FAQ FAQ - PDF by xarrnet


									      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
                                                                                                claims toll free of Benefits or a
                                                                              client service
        the left side bar of the EBMS home page.                              center toll free
        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
                                                                           • 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.

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