Benefit Management Solutions
EBMS works hard to meet customer service goals established for all areas of our organization. We believe the first part of service starts with educating our members about their benefit plan. We hope this tool will answer your benefit questions, and help you to navigate your benefit plan with EBMS.
FAQ
Q: What type of information might I receive from EBMS?
Frequently Asked Questions (FAQs) by new EBMS-administered Health Plan members:
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A: EBMS plan members receive How do I know if a claim has been paid? information You can access this information on mi Benefits (refer to the Employee Benefit Plan at the time of booklet or the miBenefits brochure for login instructions). You can also speak enrollment, with a Client Service Representative at the toll free number listed on your ID card. and throughout Prescription claims number is located on the front of your ID card, medical/dental the year, which claims number is located at the bottom of the back of your ID card. highlights programs and What type of benefits are available through my employer’s benefit plan? services available You can access a copy of your company’s Summary Plan Description (SPD) on your through your personal mi Benefits account. Or, you can speak with one of the representatives in company’s benefit our Client Service Center by calling your group’s toll free number, listed on the back plan. There are of your ID card. also times when SAMPLE What is a Preferred Provider Organization PPO? ID CARD our Claims As part of your company’s commitment to provide its members with and Eligibility a high quality, cost-effective health benefit plan, they have secured departments contracts with certain hospitals, physicians and other healthcare require providers, known as Participating Providers. Because these additional Participating Providers have agreed to charge reduced fees to persons information, covered under your health benefit plan with EBMS, your company to correctly can reimburse a higher percentage of their fees. process your How do I know if my Provider is a participant in one of our claim. EBMS group’s PPO networks? will detail what is needed through You may access Participating Provider information from documentation the PPO website, or by contacting the Customer Service on your department of each PPO (this information is available at Explanation www.ebms.com.) Click on the Find A Provider link on prescription client service the left side bar of the EBMS home page. claims toll free of Benefits or a center toll free number number personal letter. The website information and customer service phone number, when available, is also included on your EBMS ID card. These areas are outlined on the other side of this flyer.
Q: Will I still be covered if my physician or hospital facility is not a part of the networks listed above? A: Yes. Your health benefits plan will pay for all eligible healthcare services at a lesser amount. Q: How do I know which pharmacies are part of the EBMS Rx network? A: You can access this information on EBMS’ website. Visit: http:/www. ebms.com/ ebms_rx/ or call one of our friendly representatives at the Rx customer service number listed on your EBMS ID card.
Corporate Office 2075 Overland Ave., PO Box 21367 Billings, MT 59104-1367 Ph: 800.777.3575 or 406.245.3575
What type of information might I receive from EBMS?
1) Other Insurance Coverage (OIC)/Coordination of Benefits (COB) )—EBMS asks for this information on employee’s dependents who either currently have no other insurance, OR where EBMS would pay secondary (i.e. the birthday rule*). As a result of recent additions, members have the option of submitting updates at anytime through miBenefits. OIC updates will be collected: n From enrollment forms n When primary Explanation of Benefits are received at EBMS n During phone conversations with the member through the Client Services Center n When a member reaches fifty percent of the specific stop loss deductible 2) Certificate of Creditable Coverage (HIPAA Cert) — Upon enrollment in the plan, there may be a pre-existing condition clause that prevents payment on any claim for a disease process you sought care for in the previous months unless you had other coverage that did not break for more than 63 days. This letter will request from you proof of creditable coverage that may be able to prevent an investigation and minimize further delay of claims payment. n EBMS needs a certificate from your prior insurance carrier or benefit administrator. This is typically sent when your coverage ends, but you may need to call and request it as needed. n If there was a break in coverage for more than 63 days—you did not have insurance for that time—then a pre-existing condition investigation will take place. (See Number 4) n If this condition has been treated within the previous months, it will not be a covered benefit until you have been covered under the plan for 12 months. If this is the first time, or you have not been treated in the pre-existing time frame as defined by your plan, the claim will be paid according to the plan. 3) Pre-Existing Investigation — This letter will be sent if you are unable to produce a Certificate of Creditable Coverage and have had a claim that requires investigation of a pre-existing condition. n Dependent on your plan’s guidelines regarding pre-existing conditions, additional information may be requested from you or your physicians 4) Accident— n A letter will be sent when a claim is received that indicates potential third party liability. n The participant or dependent must complete the form and make sure to sign where indicated and return it in the envelope provided. n Failure to return the letter will result in further delays in claim processing. 5) Chiropractic Treatment—This letter requests information when services received from a Chiropractor include a diagnosis which indicates a possible accidental injury. n A letter will be sent when a claim is received from a Chiropractor that indicates potential third party liability. n The participant or dependent must complete the form, sign and return it in the envelope provided. n Failure to return the letter will result in further delays in claim processing. 6) Medical Records—This letter is to request medical records for pre-existing investigation or medical necessity investigation. This letter is only sent to the provider. n If the provider does not respond to the request, the claim will remain denied until the information is received. 7) Preauthorization—This letter responds to a request for preauthorization for treatment. n This letter will include whether or not proposed treatment is an eligible expense under the plan. n This does not verify the provider for this service is “in-network.” Please contact the Participating Provider Organization (PPO) listed on your ID card for more information. n This is not a guarantee of benefits. It is a benefit determination based on the plan, and the information provided at the time the request is made. The end determination will be based upon the actual services provided, plan design and eligibility at the time the services were incurred.
Successfully navigate your benefit plan with EBMS.
• The Birthday rule applies when a dependent child of parents not separated or divorced is covered by two different plans. The benefits of the Plan of the parent whose birthday falls earlier in the year are determined before those of the Plan of the parent whose birthday falls later in that year; but if both parents have the same birthday, the benefits of the plan that covered the parent longer are primary.