Group Health FAQ

Why can I only go to certain Providers?

It is the Covered Person's choice as to which Provider to use, however, when a Covered Person uses an In-Network Provider (Preferred Provider), that Covered Person will not be subject to possible additional UCR charges that they likely would be if an Out-of-Network Provider (Non-Preferred Provicer) was used.

What is UCR or U & C?

A Usual and Reasonable charge is the amount being used by the majority of the providers in the same area. Typically, on your Explanation of Benefits, if you see that something is not covered because it is over U&C, it means that the Provider is charging more than the Usual, Reasonable, and Customary amount for that service.

What does it mean when charges are applied to my deductible?

A deductible is a set amount that must be paid by you before the plan will make any payment. Usually one person must meet their individual deductible and any of the other family members can combine to meet the family deductible. So when charges are applied to deductible, the charge was covered but is the patient responsibility with no payment by the plan for that service. The deductible generally runs from January 1 to December 31.

I'm not happy with how a claim was paid, what do I do?

When a claimant receives an adverse benefit determination, the claimant has 180 days following receipt of the notification in which to appeal the decision. A claimant may submit written comments, documents, records, and other information relating to the Claim. If the claimant so requests, he or she will be provided, free of charge, reasonable access to and copies of all documents, records and other information relevant to the Claim.The period of time within which a benefit determination on review is required to be made shall begin at the time an appeal is filed in accordance with the procedures of the Plan. This timing is without regard to whether all the necessary information accompanies the filing. An outline of the appeal process is in the plan document.

You are my insurance company, aren't you?

NO - Midwest Group Benefits, Inc. is not an insurance company. We provide Third Party Administration Services. We administer and process claims on behalf of your employers Partially Self-funded Health Plan.

Why do you need information about my prior coverage?

When you are new to a plan, the first thing requested once a claim is received for you is that you send us a certificate showing any prior coverage you and your dependents (if applicable) had for one full year before coming on with the new insurance. For example, if you obtained coverage effective June 1, we would need information for all prior insurance you had going back to June 1 of the previous year. This could just be one plan or with several different carriers. The certificate can be obtained by contacting the carrier of the plan(s). If you had no insurance or had a lapse in coverage of 63 days or more, than we will investigate for pre-existing conditions, the definition of which is provided in your policy.

I am traveling out of the country; will I still be covered by my plan?

YES - However, if you receive medical services while out of the country, you will need to pay for them at that time. We suggest paying for them by credit card, which will convert the currency, then submit the bill and credit card statement, along with a description of the reason for the service and what services were provided, to us upon your return for processing.

What do you mean by my Out-of-Pocket?

Out-of-Pocket refers to the total of covered charges you pay. As you incur charges, those that are applied to your deductible or coinsurance are your responsibility, and accumulate towards your out of pocket maximum. Once you reach the established out-of pocket maximum, the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year unless stated otherwise.

Why does the cost of my health insurance continue to rise?

Higher utilization, physicians charging more due to the increase in demand for their services, new and sophisticated medical treatments, the need for training of doctors/physicians to attain new skills to offer the latest in medical treatments, physician malpractice costs, litigation and fraud, having to help compensate the health care system for people who cannot pay for their own services and poor Medicare reimbursement are just some of the reasons why costs continue to rise.

What can I do to help control the cost of health insurance?

Be a better consumer and become more cost conscious of what you are being charged, choose generic drugs, know your benefits, and take an active role in your care and practice prevention.

Is there an option for students no longer eligible on their parents' group plan?

Yes, depending on the situation that applies, COBRA is an option, individual Short-Term policies or separate individual permanent policies.

How can my provider obtain claims status and/or benefit information?

We have adopted a faxing procedure to accommodate our providers who are requesting claims status or benefit information. We ask them to fax us the request on their letterhead, with the name of the person requesting the information, the name of the patient and the insured, ID number, date of service, claim amount and return fax number. They can fax us a copy of the original claim if they prefer. We will then fax back the claim status or benefit information. If pre-certification is required, the necessary information is provided on our return fax. In certain circumstances the calls are referred to specific claims analysts.

Why don't you tell my provider if my deductible or co-insurance is met?

We do not provide this information to our providers. With claims being processed every day, the amount continuously changes.

How do I find out if a procedure is covered or if I need to pre-certify?

First check your plan document to see if the procedure is listed as covered or if pre-certification is needed. If you cannot find information specific to your question, you can call our office and speak with a claims analyst.

How do you determine how a claim is paid?

A claim is processed according to the specific plan language. Each plan is structured differently, so a claim paid one way for an insured of one group may not be paid the same way for an insured of another group. If questions exist, you can call your claims analyst for further details.

Who can obtain my plan information (ex: claims, benefits, pre-certification)?

The rules of who can obtain this information have changed significantly due to recent legislation (HIPAA). We will provide this information only to those listed as covered under the plan. If you would like somebody in addition to those covered to have access to this information, a form is available for you to complete. For example, if your spouse or dependent is not covered under your plan and you would like him or her to have access to this information, this form must be completed and on file in our office.

How does the mail order RX program work?

It's quite simple. You will need to complete a mail order form that can be obtained from our office or your human resources contact. Once you complete the form, you will have to attach the written prescription along with your payment and forward the information to your pharmacy program provider (ex: AdvancePCS).

Why did my prescription drug co-pay go up?

Many times it's because the drug you are currently taking may have been removed from the formulary list or the price of the medication has gone up.

Why do drugs go off the formulary list?

A newer, safer more effective medication has replaced the old one, the medication was recalled, if a medication becomes generic and it is more cost effective to cover the generic and/or the medication is discontinued by the manufacturer.

Who decides what drugs will be deleted from the formulary list?

The Pharmacy and Therapeutic Committee (P & T) made up of Physicians and Pharmacists.