Administrative Guide for Workplace Voluntary Benefits

Transcription

1 Administrative Guide for Workplace Voluntary Benefits /09

2 Great benefits feel good You invest in your employees and care about their future. You provide benefits that both you and your employees feel good about. The result? Happy, productive employees who stay with your company. Feel good about Humana Product experts: You ll work with a team of experts for each specialty benefits product Personalized benefits: We get to know your company, diagnose your needs, and design a specialty benefits package that s right for you Packaged savings: Add multiple products with Humana and save on your rates People who care: You ll experience friendly service with Humana, and we make decisions with your best interest in mind Four decades of experience: Humana has a long history of serving employers insurance needs and building relationships With Humana, you have access to one of the industry s broadest choices of specialty benefits designed to keep employees just like yours happy and loyal. After all, the benefits we offer are among the most valued by employees.* Group Specialty Benefits: Workplace Voluntary Benefits: HumanaDental Disability HumanaVision Life HumanaDisability Accident HumanaLife Critical Illness Cancer Supplemental Health By offering these products, you ll feel good knowing you re helping protect the personal and financial health of your employees and their families. You ll feel even better knowing you won t break your budget doing so. You can offer Humana s specialty benefits products at no cost to your business or choose to fund a portion. Whether you offer many plans or just a few, we ll be with you every step of the way. Our people know the products inside and out, listen intently, and build relationships with every interaction. You can be confident your plans will run smoothly, and you ll be well-taken care of. * LIMRA The Employee Benefits Balancing Act, 2008 Administrative Guide for Workplace Voluntary Benefits

3 Table of contents Guide for voluntary benefits Guide overview Your account executive The call center Contacts Premium accounting Cancellations Billing statements Terminations Payment processing Working with claims Claim forms Impact of premium remittance on claims Accident claim filing instructions Life claim filing instructions Critical Illness (Synergis) filing instructions Critical Illness (Critical Illness Advantage) filing instructions Disability claim filing instructions Dental claim filing instructions Cash Cancer filing instructions Cancer Plus (Expense Incurred) filing instructions Working with voluntary benefits Leave of absence procedures Reinstatement Change procedures Keeping up with the needs of your employees Adding new employees Adding or deleting dependents Administrative Guide for Voluntary Benefits

4 Guide for voluntary benefits Guide overview This guide provides an explanation of the enrollment, billing, claims, and policy service procedures for Humana Specialty Benefits and should be used as a reference guide only. Information in this guide is subject to change at any time at the discretion of Humana Specialty Benefits. No information in this guide will supersede the terms and conditions of the Master Policy/Certificate or is to take the place of any direction provided by authorized employees of Humana Specialty Benefits. The information contained in this guide may vary from group to group. Please be sure to review your Master Policy/ Certificate when quoting specific policies and procedures. This guide is provided solely to offer an administrative guideline for our clients. Your account executive Throughout your relationship with Humana Specialty Benefits, your account executive is available to help with any issues or questions. The call center When your employee chooses a policy from Humana Specialty Benefits, they not only receive a quality product but quality service as well. Each policyholder can receive assistance from your account executive or from our Customer Service Call Center. The Customer Service Call Center has a dedicated team of specialists qualified to handle all inquiries concerning policyholder service and claims. The call center s hours of operation are: Monday Tuesday Wednesday Friday 8 a.m. to 5:30 p.m. Eastern time 9 a.m. to 5:30 p.m. Eastern time 8 a.m. to 5:30 p.m. Eastern time May be contacted at kmgindivcommunications@humana.com. All Customer Care specialists have access to information concerning claim status, billing procedures, and payments. Humana Specialty Benefits can provide an interpreter for any language. Call Customer Care toll free at Specialists can be reached Monday through Friday from 8:30 a.m. until 5:30 p.m. Eastern time. Contacts General questions Customer service Fax for claims and customer service Claims address Humana Inc. PO Box 2000 Lancaster, SC Premium payment address Humana Inc. PO Box 5000 Lancaster, SC Policy service address Humana Inc. PO Box 7200 Lancaster, SC General mailing address Humana Inc. PO Box 610 Lancaster, SC For overnight mail: Humana Inc. 301 South Main Street Lancaster, SC Administrative Guide for Workplace Voluntary Benefits

5 Premium accounting Two types of bills can be provided: List bill an invoice, detailing coverage at an individual level, is generated by Humana and supplied to the employer Self bill the employer sends a remittance register to Humana showing all covered individuals and premium due; self bill is only available for accounts with over 100 employees Bills are generated online through the Common Bill application. Common Bill can accommodate voluntary benefits and STD, LTD, Life, and Excess Risk on the same bill, if purchased. The group contact receives an notification each billing cycle that the group s bill is ready to be viewed. Log-in information will be provided before receipt of first bill. Payroll deductions should begin one month before the group s effective date. The bill for the following month is always generated 15 days before the start of each billing cycle. For example, for a Jan. 1 effective date, enrollment should conclude by the end of November. Payroll deductions should begin in December, and the first bill will be generated on or around Dec. 15. Upon receipt of the bill, payment for everyone on the bill is expected. This will allow the policies to be paid current to the Feb. 1 effective date. If remitting via electronic fund transfer, please note the following for Wachovia Bank, NA: DDA Account Number No Routing No premium remittance registers to kmgpremiumaccounting@humana.com Workplace Voluntary products can be billed on the following cycles: Monthly 13th (bill is generated every 28 days) 9th (bill is generated nine times per year) 10th (bill is generated 10 times per year) Cancellations Cancellation requests must be received in writing. The cancellation request (form 1618) can be accessed at. This request must be received by the first of the month to be reflected on the next month s bill. Billing statements Billing statements are generated 15 days before the start of each billing cycle. If payment is outstanding when the next bill is generated, a past-due notice of the previous month s outstanding amount due is printed on the first line of the bill. If payment is outstanding when the next bill (month three) is generated, a past-due notice for the total outstanding amounts due is printed on the first line of the bill. Terminations If payment is not received for three consecutive billing cycles, the group will be terminated, and pending letters will be sent to policyholders. The letter advises them that the premiums will no longer be paid through payroll deductions, giving them the opportunity to continue coverage on a direct payment or Electronic Fund Transfer (EFT) payment method. The letter quotes these method premiums and the amount due. If payment is not received within 15 days, the policy will lapse. All policies have portability, conversion or both provisions based on the policy. Portability allows an employee to continue coverage when premium is no longer taken through payroll deduction. The convertibility provision allows an employee to convert the group certificate of coverage to an individual filed product. For voluntary coverage that does not include a portability provision, the policy will lapse after two no-pay periods from the group. Notice will only be sent to the group. Terminations must be communicated via to your billing representative or noted on your premium remittance register. Cancellations that do not come through your office can be viewed through a status file available by registering online. Information to access this system will be provided before the receipt of first bill. Humana Specialty Benefits offers many insurance policies that are portable. Therefore, if an employee terminates employment, please advise that he or she may have the right to continue coverage. A Voluntary Benefits Portability Election Form should be provided to the employee for completion. The form is available at:. The above is applicable per plan provisions. Note: All voluntary benefit groups are assigned a billing representative who processes premiums and is the group s single point of contact for any billing-related concerns. Payment processing A letter of notice requesting payment is generated and mailed to the payor after two consecutive non-payments. If no payment is received within 15 days, the policy will lapse. For individual policies billed where the payor is marked and annotated as terminated, the policy is terminated and a letter of notice is generated and mailed to the insured. If no payment is received within 15 days, the policy will lapse. For voluntary group policies: No notice of lapse is sent to the insured, only to the group. The agent s copies of the lapse letters are mailed two days before the insured s letter. Administrative Guide for Voluntary Benefits 5

6 Working with claims Claims procedures Policy/certificate holders are responsible for completing their own claim forms. Depending on the type of coverage, claims requirements may be different. The following pages contain claim filing instructions. Claim forms Claim forms and all referenced forms are available by contacting our call center or at. Impact of premium remittance on claims Premium must be current for the claim review to occur. Employee claim payment will be delayed until premium is received. Accident claim filing instructions With the exception of disability claims, a claim form (6654) is not required but can be used if desired. If submitting a claim without a claim form, please include the policy or certificate number on each piece of correspondence. The following is needed when filing a claim: If a claim form is used, complete only page 1, Employee s Statement of Claim If a claim form is not used, provide details of the accident including date and time of occurrence If the accident was due to a motor vehicle/motorcycle accident or assault, a copy of the police report is required Invoices from service providers, indicating diagnosis, date of service, procedure performed, and charge must accompany either the claim form or other submitted documentation For filing a disability claim, a claim form (5169) is required. Instructions for filing the claims are: Employee s Statement of Claim: Must be completed each time a claim is filed. If Insurance Class is unknown, leave blank Physician s Statement for Disability Claim: This section must indicate the dates of disability, including an expected return to work date. If the return to work date is unknown, the physician should indicate the date of the next appointment for recheck of this condition. Completing all portions of the claim form avoids delays in processing. Life claim filing instructions The following documentation is needed when filing a claim: A Death Claim Administration Form (5044) completed and signed by the beneficiary of the policy If benefits have been assigned to someone other than the beneficiary, a copy of the assignment must also be submitted If the beneficiary is deceased, a copy of the death certificate for the beneficiary is needed If the insured has an estate, a copy of the executor or personal representative papers is required A certified death certificate photocopies are not accepted as proof of death If the cause of death is listed as pending autopsy, a copy of the autopsy report is required If the death was due to an accident, a copy of the police report for the accident is required; a copy of the toxicology report and/ or the autopsy also may be required A copy of the policy; if the policy cannot be located, an Affidavit for Lost Policy (1435) must be submitted Submitting all documentation avoids delays in processing. Critical Illness (Synergis) filing instructions The claim form (5203) is not required to file a claim but may be used if desired. If submitting a claim without a claim form, include the certificate number on each piece of correspondence. The following documentation is needed when filing a claim: For the cancer benefit a copy of the pathology report showing a definite diagnosis of cancer For the heart attack/stroke benefit a copy of office notes showing the definite diagnosis of heart attack or stroke For all claims invoices from the providers with the diagnosis date of service, procedure performed, and charge Instructions for completing the claim form: Complete policy and insured information and answer questions 1 through 5; sign and date the Authorization Section for your physician to release information to Humana Attending Physician s Report (only required in lieu of a billing with CPT-4 codes): Part A: Only sign in this section if you want the benefits assigned to the provider; if no signature in this section, the benefits will be paid to the insured Part B: Ask your attending physician to complete this section; question 1 must list the diagnosis code; if not using CPT or ICD-9 codes, a description of services must be provided 6 Administrative Guide for Workplace Voluntary Benefits

7 Critical Illness (Critical Illness Advantage) filing instructions The claim form (6445) is not required to file a claim but may be used if desired. If submitting a claim without a claim form, please include the certificate number on each piece of correspondence. Instructions for completing the claim form Insured (Employee) s Statement of Claim Must be completed each time you file a claim Be sure to answer every question Authorization Claimant or authorized representative must sign and date the Authorization Section to allow physician to release medical record to Humana Pre-existing Investigation Form If the claim is being filed in the first year of the policy and is for an illness, complete this page with all physicians seen or medications taken in the past 12 months If provider fax numbers are known, provide them to expedite this process Authorization section on Page 2 must be signed and dated Physician s pages Ask your attending physician to complete this section This section must indicate the details of the critical illness and the dates of diagnosis along with any referring physicians Pages 5 and 6 provide the physician with the exact medical documentation to attach to the form to document the critical illness being claimed; all portions of this claim form must be completed (unless filing only for the Health Screen Benefit) to avoid delays in processing your request for benefits If filing for the Health Screening Benefit only, no claim form is required. Please submit the Superbill or HCFA from the physician indicating the health screening procedures performed, including the procedure codes. The claimant s name and policy number also should be indicated on the documentation. Disability claim filing instructions When filing a disability claim, form 5169 is required. Following are instructions for completion: Employee s Statement of Claim: Must be completed each time a claim is filed. Complete the last date worked and indicate whether you have returned to work and if it is on a part-time or full-time basis Sign and date the authorization section for your doctor to release information to Humana If disability is due to an accident, indicate details including date and time of accident Employer s Statement of Claim: All questions must be completed by the supervisor or an authorized personnel department staff member Benefits will be paid based on the last date worked and expected return-to-work date provided by the employer and physician on this form; if a return-to-work date is not completed by the employer, benefits will be paid to the date that the employer signs this form To ensure that taxes are handled properly, the questions regarding Section 125 (whether premiums are deducted pre-tax or post-tax) and employer/employee contribution need to be carefully reviewed and answered If Insurance Class is unknown, this question can be left blank Physician s Statement for Disability Claim: Attending physician is to complete this section This section must indicate the dates of disability including an expected return to work date; if the return-to-work date is unknown, the physician should indicate the date of the next appointment or recheck for this condition All sections regarding limitations and progress should be carefully reviewed and completed based on employee s current condition, to assist in determining extent of disability and decrease the need for progress notes If employee is able to perform limited duty or part-time activities, this should be indicated on the form Administrative Guide for Voluntary Benefits 7

8 Dental claim filing instructions A claim form is not required to file a claim. We will accept the standard ADA claim form filed by your dentist. However, if a claim form is desired, Form 5068 can be used. If submitting a claim without a claim form, include the policy number or certificate number on each piece of correspondence. The following documentation is needed when filing a claim: Claimant s name, address, and date of birth ADA procedure codes for each procedure performed Date of service for each procedure Actual charge for each procedure All dentist information including name, credentials, address, telephone number, and tax identification number. Orthodontic Benefit When filing a first-time orthodontic claim, a complete treatment plan is needed, including: Bonding date, or date treatment first began Estimated length of treatment Charge for total treatment Amount of initial payment Amount of monthly payments, if applicable After the first claim, a statement is required each month with the date of service, charge, and provider of service. Unless the treatment plan is adjusted after the first claim, a complete plan is not needed. Claims are paid monthly by a schedule of treatment calculated by the estimated length of treatment and the total cost minus the initial payment. If the treatment time is lengthened but no additional cost is charged, additional benefits will not be paid. Cash Cancer filing instructions A claim form is not required to file a claim. However, if a claim form is desired, Form 5228 can be used. If submitting a claim without a claim form, please include the certificate/policy number on each piece of correspondence. The following documentation is needed when filing a claim: A copy of the pathology report showing a definite diagnosis of cancer for the specific cancer If the diagnosis is based on clinical diagnosis rather than pathology, your attending physician will need to provide a statement indicating the reasons for the diagnosis; there is space on the claim form for this information Instructions for completing the claim form: Complete policy and insured information and answer questions 1 through 5; sign and date the Authorization Section for your physician to release information to Humana Attending Physician s Report Ask your attending physician to complete this section; question 1 must list the diagnosis code; if not using ICD9 codes, the name of the code must also be given Attach a copy of the pathology report establishing the diagnosis of cancer If the diagnosis is based on clinical diagnosis rather than pathology, the attending physician will need to provide a statement indicating the reasons for the diagnosis; there is space on the claim form for this information Cancer Plus (Expense Incurred) filing instructions A claim form is not required to file a claim. However, if a claim form is desired, form 5057 can be used. If submitting a claim without a claim form, please include the certificate number on each piece of correspondence. The following documentation is needed when filing a claim: For the cancer benefit a copy of the pathology report showing a definite diagnosis of cancer For all claims billings from the providers showing the diagnosis date of service, procedure performed, and charge. Instructions for completing the claim form: Complete policy and insured information and answer questions 1 through 5; sign and date the Authorization section for your physician to release information to Humana Attending Physician s Report (only required in lieu of a billing with CPT-4 codes): Part A: Only sign in this area if you want the benefits assigned to the provider; if no signature, the benefits will be paid to the insured Part B: Ask your attending physician to complete this section; question 1 must list the diagnosis code (if not using ICD9 codes, the name of the code also must be given) We try to process all claims in seven to 10 business days after receipt. 8 Administrative Guide for Workplace Voluntary Benefits

9 Working with voluntary benefits Leave of absence procedures If one or more of the payors will be on temporary leave of absence and premium will not be collected, please notify the billing representative. We will contact the payor directly regarding premium payments and remove the individual from the group billing. When the employee has returned to work, notify the billing representative so the employee can be added back to the group billing. This also can be noted on the premium remittance register that is remitted during each billing cycle. Reinstatement If a payor lets the policy lapse and would like to apply for reinstatement, use the following guidelines, according to the type of coverage: Health coverage can be reinstated for up to one year from the lapse date. The policyholder must submit a Request for Reinstatement Form (6032) from. With this form, a payroll deduction authorization is required to be added back to the group billing statement after reinstatement. Any policy not in force for more than one year will require a new application. Term life coverage can be reinstated within one year from the lapse date. The policyholder should submit a Request for Reinstatement Form (6032) from. With this form, a payroll deduction authorization is required to be added back to the group billing statement after reinstatement. Whole life coverage can be reinstated within three years from the lapse date. All back premiums must be submitted with the Request for Reinstatement Form (6032) from. With this form, a payroll deduction authorization is required in order to be added back to the group billing statement after reinstatement. Group trust products are ineligible for reinstatement. Keeping up with the needs of your employees Adding new employees Other than your annual enrollment process, any new employee, spouse, or dependent must complete an application/enrollment form requesting coverage. Contact your account executive for enrollment paperwork. Please review the Post Enrollment Guide for specific product guidelines. Adding or deleting dependents To add a dependent to existing coverage, an application/ enrollment form is required To delete a dependent from an existing policy, submit a Policy Service Request Form (6016) from Note: If the coverage is under a Section 125 plan, be aware of the limitations concerning the addition or deletion of dependents. If you have any questions, contact your Section 125 Administrator. Change procedures Please coordinate changes to the employer s address, phone number, or contact person with your billing representative To request a change of Agent or Broker of Record, send a letter with the reason for this request to agencymgt@humana.com To make a change in the employee s name or address, submit a Policy Service Request Form (6016) from To make a change in the beneficiary designation on a life policy, submit a Standard Change of Beneficiary Form (6042) from Administrative Guide for Voluntary Benefits 9

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