should ask that a claim be filed. This will ensure that the
provider has the correct identification number.
2.
An incomplete or inaccurate Patient Questionnaire takes longer to process. Insureds
submitting their own claims must give us all the information requested on the Patient
Questionnaire. Double check that all the requested information is provided, especially the
enrollee number. Using the wrong number slows claims processing unnecessarily.
3.
In some cases, the amount allowed for payment will be affected by whether the insured has
other insurance or was involved in an accident. In these situations, we may need additional
information. We will write and ask the insured for additional information to enable the
complete processing of the claim.
4.
Occasionally, we may have questions or need to see medical records before processing a
claim. We will write and ask the insured or the provider for the information.
5.
Finally, it is important that we have current addresses. This will help us promptly notify your
employees of their benefits. Insureds should use Enrollment Address Change Cards to notify
us of address changes.
30

Group Administrator`s Manual

Transcription

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