2013 UNIVERSITY OF WINDSOR DECEMBER 17, 2013

Transcription

1 2013 UNIVERSITY OF WINDSOR DECEMBER 17, 2013

2 Today s Agenda What is new at Green Shield Canada Information Related to Frequently Asked Questions

3 The Plan Member Experience Our Customer Contact Centre Monday through Friday 8:30am to 8:30pm Call us, us, or fax us. Our Customer Contact Centre s Front Counter Anchor Drive Monday through Friday 8:30am to 4:30pm- Although the mail slot is open 24/7 Plan Member Online Services- Access your benefit booklet here, or also on the University s website at: www1.uwindsor.ca/hr/benefits-0 Mock Claims-Access Green Shield Canada s adjudication engine to see how your claim will pay or simply check eligibility on medical items and professional services. Setup direct deposit

4 Provider Connect- Providers that bill us directly on your behalf Pharmacies Dentists Physiotherapists Registered Massage Therapists Chiropractors Optometrists and Opticians If your provider does not already have a direct billing relationship with Green Shield Canada, please encourage them to call us so we can set them up right away!

5 New Year; New Policies Diabetic Supplies Test Strip Maximum-August 1 st, 2013 We exceed the Canadian Diabetes Association guidelines for testing to allow for additional testing if required Non-Insulin Dependent- 600 Test Strips per year Insulin Dependent Test Strips per year

6 Insulin Supplies for Seniors in Ontario January 1 st, GSC will coordinate with Ontario s Assistive Device Program (ADP) as the Provincial plan will be the primary payer. Grant Information- $170 annually per Senior. All impacted plan members will have received our correspondence with helpful instructions. Initial Days Supply and High Cost Medications Initial fills on most medications are limited to a 30 day supply and then subsequent fills can be for 90 days. When a medication has a cost greater than $40 per day we allow a 10 day supply on initial fills and subsequent fills can be for 30 days.

7 Custom Made Orthotics Claims can be submitted directly to us by Providers or Plan Members Medically Necessary- Rx to include diagnosis Control Potential Abuse- 5 provider types are eligible to dispense Chiropractor Podiatrist Chiropodist Orthotist Pedorthist The Provider and Plan Member s check list; How You can help! General Claim Submission Form Biomechanical Exam or Gait Analysis, and Casting Technique Itemized Lab Invoice (breakdown of costs) Itemized Receipt showing pick up date and payment in full

8 Hospital Accommodations Ward- More than 2 beds per room Ward rooms funded by the Ontario Health Insurance Plan (OHIP) Semi Private Accommodations- 2 beds per room Private Accommodations-1 bed per room Hospital Accommodations- Audit Assistance Hospitals must ask and have you authorize semi private or private rooms Participants that have had a hospital stay may be selected for our random audit Protecting the integrity of the University of Windsor s Health Plan

9 Private Duty Nursing- Your Plan details The University of Windsor s benefit program through Green Shield Canada provides coverage for Private Duty Nursing to supplement the services provided through the local Community Care Access Centre (CCAC). The services must be those provided by a Registered Nurse (RN) on a full or part shift basis and are payable up to your plan maximum. If additional RN services are required above and beyond what the CCAC provides, patients and their families must obtain authorization from Green Shield Canada. Please call for further details.

10 Your Community Care Access Centre Working with Your CCAC When you contact your local CCAC, you will be introduced to a Case Manager (also referred to as a Care Coordinator ), who will: Talk with you about your needs, answer questions about what CCACs can provide and what s available in your community. Conduct a health care assessment Develop a customized care plan that meets your specific needs Check in regularly with you and adjust your plan if your needs change Your CCAC Case Manager works on your behalf to make sure you have access to the care and services you need.

11 Predeterminations Important- Providers do not know your specific plan details as well as we do! Medical items Since medical item costs can also add up quickly we recommend that any medical device that exceeds $300 in cost be submitted for predetermination. Medical item predeterminations can be sent in via , fax, or Canada Post. These items include a copy of your medical doctor's prescription that references the medical device being quoted and your diagnosis, a copy of the price quote (or detailed invoice from the service provider, and a completed preauthorization claim form.

12 Dental Predeterminations What you should know Dental costs can add up quickly, we recommend that patients request their dental office to submit an estimate to GSC when costs exceed $300. Predeterminations allow consumers to make cost effective choices. Predeterminations are quick and easy, and completed in real time if submitted electronically. We also have web based services that allow claims that formerly were sent in by mail services only (x-rays) to be submitted electronically.

13 Orthodontic Treatment Assistance and Guidelines If you chose a payment plan, with an initial down payment and subsequent monthly payments. Initial Reimbursement When you submit your initial claim for orthodontic treatments, as an initial payment, we will only reimburse you up to a maximum of 35% of the overall total orthodontic treatment cost. Your initial reimbursement is then subject to your 50% copayment and your Orthodontic lifetime maximum. Subsequent Payments After the initial payment, subsequent payments for orthodontic treatments are made once per month (regardless of the number of adjustments or visits per month) based on the amount that you are claiming (typically this is the remaining balance amortized over the length of the treatment). Again, subject to your 50% copayment and your Orthodontic lifetime maximum.

14 We thought an example might be helpful Total Orthodontic Treatment Cost $7,000 Your Benefit Plan Coverage 50% Eligible Initial Payment (35%) $2,450 (35% of $7,000) Initial Reimbursement $1,225 (50% of $2,450) Remaining Balance $4,550 Length of Treatment 10 months Monthly Eligible Payment $455 ($4,550 over 10 months) Monthly Reimbursement $ (50% of $455)

15 If you chose to pay the full orthodontic treatment cost up front We do not reimburse lump sum amounts. If you pay for entire orthodontic treatment cost up front, you only have to send us your receipt once. After the initial reimbursement of up to 35% of the total treatment cost. We will amortize the remaining balance into monthly payments over the length of treatment.

16 What is Next We re back on January 14th 2014 to present Travel Thank you! Questions?