Frequently Asked Questions

Transcription

1 Frequently Asked Questions Q. What is an Open Delivery System? A. An Open Delivery System provides access to a host of affiliated providers with admitting privileges at various HAP-contracted hospitals and has multiple PCP referral options throughout the entire HAP delivery system. Providers are not restricted by the physician's hospital affiliation when providing PCP-directed specialty care and inpatient admission options. Q. What is an Integrated Delivery System? A. An Integrated Delivery System provides a wide range of clinical services and coordinated care through a physician group practice, closely affiliated physicians and/or academic faculty physicians. Providers have access to common electronic patient records, electronic prescribing and other administrative support that allows for ease of PCP-directed specialty care and scheduling of appointments within the integrated system. Q. Who should I contact to have my spouse or dependent activated or terminated under my contract? A. If you are enrolled with us through your employer, you must contact your employer's Human Resources Department and ask them to notify us on your behalf that you would like to have your spouse or dependent activated or terminated under your contract. If you are not enrolled with us through your employer, simply contact Client Services and request a Membership and Record Change Form. After you complete and submit the form, we will make the necessary changes to your record. Q. I have other health coverage, but I don't see it listed under the "Other Carriers on File" section of the Member Information page. What should I do? A. Please mail evidence of your other carrier to: HAP Attn: Coordination of Benefits 2850 W. Grand Blvd. Detroit, MI It is very important that you notify us if you have other coverage because doing so facilitates the coordination of benefits between us and your other health plans. Through the coordination of benefits, we can maximize your benefits by ensuring that your primary health plan pays claims first and that your secondary plan(s) pay any additional amounts. June

2 Q. I am no longer a Member of the health plan listed under the "Other Carriers on File" section of the Member Information page. What should I do? A. Please contact the carrier in question and request that they send a written letter stating the dates that your coverage with that carrier began and ended to: HAP Attn: Membership and Billing 2850 W. Grand Blvd. Detroit, MI Q. What is a copay? A. A copay is a fee that you are responsible for paying at the time of service. Typically, Members have copays for prescription medications and office visits. Q. What is coinsurance? A. Similar to a copay, a coinsurance is a fee (a % of charges) that you might be responsible for paying at the time of service. Q. What is an in-network deductible? A. The dollar amount that must be paid by the Member for medical services by providers who are affiliated with your specific health plan before HAP will pay any expenses. Q. What is an out-of-network deductible? A. The dollar amount that must be paid by the Member for medical services by providers who are NOT affiliated with your specific health plan before HAP will pay any expenses. Q. What are in-network out-of-pocket balances? A. The accumulated dollar amount paid by the Member for medical services by providers who are affiliated with your specific health plan within the current plan year. Q. What are out-of-network out-of-pocket balances? A. The accumulated dollar amount paid by the Member for medical services by providers who are NOT affiliated with your specific health plan within the current plan year. Q. Is there a copay for Outpatient Mental Health and Outpatient Chemical Dependency services? A. If no copay is listed for these services, then it does not apply. June

3 Q. What does CBHM stand for? A. CBHM stands for Coordinated Behavioral Health Management. This department is responsible for managing Behavioral Medicine services (i.e. for mental health and chemical dependence / addiction problems) for all Members across all product lines. CBHM can be contacted toll-free at (800) Q. Are all orthotic devices covered under the Orthotic Devices section of my benefit package? A. Shoe inserts and custom orthotics (unless it is a brace that is attached to a shoe) are not covered by your benefit package. Q. Are physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) services covered under the Home Health Care section of my benefit package? A. PT, OT and ST services may be covered by your benefit package. Please check your specific plan documents. Q. What is a Summary of Benefits and Coverage? A. A document that shows what your plan covers and what it costs. Q. Where can I find additional contract and coverage information? A. Additional contract and coverage information is available via HAP s website. From your My Plan page, click on Contracts, Benefit Guides & Riders or the Benefit Admin Manual. June

4 Glossary Click to search for the selected member or the selected benefit year Click on this hyperlink to view a PDF version of the Summary of Benefits and Coverage (Benefit Summary) Click on the hyperlink to view the dollar amounts that the Member Carrier Coordination of Benefits Emergency Room Coinsurance Emergency Room Copay Group Group ID Hearing Coinsurance Hearing Copay Hearing Information Network Out-of-Pocket Balances PCP Office Visit Coinsurance PCP Office Visit Copay The name(s) of all companies from which the Member receives health care coverage Information related to other insurance carriers which may provide coverage for the member time of service for a visit to the Emergency Room The amount that the Member is expected to pay at the time of service for a visit to the Emergency Room The Employer Group through which the Subscriber is enrolled with HAP The Group s unique ID number it is composed of the Group ID + the Subgroup ID time of service for hearing aid-related services time of service for hearing aid-related services Information pertaining to the Member s Hearing Benefit coverage and last claim on file The Network to which the PCP belongs The accumulated dollar amount paid by the Member for medical services and prescription medications within a specified plan year this amount includes deductibles and coinsurance amounts time of service for an appointment with his/her PCP time of service for an appointment with his/her PCP June

5 Pharmacy Coinsurance The % of charges that the Member is expected to contribute towards the cost of the following types of prescription drugs: Generic Preferred Brand Non-Preferred Brand Pharmacy Copay Plan RX Group Select Member / Contract Select Year Specialist Office Visit Coinsurance Specialist Office Visit Copay Subscriber Name Summary of Benefits and Coverage Urgent Care Coinsurance Urgent Care Copay Vision Information Vision: Glasses and Contact Lenses Coinsurance Vision: Glasses and Contact Lenses Copay The $ amount that the Member is expected to contribute towards the cost of the following types of prescription drugs: Generic Preferred Brand Non-Preferred Brand The type of HAP contract held by the Member The Pharmacy Group ID Select the Member and/or the contract for which you would like to view eligibility and benefits information Select the contract year for which you would like to view eligibility and benefits information time of service for an appointment with a Specialist time of service for an appointment with a Specialist The name of the primary cardholder for the contract What your plan covers and what it costs time of service for a visit to an Urgent Care Clinic time of service for a visit to an Urgent Care Clinic Information pertaining to the Member s Vision Benefit coverage and last claim on file time of service for glasses and contact lenses time of service for glasses and contact lenses June

6 Vision: Medical Eye Exam Coinsurance Vision: Medical Eye Exam Copay Vision: Office Visit Coinsurance Vision: Office Visit Copay time of service for a medical eye exam related to glasses and contact lenses time of service for a medical eye exam related to glasses and contact lenses time of service for an office visit to an eye care professional time of service for an office visit to an eye care professional June