Sample Employee Communication Kit PROCEDURE FOR HRA REIMBURSEMENT

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1 Sample Sample Employee Communication Kit PROCEDURE FOR HRA REIMBURSEMENT 1. Visit in-network provider and pay nothing at time of service. -Your MySource card should ONLY be used for prescription purchases (and not for physician or other medical charges). To access the list of pharmacies where the card can be used go to the IIAS/Merchant List Link at - Make sure to retain your Prescription Stub before you destroy the receipt. You will receive notification from us via that the debit card transaction has been resolved, or whether you need to submit the Prescription Stub to us to prevent your debit card from being deactivated. 2. In-network doctor s office submits eligible medical claims to (Carrier Name) for processing. 3. When you receive your Explanation Of Benefits (EOB) statement from (Carrier Name), make a copy. For prescriptions only, you may use your pharmacy stubs in lieu of your EOB statement. This is a receipt that is attached to the bag containing your prescription (It is not the cash register receipt). Be sure this stub contains the following information: the name of the drug, date prescription was filled, who the prescription was filled for, and the price paid for the prescription. Submit the stub along with an O.C.A. claim form to receive 100% of your prescription costs back that accumulate against your deductible. 4. Receive the bill from in-network doctor s office. 5. Make sure EOB from (Carrier Name) and billed amounts match. For example: Office visit bill $150, (Carrier Name) s allowable or contracted rate is $70, the doctor s bill should read owed amount is $ Mail, fax, or the copy of your EOB with a completed O.C.A.- HRA claim form to O.C.A. Benefit Services for processing. Our address is: 3705 Quakerbridge Road, Suite 216, Mercerville, NJ O.C.A. s facsimile number is (609) The HRA claim forms can be obtained from your Human Resources department or your MyRSC account at To your claims, use the following address: claims@oca125.com 7. Expenses that (Carrier Name) credits to your deductible are reimbursed at 100% up to $2,000 for single coverage and $4,000 for employee s electing dependent coverage. 8. The HRA plan runs calendar year (January 1 December 31) and at the end of the plan year you have a grace period of 90 days. This will allow you to submit your current plan years claims beyond the deadline up through March 31 st (or March 30 th if a leap year). Any claims received after this date are not eligible for reimbursement.

2 O.C.A. Benefit Services, LLC. Page 1 of 1 Sample 02/15/2011

3 Sample Finding a list of all merchants that can legally accept the mysource debit card is just 2 clicks away.

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5 Sample mysource Debit MasterCard and Your HRA! 1. Your mysource card should ONLY be used for prescription purchases and not for physician or other medical charges, particularly at the time of service. 2. When you visit a pharmacy, always show your health insurance identification card. This will ensure the pharmacist runs your prescription through your insurance and is applied towards your deductible appropriately. (Remember the mysource card is simply a vehicle to make your purchase. It does not replace your insurance card.) 3. By Government requirements in order for the mysource card to work, a pharmacy must be considered an I.I.A.S. (Inventory Information Approval System) certified merchant. There are two different ways I.I.A.S. certified merchants transmit the purchase information: a. If the pharmacy supports what is called Prescription Subtotals (*Category 10 & 11), then the pharmacy will transmit back to our system all the information about the prescription we will need (and in most cases) to auto-substantiate the debit transaction with no further information needed from you. b. If the pharmacy does NOT support Prescription Subtotals (Category 10 Only), then these pharmacies will transmit all eligible Section 213(d) healthcare items (including prescription purchases) back to our system coded strictly as a healthcare items. When this happens our system cannot differentiate between a prescription and a bottle of headache medicine, thus requiring you to submit paperwork supporting the purchase to ensure that it is in accordance with your company s plan. 4. Depending on which merchant you choose to use your mysource card at, may or may not necessitate the need to submit a claim form. In any event, you will always receive auto-generated system color-coded s informing you what action, if any, needs to be taken each and every time you use your card. Those s would be received as follows: a. GREEN Your transaction was resolved (via auto-substantiation, paper claim supporting the purchase or off-set from another claim reimbursement) and no action is necessary. b. YELLOW - Your transaction did not auto-substantiate and you will have 14 days from the date of purchase to submit the proper supporting documentation to substantiate the charge. c. ORANGE - Your transaction is still outstanding and you have 7 days remaining to submit the supporting documentation to substantiate this charge. d. RED - Your transaction is still unresolved and your debit card has been temporarily timed out. Once we receive the proper substantiation, or if this was for an ineligible item and the amount was paid back to your employer then the card becomes reactivated by the next day. * Category 10 and 11 refers to the specific information I.I.A.S. merchants transmit to third-party administrators across the country. Category 11 is specific to prescription information, where Category 10 relates to all Section 213(d) healthcare items. When a merchant is classified as Category 10 only, it lumps prescription information in with all healthcare items. Therefore, third-party administrators are unable to determine whether you purchased a prescription from an over-the-counter item, thus requiring paperwork to support the purchase.

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8 Fill Out Claim Forms Online Take claim entry into your control! Benefit Administration you can Depend On! You can now go to to fill out your claim forms online. Log in, complete the form, print and fax the transmittal to OCA. No more filling out forms by hand! Sample 1. Log in to 2. Click the Online Claims Entry option in the menu. 3. Click Add a New Claim Form and then select which form you need. You will see links to add Medical (FSA or HRA), Dependent Care, and Parking/Transit. 4. Print and fax claim, along with receipts, to OCA at As claims are added, you will see them listed. An individual claim can be edited or deleted, until the Transmittal Form is printed. O.C.A. Benefit Services 3705 Quakerbridge Road, Suite 216 Mercerville, NJ

9 Online Claim Entry Receipt Cover Page Fax this page along with receipts for services Date Printed: 5/20/2010 Account Holder Info: Employer: Account Holder: Access ID: Address: SSN: Address: Commercial Printing Michael Notsohumble St. Charles Blvd Fax to: Little Rock, AR Plan Service Provider Info: Plan Service Provider: Address: Voice: DataPath Administrative Services 1601 Westpark Drive Suite 9 Little Rock, AR Card Type DOB Claimant Dates of Service Amount Service Provider Provider Pay Provider TaxID Receipt Attached N/A Medical Note: 5/3/2000 Michael Sample 5/1/2010 5/1/ Prescription/RX Total: Account Holder Signature Date I certify that the expenses for reimbursement indicated on this substantiation form were incurred by me (and/or my spouse and/or eligible dependents), and were not reimbursed by any other plan nor will I seek reimbursement from any other source. To the best of my knowledge and belief, the expenses are eligible for reimbursement under my Reimbursement Plans. I (or we) will not use the expense reimbursed through this account as deductions or credits when filing my (our) individual income tax return. Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider, files a statement of claim containing false, incomplete, or misleading information may be guilty of a criminal act punishable under law. OCE Page 1

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11 HOW TO READ YOUR Explanation of Benefits Statement Below is a sample Explanation of Benefits (EOB) Statement. This is the information you will receive after your benefits claim has been processed. In order to understand this example, match the field number on the EOB to the corresponding number shown in the following narrative Contract Holder Name individual who holds the contract. (Usually the employee, for company sponsored benefit plans.) 9 Provider Charges the amount the provider actually charged for the services. 2 3 Member ID employee s member identification number. (This is the identification number listed on your medical identification card.) Claim Activity For name of the individual who received the services. (If claims for multiple family members are processed during the same period, each patient will have a separate page.) Our Allowance amount covered under your program. (If you use a provider that participates with Highmark, they must accept Our Allowance as payment in full and cannot bill you for the difference between the Provider Charges and Our Allowance. ) Your Deductible the amount that was applied to your program s deductible Sample Claim Number number assigned by the computer for identification purposes. Dates of Service date range this EOB contains information for. We Sent Check to individual/facility who reimbursement was sent to. (If you receive services from a participating provider, reimbursement will be sent directly to the provider. If you receive services from a non-participating provider, your reimbursement check will be sent to you.) Provider May Bill You summary of what you owe the provider. The individual breakdown is shown in the Member Responsibility chart. Provider provider s name. (A provider is a facility or professional performing or supplying the services.) Date of Service date of service(s) performed or supplied. Type of Service e.g. surgery, office visit, etc. Service Code code to identify what services were performed Amount Remaining amount remaining after your deductible has been subtracted from the Allowance. Health Plan Pays At percentage that your program pays after any deductible, coinsurance or copayment amounts have been met. For example, if you have an 80/20 program, your program pays 80% and you are responsible for the other 20%. Health Plan Pays the actual dollar calculation of the amount the health plan pays. (ie. Health Plan Pays at percentage multiplied by Amount Remaining or, 80% x $709.73) Your Share of Amount Remaining the amount remaining after your program s payment has been subtracted. (ie. Amount Remaining minus Health Plan Pays at, or $ $567.79) Amount You Owe Provider the total of all of your responsibilities. This includes any deductible, coinsurance or copayment amounts plus your share of the remaining amount. Remarks explains why certain charges were not covered.

12 1. Go to and click mysourcecard. Sample 2. Type in Primary Card Number.

13 Sample 3. Fill in one or all of the follow. (Please remember this is the primary account holder information.) 4. Fill in all Fields below.

14 Sample 5. Fill In Password.

15 HOW TO USE THE MYSOURCE CARD AT THE PHARMACY? Sample Employee visits Pharmacy Employee provides Pharmacy the insurance card (The insurance card will ensure Rx is charged appropriately and applied toward insurance as designated by company s medical plan [i.e. deductible, co insurance, Rx tier]) Employee pays for Prescription either using personal funds or MySource Debit Card Employee sends EOB (Explanation of Benefits from insurance carrier) or Rx Stub* along with OCA claim form to receive HRA reimbursement or for Debit substantiation (unless requested via ***) Once OCA receives claim and processes, Employee should receive reimbursement either in the form of a check (distributed via Employer) or via ACH (direct deposit) ** *Rx Stub is not the cash register/receipt. This is the attachment to the bag that states date of fill, name of the drug, who the drug was dispensed for, and the amount paid. **Employees sending an EOB or Rx stub along with OCA claim form for Debit Card substantiation do not receive reimbursement. This is to verify the charge. ***Employees will receive auto generated system s with information as to whether the debit transaction requires documentation sent to OCA for substantiation or whether the transaction was IIAS compliant and auto substantiated which requires no documentation. For more information and a complete list of IIAS merchants, please visit our website

16 HOW DOES AN HRA WORK USING AN IN NETWORK PROVIDER? Sample Employee visits Physician (Pay nothing at point of service) In Network Physician submits claims directly to the Carrier Carrier applies the In Network discount and sends an EOB (Explanation of Benefits) directly to the Physician and also one to the Employee Physician receives discounted EOB and generates an invoice to send to Employee for payment Employee sends EOB along with OCA claim form to receive HRA reimbursement in order to pay Physician s invoice * Once OCA receives claim and processes, Employee should receive reimbursement either in the form of a check (distributed via Employer) or via ACH (direct deposit) ** *Those Employees with Debit Cards may use them ONLY AFTER receiving covered expenses as designated by the Company s plan. the EOB to pay for **Employee sends EOB along with OCA claim form for Debit Card substantiation

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18 Don t know who to call for help? As many have experienced first hand, trying to navigate through the world of insurance can be quite a daunting task at best. There are often many hands in the pot and one can be shuffled around with nothing but a sense of frustration at the end of the day. Hopefully, the following information will assist in clarifying much of the confusion. BROKERS The Broker is the individual who mediates between the Employer (and on behalf of their Employees) and the insurance company. They represent your company and you whenever necessary to resolve coverage issues. They are also available to answer general questions relating to the specifics of the insurance plan (what is and is not covered), pre-certification questions, network related questions, or even when issues arise involving Explanation of Benefits being processed incorrectly. Your Broker is (Broker Name). He can be reached directly at (Broker and Phone Numbers). Sample O.C.A. BENEFIT SERVICES (Plan Service Provider or PSP) O.C.A. (the PSP) works closely with the Brokers, Employers and their Employees. We are responsible for processing Health Reimburse Arrangement (HRA) claims as outlined in the company s Summary Plan Description, as well as in accordance with IRS guidelines. O.C.A. processes these claims in order to protect the privacy (HIPAA) of each individual from having their medical information shared with their employer. We should be contacted whenever questions arise regarding processing of HRA claims, how to submit HRA claims, how HRA plans work or relate to your existing insurance plan, debit cards (if applicable), our web access portal (MyRSC), or just general knowledge/guidance questions. Our office number is , and our fax is You can also submit questions and claims via at claims@oca125.com. INSURANCE CARRIER All insurance carriers have Member Services a department dedicated to assisting their members with any issues or questions relating to their insurance. It is suggested that employees call the 800 number listed on the back of their insurance card to contact the carrier directly when comfortable resolving issues on their own. (Carrier) s Member Services number is Quakerbridge Road, Suite 216 * Mercerville, NJ * (609)