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The premium quoted by my agent is different from the amount that we have been billed. Why? |
| Typically, your agent has quoted the standard premium, which is based on many factors, including the applicant’s age, gender, tobacco usage, and the plan and benefit options selected. If any one of the items were inaccurately identified when the original data was entered the premium may be different. In addition, the effective date may have changed from the time the quote was prepared to the time the certificate of coverage was actually issued. Your medical history, changes or additional information to the above listed factors may also cause your premium to change. |
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I requested a specific effective date, which was approved, but my coverage was not issued until after that date. Will claims incurred after the requested effective date, but before coverage was issued, be considered? |
| Yes. As long as the eligible claims were incurred on or after the effective date of your coverage as reflected on the face page of your Certificate of Insurance, they will be considered under the terms and conditions of the Certificate of Coverage and processed accordingly. |
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I requested a specific effective date but you issued coverage with a later effective date. Why? |
| If coverage cannot be issued within 60 days of the date the application was signed, a date later than the requested effective date is used. |
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How long will it take to receive my ID cards and/or Certificate of Insurance? |
| Once issued, the information is typically mailed within three business days to the Producer. |
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What is included with the Certificate of Insurance and why is it mailed to my agent instead of me? |
| The administrative information includes a copy of the certificate along with the ID/ Prescription or Discount Drug card and other administrative information. Typically, this kit is mailed to the agent for delivery. This gives the agent the opportunity to explain your benefits and answer any additional questions you may have. However, at the request of the agent, the administrative kit can be mailed directly to you. |
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When I requested a refund of my initial deposit I did not receive a full refund. Why? |
| There is a one-time non-refundable enrollment fee as indicated on the application you signed. If the application is withdrawn, or we are unable to offer coverage, all monies except this one time fee are refunded. |
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How can I find out the reason my application for coverage was declined, restricted or rated up? |
| To find out why your application for coverage was declined, restricted or rated up, a written request is required for the information to be released. Upon receipt, IAC will mail the reason for the medical decision. |
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Why am I getting a letter that indicates that my or my dependent’s coverage is being changed even though it was approved and premiums have been paid? |
| When you initially applied for coverage, you provided information on which approval was based. While processing a claim that was recently submitted, it became evident that material medical history was not properly disclosed in response to the health questions on the enrollment application. As a result, in accordance with our underwriting guidelines, the coverage is being reformed or rescinded to represent the decision that would have been made had there been full disclosure to the questions on the application. The change is retroactive to the effective date of coverage. Such change can be reflected as an exclusionary rider, a premium surcharge, or both. A rescission of coverage means that all coverage has been canceled retroactive to the effective date. You will be kept apprised of the progress of the investigation and afforded the opportunity to comment on our findings by submitting a written response. |
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I submitted my medical history when I completed my application. Why are you conducting a prior treatment review now? |
| We have received a claim that indicates that the condition for which you have been treated may have existed prior to your application for insurance. The information supplied on the application does not provide all the necessary information needed to complete the pre-existing condition review. |
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How long will the prior treatment review take? |
| We will not be able to complete the prior treatment review until we receive the completed Prior Treatment Letter from you and all of the medical records from your providers. You can help to expedite the investigation by:
• Returning the completed Prior Treatment Letter; and
• Making sure that your providers have responded to our request for records. |
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Why do you need my child’s student status when I supplied this information last year? |
| Because students graduate and take time off from school, we require student status for each quarter to verify if the dependent continues to be a full-time student to meet the eligibility requirements of your plan. Please see your Certificate of Insurance for the definition of “student” to confirm whether your child still qualifies. |
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Do my co-payment or deductible amounts satisfy my annual out of pocket maximum? |
| No, not on most of our plans. Please check your Certificate of Insurance to verify your coverage. |
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What are “Usual and Customary” charges”? |
| This means the usual charge made for necessary medical services and supplies generally furnished for sickness or injuries of comparable severity and nature in the geographic area in which the services or supplies are furnished. The Out-Of-Network Providers are subject to Usual and Customary charges. We use and subscribe to a standard industry reference source that collects data and makes it available to its member companies. The database used reflects the amounts charged by network and non-network providers in your area. |
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Is my provider in the network? |
| The back of your ID card lists the phone number (and website address) for the PPO network applicable to your plan. Please contact the network to verify whether your provider is a participating member. |
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Why was a claim from my provider previously paid at the in-network level but the most recent claim paid at the out-of-network level? |
| Your provider may have left the PPO network at the time of this service. Please call your PPO network at the number listed on the back of your ID card to verify whether your provider is still in the PPO network. Be sure to have the provider’s address available when you call. |
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Do I need a referral to see a specialist? |
| No, your plan does not require that you obtain a referral to see a specialist; however, we recommend that you verify with the network that the specialist is a participating provider. (Depending on your plan and the provider, your benefits can vary based on a number of factors including, but not limited to, whether the condition pre-dates the effective date of your plan, whether pre-certification medical necessity is required and obtained, or whether the provider you see is participating in-network.) |
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Should I call to obtain pre-certification or should my provider’s office call to obtain pre-certification? |
| Either you or your attending physician must contact the Pre-Certification Service at least 7 days in advance of non-emergency services. Because we may ask for specific medical information, your provider’s office may be best able to call for pre-certification. Please refer to your Certificate of Insurance for those procedures and services that require pre-certification. Please refer to back of your ID card for the Pre-certification Instructions. |
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Do I need to get a second opinion? |
| We have the right to request that you obtain a second opinion prior to initiating any treatment; however, you are not required to obtain one unless we specifically asked you to do so. Two opinions are required for consideration of transplant surgery. |
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What do I do if I am out of my PPO network area and need care? |
| In the event of a medical emergency, call 911. Otherwise, please refer to the back of your ID card and call PHCS for available discounted services outside your service area. |
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Why can’t you discuss my spouse’s claims information and plan benefits with me? |
| Claims information includes medical information such as diagnosis codes and procedure codes. State and federal privacy laws and regulations require us to protect the confidentiality of such information. This prevents us from disclosing any information that pertains to your spouse’s health care or treatment, including claims information, without an authorization from your spouse. If your spouse would like you to be able to discuss his or her claims information with us, then your spouse may send us an authorization that allows us to release such information to you. |
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Why can’t you discuss my adult children’s claims information with me? |
| Even though your adult child may be a dependent on your health insurance policy, he or she is entitled to the privacy of his or her medical information. State and federal privacy laws and regulations require us to protect the confidentiality of such information. This prevents us from disclosing any information that pertains to your adult child’s health care or treatment, including claims information. If your adult child would like you to be able to discuss his or her claims information with us, then your adult child may send us an authorization that allows us to release such information to you. |
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Why can’t you discuss my children’s claims information if I’m not on the insurance coverage that my spouse and children are on? |
| State and federal privacy laws and regulations require us to protect the confidentiality of your children’s health information. Even though you may be the children’s parent, we have no way of knowing that if you are not on the same policy as them. You may obtain access to your children’s claims information if the adult who is in the policy sends us an authorization that allows us to release such information to you. |
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| ©2010 IHC Health Solutions Disclaimer |
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