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.
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