6 - Benefits and Eligibility

Transcription

1 08 SHL Provider Summary Guide 6 - Benefits and Eligibility 6. Enrollee Benefits Sierra Health and Life (SHL) offers a variety of medical and dental benefit plans that are made available to eligible employees and their eligible family members for many employer groups. If you have questions regarding the benefits for a specific medical or dental benefit plan, including their exclusions and limitations, please contact SHL Member Services at the following numbers: SHL (800) IVR (70) Toll Free (800) Business Hours: Mon. Fri., 8:00 a.m. 5:00 p.m. Pacific Standard Time 6. Eligibility and Plan Coverage Verification The Member Services Department has a staff of representatives and specialists who can assist you with the following: Eligibility Plan coverage ID card questions Member concerns The following steps will help you identify SHL members and determine their eligibility and plan coverage. A member s eligibility needs to be determined before services are rendered. Every member and dependent is issued an identification card. All information on the card serves as identification; however, it does not guarantee eligibility. For verification of eligibility and benefit please contact Member Services IVR (Interactive Voice Response) system at (70) or (800) or utilize SHL s online See Section 6.4 for details Please Remember any payment for covered services is subject to the member s eligibility at the time of service, compliance with the managed care program, contractual limitations/exclusions and coordination of benefits as set forth in the Evidence of Coverage/Certificate of Coverage/Agreement of Coverage. 6.3 Interactive Voice Response System (IVR) Eligibility and Benefit Information: 7 days/week, 4 hours/day The Interactive Voice Response system will enable you to obtain eligibility and benefits for members as well as claim payment information at the touch of a button. SHL 08 Section 6 Benefits and Eligibility

2 08 SHL Provider Summary Guide Providers can receive a fax with information obtained from the IVR system. Direct numbers to IVR system: SHL (70) SHL Toll free (800) This service is available 4-hours-a-day, 7-days-a-week. This feature is part of our continuing effort to improve service to our providers. A flow chart that outlines the process follows in this section. MEMBER SERVICES: Interactive Voice Response System (IVR) (70) Toll free (800) SHL Telephone (800) SHL 08 Section 6 Benefits and Eligibility

3 08 SHL Provider Summary Guide Medical E & B InterVoice V. 4 Englehart MEDICAL ELIGIBILITY & BENEFITS IVR APPLICATION (PROVIDERS) Direct to IVR (HPN) (SHL) (THC) Enter Fax # (including area code) 3 Voice Only - Fax Only - Voice & Fax - 3 Enter Fax # (including area code) If fax requested A fax document has been created and w ill be sent to fax # entered. Enter -digit Member # Enter D.O.B. (-digit month, -digit day, 4-digit year) no yes Effective today's date, press # For prev ious date, enter -digit month, day of serv ice, year of serv ice (Member effectiv e?) Term date is Enter different date - Enter different mbr # - 9 Speak w /Rep - 0 if fax & v oice requested yes PCP Name & Group Effective date OB/Gyn PCP & Group Plan code & RX code Deductible amount & Accumulator HMO,SHL & OOP Co-Payment information Office Visit - Lab/Xray - Urgent Care/Emergency Room - 3 Out Patient - 4 In Patient - 5 All Co-payments - 6 Enter New Mbr # - 9 Return to Main Menu - * Transfer to Rep Routine Office Visit Route Specialist Visit Lab & X-ray Facility & Physician Physician Facility Anesthesia Comp.Dx Therapy Facility All Co-payments Press * to return to main menu SHL 08 Section 6 Benefits and Eligibility 3

4 08 SHL Provider Summary Guide Den tal E & B Inte rvoice 8/6 /0 Draf t Eng lehart DENTAL ELIGIBILITY & BENEFITS IVR APPLICATION (PROVIDERS) Direct to IVR (HPN) (SHL) En ter Fax # (including area code) 3 Vo ice On ly - Fax Only - Vo ice & Fax - 3 En ter Fax # (including area code) If fax requested A fax document has been created and will be sent to fax # entered. yes Enter -digit Member # Enter D. O.B. (-digit month, -digit day, 4-digit year) Effective today's date, press # Fo r previous date, enter -dig it mo nth, day o f service, year o f service (Member effective?) no Ter m date is En ter di fferen t date - En ter di fferen t mbr # - 9 Sp eak w/rep - 0 if fax & voice requested yes Effective date Calendar year maximum benefit & accumulator Plan and /or N on-p lan deductible for insured & accumul ator Plan and /or N on-p lan deductible for family & accumulator (pl ays only when member has plan & non-plan benefits) PLAN BENEFITS Product plan code Waiting period (if applicable) Benefits using plan providers - Benefits using non -plan providers - Benefits for b oth p lan & non-plan provi ders - 3 NON-PLAN BENEFITS Product plan code Waiting period (if applicable) TYPE I Routine Exams Cleaning s Bite-wing x-rays Flourides & Sealants Complete X-ray series/panorex TYPE II Periodontal scaling Root planing Fil lings Root canals Extractio ns TYPE III Cro wns Bri dges Dentures Orthodo ntia TYPE I Routine Exams Cleaning s Bite-wing x-rays Flourides & Sealants Complete X-ray series/panorex TYPE II Periodontal scaling Root planing Fil lings Root canals Extractio ns TYPE III Cro wns Bri dges Dentures Orthodo ntia *** **** Press 9 to skip to next type of benefits SHL 08 Section 6 Benefits and Eligibility 4

5 08 SHL Provider Summary Guide Clai ms Status HPN (Provider) InterVo ice Revisio n 3 4/05 /0 Engleh art CLAIMS STATUS IVR APPLICATION (PROVIDERS) Direct to IVR (HPN) (SHL) (THC) Enter Fax # (includin g area cod e) & 3 Voice Only - Fax Only - Vo ice & Fax - 3 Enter SH S Pro vider # F or Alp ha N umer ic Instructi ons - Press * Hear claims by memb er # - Hear claims b y claim # - Enter -digit claim # Enter -di git member # HEAR Amoun t Billed Allowable Amou nt Amou nt Paid C heck # Date Paid system will scroll throug h all clai ms fo r member by most recent date of servi ce Hear additional Info - Hear new Claim # - HEAR Dedu ctibl e Amo unt (if app licab le) C o-insurance (or) Co-Payment Date Pro cessed 9 Repeat Information - Press # Hear New Claim w/ Same Provid er # - Hear New claim w/ Different Provid er # - 9 Retur n to Main Menu - * Speak w/ Repr esentative - 0 SHL 08 Section 6 Benefits and Eligibility 5

6 SHL Provider Summary Guide Convenient and available 4/7, Sierra Health and Life s online is geared toward providing greater convenience and efficiencies for our contracted providers. Contracted providers and their administrative staff have access to important information when they need is a real time application that provides information such as member eligibility and benefits, prescription drug coverage information, prior authorization and claim status. Additional features include viewing and printing EOP s, as well as submitting prior authorization can reduce or avoid time spent on the telephone with SHL s Member Services Department. For contracted provider that are not yet connected please submit a request online via website by clicking Create an Account and following the on screen instructions. Or refer to Section 3. of this guide for Administrator Account request form. Provider Tutorial is accessible on the SHL website and Provider Services is available to answer any specific questions you may have regarding the application. 6.5 Sierra Health and Life Web Site The SHL web site is a valuable tool for you and your office staff. The SHL website has a section devoted entirely to providers and their needs. By visiting the SHL website you ll gain access to: Online provider directories SHL Preferred Drug List Mail-order pharmacy information Plan pharmacies SHL clinical guidelines UM Protocols Information (SHL s online portal) Credentialing information Online Provider Summary Guide Information regarding New Medical Technology The SHL website will be periodically updated to communicate health plan updates and ongoing information related to services, care, process changes and legislative and regulatory updates impacting providers. 6.6 ID Cards Copies of identification cards are provided to better identify our members. The front of the card contains information pertaining to the member and their benefits. Included in this information are the following: Employer Name: The employer name may be included on the card Member Name: Name of member, can be dependent, spouse or insured Member Number: Unique digit number identifying each member Group Number: Employer Group Number Benefits: Medical Pharmacy Vision Dental SHL 08 Section 6 Benefits and Eligibility 6

7 08 SHL Provider Summary Guide Code: Effective Date: Copays: Plan Name: For each benefit a patient is eligible for, a corresponding code will be listed Effective dates will be displayed for each benefit code the member is eligible for Copays will be listed for Office Visits and other benefits if applicable Sierra Health and Life IVR or Member Services can provide additional copay information. Based upon the benefits the member has, the information on the back of the card may contain some of the following information: Disclaimer: Emergency: Claims Address: Benefit Questions: Mental Health: Web Site: Network: Instructions for the member and providers regarding eligibility & prior authorizations Members are to call 9 or go to the nearest hospital in case of an emergency and contact member services as soon as reasonably possible Where to send claims Phone number to contact Member Services If the member has Mental Health Benefits through SHL, the name and number of the Mental Health Provider Web Site Address information Plan Provider Network Health plan members may now access their ID cards (online or on their smartphones). Sample ID Cards for plans that you may come in contact with, have been included for your review. SHL Solutions Group PPO Plan: SHL Solutions Group EPO Plan: SHL 08 Section 6 Benefits and Eligibility 7

8 SHL Solutions Group HSA EPO Plan: 08 SHL Provider Summary Guide Individual PPO Plan: Individual PPO Plan with Calendar Year Deductible: Individual EPO Plan: SHL 08 Section 6 Benefits and Eligibility 8

9 08 SHL Provider Summary Guide Individual HSA EPO Plan: Dental: SHL 08 Section 6 Benefits and Eligibility 9