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Health & Welfare Medical
Medical - Frequently
Asked Questions
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General Questions
Preferred Provider Questions
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How long
will it take to get my claim processed?
Most claims are processed within 14 days from
the day the Plan receives the claim in the Administrative Office.
Processing of claims that may be paid by other insurance and claims
for injuries caused by an accident with third party responsibility
tend to take a little longer.
An updated Annual Medical/Dental Claim Form for
the patient must be on file at the Administrative Office for any claims to be
processed. If the Annual Enrollment Update Form is not current,
the participant will be requested to fill one out and the claim will
be not be paid until the form is completed. The most common
cause for a delay in processing a claim is that the patient does not
have a current Annual Enrollment Update Form on file.
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How many times do I have to fill out one of those medical claim
forms?
The Plan requires that an Annual Enrollment
Update Form be updated once every twelve months or whenever the
patient’s information changes. For example, the form should be
updated when a spouse’s medical insurance changes through his or her
employer. If you cannot remember when each family member’s form
expires, and you anticipate using the Plan within the year, you may
download the form in January and fill one out for each covered
family member.
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How long do I have to
file a claim?
The Plan accepts claims for medical services
for twelve months from the date of service.
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What is
pre-authorization and why does my procedure
need to be pre-authorized?
Pre-authorization is a medical review by an
independent group of physicians to determine whether a procedure or
treatment is medically necessary. The Plan will only cover
procedures and treatments that are medically necessary and has
contracted with HealthCare Strategies to perform medical reviews.
The Plan
requires pre-authorization on all in-patient hospital stays and on
the following outpatient procedures:
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Bariatric Surgery (surgery to
treat obesity)
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Bletharoplasty
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Botox Injection
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Breast Surgery
-
CT Scan for Virtual
Colonoscopy
-
Durable Medical Equipment
over $1,500
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Home Health Care
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Home Infusion Therapy
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Lithrotripsy
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Panniculectomy
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Varicose Veins,
stripping, ligation and sclerotherapy
The Plan also requests that maternity stays be
pre-authorized as soon as practicable. To pre-authorize your procedure,
have your physician or health care provider call HealthCare Strategies at
1-800-582-1535.
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How do I add a dependent?
If you are currently enrolled in a Plan that
covers family members, simply update your
Enrollment Form. When
submitting the enrollment form, include copies of the following
documents, as appropriate:
- Marriage certificate
- Birth certificate
- Adoption papers
- HIPAA certificate showing change in other
insurance coverage
- Court orders in case of divorce decree and or
any other legal documents specifying the order to provide medical
support for a dependent.
For an overview on eligible dependents, please
see Who’s Eligible.
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What is a pre-existing
condition?
A
pre-existing condition is one for which medical advice, diagnosis,
care or treatment was recommended or received in the SIX MONTH period
preceding the effective date of coverage. The Plan will pay
benefits of no more than $5,000 for the treatment of a pre-existing
condition during the first 12 months of coverage. Should you
have a HIPAA letter showing credible coverage, please provide the
Administrative Office with a copy. It may reduce the 12 month
pre-existing limitation period.
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How do I mail order my
prescriptions?
Mail order is a cost-effective way to obtain
medication you take on an on-going basis. Prescriptions are filled for
up to 90 days. To fill a new prescription, you must submit an order form and
provide an original doctor’s script which indicates whether a brand
name drug or a generic is appropriate. You can then refill the
prescription by phone, mail, or via the internet at
www.caremark.com. For further information see Prescription
Drugs.
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Do my
prescriptions apply to my medical deductible?
No, your prescriptions DO NOT apply to your
medical deductible.
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Are travel expenses covered?
Travel to the nearest facility will be reimbursed
by the Plan if treatment is unavailable locally and it is medically
necessary. If the member traveling is a minor, the Plan will
reimburse travel for one parent or guardian to accompany the minor.
The Plan will also reimburse travel for one companion to assist an
adult member if the member is incapacitated due to a medical condition
and will need assistance.
Please note that the Plan does not reimburse for
ground transportation or room and board. This means that car rentals,
motels/hotels, parking, and cab fares are not covered expenses.
For reimbursement for travel expenses, you must
submit a letter of medical necessity from your current physician, a
copy of the ticket(s) with the dates and costs of travel, and the
boarding pass(es) as proof that the travel took place. Travel
benefits are subject to medical deductible and eligibility
requirements.
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What is a subrogation agreement and why do you want me to sign it?
In general, subrogation is the substitution of
one creditor for another. Each member of the Plan is subject to
subrogation if they are involved in a matter where a third party may
be liable for medical expenses. If the Plan pays medical expenses for
you and you subsequently receive reimbursement from a third party, you
are obligated to reimburse the Plan for the medical expenses the Plan
has paid.
By
signing a subrogation agreement you assure the Plan that you will
reimburse the Plan its expenses when your settlement is received. If
you are represented by legal counsel, your attorney must also sign the
subrogation agreement. Please see the Subrogation section of the
Summary Plan Document for details.
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May I use the Wellness and Minor Care Plan for treatment of
a long-term condition?
No, the Wellness and Minor Care program is not for treatment
of chronic or long-term conditions such as diabetes or
asthma. You are welcome to use the providers that
participate in the Wellness and Minor Care program for
treatment of a chronic condition; however, your claims must
be processed under the provisions of the major medical plan. Top
How much do I pay when using the Wellness and Minor Care Plan?
The cost for service is $10
per person per visit, or $25 if three or more family members visit
the clinic at the same time for services. Charges for services will
not apply to your annual deductibles, reimbursement percentages, or
out-of-pocket limits.
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What is the penalty for using a non-preferred provider (within the
Municipality of Anchorage)?
If you use a health care provider within the Municipality
of Anchorage that is a not a preferred provider, the Plan will base
your reimbursement on the preferred provider rate and will then
reduce your regular reimbursement percentage by 20% for the first
$50,000 in covered charges. In addition to these
reductions, a $1,000 penalty will be imposed to each inpatient
admission to a non-preferred provider.
For example, you live in Anchorage and need to
have outpatient physical therapy. The preferred provider charges the Plan
the negotiated rate of $100 for this type of treatment. A non-preferred provider in Anchorage charges $200 for this type of treatment. You have already
met your deductible for the year and the Plan usually reimburses at
85%.
If you have this treatment at the preferred
provider, the Plan will pay $85 ($100 X 85%). Your out-of–pocket
expense will be $15.
If you have treatment at the non-preferred
provider, the Plan will pay $65. First, the $200 expense is marked
down by 50% to $100, then the reimbursement
rate is reduced by 20%. ($100 X 65%) Your out-of-pocket expense
will be $135. For further examples of out-of-network
penalties, review
Using Preferred Providers - Municipality
of Anchorage.
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What
area does the Municipality of Anchorage include
The Municipality of Anchorage is comprised of the area
from Girdwood to the Knik River Bridge including the Anchorage bowl
area.
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Who are my preferred providers in the Municipality of Anchorage?
Your preferred providers within the Municipality of
Anchorage are as follows:
|
Service Needed |
Preferred Provider |
| Inpatient hospital
stays |
Alaska Regional Hospital |
|
Outpatient x-ray services (including MRI, CAT scan,
mammogram, sonogram) |
Alaska Regional Hospital
|
|
Outpatient laboratory |
Alaska Regional Hospital |
|
Outpatient surgery |
Alaska Regional Hospital |
|
Emergency room (when possible) |
Alaska Regional Hospital |
|
Sleep study tests |
Alaska Regional Hospital |
| Physical therapy services |
Chugach Physical Therapy
|
| Occupational
therapy services |
Chugach Physical Therapy
|
|
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How
do I know where my labs and x-rays are being sent?
Ask! It is your responsibility, as a plan
participant, to educate your physician(s) and medical care
providers, as well as your dependents, regarding your preferred
providers. Let your physician know who your preferred
providers are and he/she will make arrangements for labs and x-rays
to be performed at your preferred provider.
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What is Multi-Plan (for services outside the Municipality of
Anchorage)?
Multi-Plan is a nationwide group of contracted
preferred providers that offer considerable discounts to the Plan
for use of their facilities, groups, and doctors. When you select a
preferred provider from the Multi-Plan network, you will save money
and the Plan will save money. You may call 1-877-478-1246,
option 5, or review
Multi-Plan’s website, to find a Multi-Plan provider near you.
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What is the penalty for using a non-preferred provider (outside the
Municipality of Anchorage)?
The Plan uses Multi-Plan providers nationwide.
If you use a facility that is not Multi-Plan and it is within 25
miles of a Multi-Plan provider, the Plan will reduce your
reimbursement rate by 20%. You can search for a Multi-Plan provider
near you on
Multi-Plan’s website, or by calling 1-877-478-1246,
option 5.
Is Primary
Care Associates a preferred provider?
Primary Care
Associates is not a preferred provider, but is a provider for the
Wellness and Minor Care
program. Primary Care Associates has agreed to reduced
rates on other services available at their Anchorage and Eagle River
clinics. For example, if you seek treatment at Primary Care
Associates for chronic services covered under the major medical
plan,
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you will save money because
your out-of-pocket costs will be lower in most cases,
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and you will not have to deal
with any usual and customary restrictions.
Please
be aware that HealthSouth Surgery Center, HealthSouth Diagnostic
Center, and HealthSouth Physical Therapy have offices in the same
building as Primary Care Associates, but they are non-preferred
providers for outpatient hospital services. Primary Care
Associates recognizes Alaska Regional Hospital and Chugach Physical
Therapy are the Preferred Providers for inpatient and outpatient
hospital services for our Plan.
You may obtain treatment
for minor illnesses and preventive care for adults and children age 2
and over using the
Wellness and Minor Care program.
The cost for service
is $10 per person per visit, or $25 if three or more family members
visit the clinic at the same time for services. Charges for services
will not apply to your annual deductibles, reimbursement percentages,
or out-of-pocket limits.
Deductibles and other
plan provisions of the major medical health plan will apply
if you obtain services
outside the scope of services available through the Wellness and Minor
Care Program.
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