Benefit Management Solutions FAQ
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 Q: What type of
about their benefit plan. We hope this tool will answer your benefit questions, and
information might
help you to navigate your benefit plan with EBMS.
I receive from
Frequently Asked Questions (FAQs) by new EBMS-administered EBMS?
Health Plan members: A: EBMS plan
members receive
Q: How do I know if a claim has been paid? information
A: 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
Q: What type of benefits are available through my employer’s benefit plan? programs and
A: You can access a copy of your company’s Summary Plan Description (SPD) on your services available
personal mi Benefits account. Or, you can speak with one of the representatives in through your
our Client Service Center by calling your group’s toll free number, listed on the back company’s benefit
of your ID card. plan. There are
SAMPLE also times when
Q: What is a Preferred Provider Organization PPO? ID CARD
our Claims
A: 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
Q: How do I know if my Provider is a participant in one of our claim. EBMS
group’s PPO networks? will detail what
A: You may access Participating Provider information from is needed through
the PPO website, or by contacting the Customer Service documentation
department of each PPO (this information is available at on your
www.ebms.com.) Click on the Find A Provider link on Explanation
prescription
claims toll free of Benefits or a
client service
the left side bar of the EBMS home page. center toll free
number
The website information and customer service phone number,
number personal letter.
when available, is also included on your EBMS ID card.
Q: Will I still be covered if my physician or hospital facility is not a part of the These areas are
networks listed above? outlined on the
A: Yes. Your health benefits plan will pay for all eligible healthcare services at other side of this
a lesser amount. flyer.
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 5) Chiropractic Treatment—This letter requests
(COB) )—EBMS asks for this information on employee’s information when services received from a Chiropractor
dependents who either currently have no other insurance, OR include a diagnosis which indicates a possible accidental
where EBMS would pay secondary (i.e. the birthday rule*). As a injury.
result of recent additions, members have the option of submitting n A letter will be sent when a claim is received from
updates at anytime through miBenefits. a Chiropractor that indicates potential third party
OIC updates will be collected: liability.
n From enrollment forms n The participant or dependent must complete the
n When primary Explanation of Benefits are received at form, sign and return it in the envelope provided.
EBMS n Failure to return the letter will result in further delays
n During phone conversations with the member through the in claim processing.
Client Services Center 6) Medical Records—This letter is to request medical
records for pre-existing investigation or medical
n When a member reaches fifty percent of the specific stop loss necessity investigation. This letter is only sent to the
deductible provider.
2) Certificate of Creditable Coverage (HIPAA Cert) — Upon n If the provider does not respond to the request, the
enrollment in the plan, there may be a pre-existing condition claim will remain denied until the information is
clause that prevents payment on any claim for a disease process received.
you sought care for in the previous months unless you had other 7) Preauthorization—This letter responds to a request
coverage that did not break for more than 63 days. This letter for preauthorization for treatment.
will request from you proof of creditable coverage that may be
able to prevent an investigation and minimize further delay of n This letter will include whether or not proposed
claims payment. treatment is an eligible expense under the plan.
n This does not verify the provider for this service
n EBMS needs a certificate from your prior insurance carrier or is “in-network.” Please contact the Participating
benefit administrator. This is typically sent when your coverage Provider Organization (PPO) listed on your ID card
ends, but you may need to call and request it as needed. for more information.
n If there was a break in coverage for more than 63 days—you n This is not a guarantee of benefits. It is a benefit
did not have insurance for that time—then a pre-existing determination based on the plan, and the information
condition investigation will take place. (See Number 4) provided at the time the request is made. The end
n If this condition has been treated within the previous months, determination will be based upon the actual services
it will not be a covered benefit until you have been covered provided, plan design and eligibility at the time the
under the plan for 12 months. If this is the first time, or you services were incurred.
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. Successfully navigate
n Dependent on your plan’s guidelines regarding pre-existing your benefit plan with
conditions, additional information may be requested from EBMS.
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.
• The Birthday rule applies when a dependent child of parents not separated or
n Failure to return the letter will result in further delays in claim divorced is covered by two different plans. The benefits of the Plan of the parent
processing. 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.