Health Connector Policy: Premium Billing and Payments

Size: px
Start display at page:

Download "Health Connector Policy: Premium Billing and Payments"

Transcription

1 Health Connector Policy: Premium Billing and Payments Policy #: CM-3 Date revised: 11/4/2014 Category: Payment Effective date: 1/1/2015 Approved by: Ed DeAngelo Applicable to all Health Connector Products (Non-Group and Small Group Qualified Health Plan or QHP/Qualified Dental Plan or QDP) Payee Entity Individuals and families subject to premium may elect to pay the Health Connector or the issuer directly. Exceptions are ConnectorCare-eligible individuals/families who receive state financial assistance and small groups enrolled under the Standard Operating Model; those groups may only pay the Health Connector. Once the enrollee chooses the payee entity, that choice cannot be changed until the end of the plan year. Premium Billing Responsibility If the enrollee chooses to pay the issuer directly, the issuer is responsible for establishing a process for collection of premium payments. This process is to be compliant with the provisions of the Affordable Care Act and consistent with the Health Connector s processes. If the enrollee chooses to pay the Health Connector, the Health Connector s Customer Service Center is responsible for premium billing, processing payments and updating appropriate systems in accordance with the Health Connector s and Customer Service Center s internal policies and procedures. Initial Payment Process and Deadline Initial Payment Due Date for all non-group products is the 23 rd calendar day of the month before coverage effective date. Initial Payment Due Date for small group products varies by product type. Please see the Enrollment Timelines policy for the applicable initial payment due dates. 1 Paying the Issuer: 1. The Health Connector transmits daily to the issuer the enrollee s health plan and product selection as well as all other necessary information. 2. The issuer transmits to the Health Connector daily confirmation of payment receipt. 3. The Health Connector processes enrollment and transmits daily enrollment confirmation to the issuer. 4. The issuer effectuates enrollment daily, produces member ID number, and generates member packet and card mailing to enrollee. 1 of 5

2 Paying the Health Connector: 1. The Health Connector generates the initial bill and sends to the enrollee. 2. The enrollee pays the initial bill using one of the available payment methods. 3. The Health Connector processes enrollment and transmits daily enrollment confirmation to the issuer. 4. The issuer effectuates enrollment daily and produces member ID number and generates member packet and card mailing to enrollee. Ongoing Payment Process and Deadline The Ongoing Payment Due Date for all non-group products is the 23 rd calendar day of the month before the coverage month. Ongoing Payment Due Date for all small group products is five (5) business days before the first day of a coverage month. An enrollee must pay his/her monthly premium in full by the payment due date each month. Paying the Issuer: An enrollee must pay his/her monthly premium in full by the payment due date each month in accordance with the process established by the issuer. Paying the Health Connector: If the enrollee chooses to pay the Health Connector: The monthly bill is generated on the 1st of each month and sent to enrollee The monthly payment is due on the 23 rd calendar day of the month for all non-group products and 5 business days before the first of the next month for all small group products The monthly bill is for the next month's coverage Several payment methods are available: Payment via mail by checkor money order Payment by one time or monthly recurring Electronic Funds Transfer (EFT) using the Health Connector s secure online system Payment in person at the Customer Service Center by check or money order Payment via mail or electronically sent by the enrollee s bank or financial institution Payments are processed and credited to enrollee s account the same day they are received, provided the payment was submitted in accordance with the procedure established by the Health Connector. Payment Procedure If the enrollee chooses to pay the Health Connector, s/he must follow the procedure outlined below: For payments made via mail by check/money order: 1. Fill out check/money order completely and correctly 2 of 5

3 2. Make check/money order payable to the Health Connector 3. Include the detachable payment coupon located at the bottom of the bill; the coupon contains the account number which designates the plan payment should be credited to, i.e. medical or dental 4. If payment coupon is not available, legibly write account number in the memo field; account number designates the plan that payment should be credited to, i.e. medical or dental 5. Mail payment to the correct mailing address For payments made by one-time or monthly recurring Electronic Funds Transfer using the Health Connector s secure online system: Provide member entered exactly the same as on the eligibility application Provide correct bank account number and routing number Provide correct account number for each payment made Select last month for recurring electronic funds transfer (EFT) payment; the current month will be the first month by default For payments made in person at the Customer Service Center: Check/money order is accepted Check/money order procedure as described above applies Cash is not accepted For payments sent via mail or electronically by the enrollee s bank or financial institution: In addition to following all instructions and procedures of the bank or financial institution remitting payment, enrollee must provide correct account number with the payment; account number designates the plan that payment should be credited to, i.e. medical or dental If setting a recurring payment, enrollees are advised to set the payment date to 2 business days before the Health Connector s payment due date. Improperly submitted payments If the Health Connector receives a payment that does not contain sufficient or correct information on or with it and lack of information/incorrect information results in the Health Connector not being able to promptly and properly credit the payment to the enrollee s account, the payment may be not applied or applied late to the enrollee s account as a result of incorrect or missing information. In this case, enrollee s account will be considered delinquent and/or enrollee will be subject to disenrollment or enrollment will not be effectuated. Applying partial payments 1. Customers shall designate the account number that their payment should be credited to. When paying online whether by one-time or recurring Electronic Funds Transfer, the system will require such designation for each payment. When using other payment methods, the customer shall include either his/her detachable payment coupon located at the bottom of the bill or complete account number as described in the Payment Procedure section above. 3 of 5

4 2. Payments that are designated medical or dental plan shall be applied according to the specified designation. 3. For payments with no designation of allocation to medical or dental plan, the payments will be applied to fees first (if applicable), followed by the following application method: a. If the remaining payment is larger than the total of outstanding premiums on the oldest invoice, it is applied to both premiums. Any remaining payment amount will be applied similarly to the premiums on the next oldest invoice. b. If all outstanding balances are paid and credit balance remains, the credit balance will be applied when the next invoice is processed consistent with 3.a. above. c. If the remaining payment amount is less than the total balance (for the medical or dental plan) of the oldest invoice, but greater than the larger of the premiums, the remaining payment amount shall be applied to partially pay the remaining premium on the oldest invoice. d. If the remaining payment amount is less than the total balance (for the medical or dental plan) of the oldest invoice, and less than the larger of the two premiums: i. If it is greater than the amount of the lower premium, the payment is applied to that premium, with the remaining payment amount applied to the other premium on the oldest invoice with a balance. ii. If it is less than the amount of either premium on the oldest invoice, it is applied to the larger of the premiums on that invoice. Late Payments An enrollee must pay his/her monthly premium in full by the payment due date each month. A payment received after the payment due date is treated as non-payment for the purposes of effectuating enrollment, calculating delinquency status, and terminations for non-payment. A late payment may result in: The suspension or denial of claims by the issuer for healthcare services rendered for enrollee(s) Effectuating enrollment with a later effective date or not effectuating enrollment for enrolling individuals, families, employers or employees Returned Payments If an enrollee s payment is returned for insufficient funds, the Health Connector will process payment return and update appropriate systems. The Health Connector will notify the enrollee. If the enrollee is enrolled in monthly recurring EFT using the Health Connector s online system and a payment is returned for insufficient funds, the Health Connector will change the payment method for the enrollee to paper. The enrollee can establish a new recurring EFT at a later time. Returned payment will result in account delinquency. If so, the Health Connector will notify the issuer of the account delinquency status. The Health Connector may, in its sole discretion, charge the enrollee the fees that the Health 4 of 5

5 Connector is charged by its bank or financial institution for returned payments. The Health Connector may, in its sole discretion, request that enrollee pay by a bank check or money order in cases where an enrollee has had more than three (3) occurrences of returned payments in a ninety (90) day period provided that all three (3) payments were made by the same payment method. Charges and Fees The Health Connector is not responsible for fees charged by the enrollee s bank or financial institution. The Health Connector may, in its sole discretion, charge the enrollee the fees that the Health Connector is charged by its bank or financial institution. In this case, the Health Connector will notify the enrollee of such charges on the invoice generated in the billing cycle subsequent to the date payment was returned. The fee charged to the enrollee shall not exceed the fee the Health Connector is charged by its bank or financial institution. 1. Please reference the policy Enrollment Timelines (SB-6A) 5 of 5

SMALL BUSINESS HEALTH OPTIONS PROGRAM. Marketplace BILLING & PAYMENT SERVICES USER GUIDE. Billing & Payment User Guide 1

SMALL BUSINESS HEALTH OPTIONS PROGRAM. Marketplace BILLING & PAYMENT SERVICES USER GUIDE. Billing & Payment User Guide 1 SMALL BUSINESS HEALTH OPTIONS PROGRAM Marketplace BILLING & PAYMENT SERVICES USER GUIDE Billing & Payment User Guide 1 Table of Contents 1. SHOP Marketplace Billing & Payment Systems for Employers... 3

More information

billing Oxford Billing Contact Information Billing Basics How to Submit a Payment How to Check Your Invoice on Oxford s Web Site Your Oxford Invoice

billing Oxford Billing Contact Information Billing Basics How to Submit a Payment How to Check Your Invoice on Oxford s Web Site Your Oxford Invoice at a glance Billing Basics How to Verify Invoice Accuracy How Premiums are Prorated Billing Discrepancies & Member Information How to Submit a Payment How to Check Your Invoice on Oxford s Web Site How

More information

Federally Facilitated Marketplace Enrollment Operational Policy & Guidance

Federally Facilitated Marketplace Enrollment Operational Policy & Guidance Federally Facilitated Marketplace Enrollment Operational Policy & Guidance October 3, 2013 This draft manual will go into effect with minimal changes as of October 1, 2013. All enrollments made on or after

More information

COBRA Procedures and Basic Compliance Rules for Employers

COBRA Procedures and Basic Compliance Rules for Employers COBRA Procedures and Basic Compliance Rules for Employers Caution: COBRA TPAs must use discretion in using these suggested procedures as their deadlines and processes may be different. The following pages

More information

Access to Health Insurance Invoice Process

Access to Health Insurance Invoice Process Access to Health Insurance Invoice Process Invoicing Guidelines The Department will send the premium payment reimbursement directly to the Insurance Company. The Insurance Company collects the rest of

More information

A Reference Manual for Brokers with Prime and Complete Dental Programs

A Reference Manual for Brokers with Prime and Complete Dental Programs A Reference Manual for Brokers with Prime and Complete Dental Programs empireblue.com TABLE OF CONTENTS WELCOME TO EMPIRE BLUE CROSS AND BLUE SHIELD DENTAL PROGRAM..1 WHO TO CONTACT..2 WEB SITE 3 NEW GROUP

More information

Full Service Health Savings Account. Client Administrative Portfolio

Full Service Health Savings Account. Client Administrative Portfolio Full Service Health Savings Account Client Administrative Portfolio 1 Thank You for Participating in the FlexSystem Full Service Health Savings Account As a FlexSystem Full Service Health Savings Account

More information

How To Get A Cobra Plan In California

How To Get A Cobra Plan In California Covered California for Small Business Employer Guide Table of Contents 1 Welcome to Covered California Overview of Covered California for Small Business Program 2 Small Business Tax Credits Privacy Statement

More information

COBRA & DIRECT PAY JOB AID

COBRA & DIRECT PAY JOB AID Table of Contents TABLE OF CONTENTS COBRA & DIRECT PAY JOB AID 1 2 10/2014 Table of Contents... 3 Direct Pay... 5 Invoicing & Terms of Payment... 5 Premium Remittance... 6 Non-Sufficient Funds and Stop

More information

LTC Monthly Claims Training How to Bill UB04 on Web Portal

LTC Monthly Claims Training How to Bill UB04 on Web Portal LTC Monthly Claims Training How to Bill UB04 on Web Portal Statewide Medicaid Managed Care: Key Components STATEWIDE MEDICAID MANAGED CARE PROGRAM MANAGED MEDICAL ASSISTANCE PROGRAM LONG-TERM CARE PROGRAM

More information

Producers Administrative Guide to Selling Individual Plans in Oregon Spring 2014

Producers Administrative Guide to Selling Individual Plans in Oregon Spring 2014 Producers Administrative Guide to Selling Individual Plans in Oregon Spring 2014 Table of Contents Eligibility and Enrollment Periods... 2 Application Process Outside of the Exchange... 4 Premium Payments

More information

COBRA AND Cal-COBRA. What is COBRA?

COBRA AND Cal-COBRA. What is COBRA? COBRA AND Cal-COBRA What is COBRA? The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) is a federal law enacted to help prevent gaps in healthcare coverage. COBRA applies in general to companies

More information

Alternate Initial Payment Methods

Alternate Initial Payment Methods Alternate Initial Payment Methods Lesson Agenda Section 1: Overview Practice Exercise Scenario 1 Practice Exercise Scenario 2 Practice Exercise Scenario 3 Course Summary 30 minutes 5 minutes 5 minutes

More information

Individual Medicare supplement application

Individual Medicare supplement application Individual Medicare supplement application Please mail your completed application to: Moda Health Plan, Inc., Attn: Medicare Billing & Eligibility, PO Box 40384, Portland, OR 97240-0384 phone 503-265-4762

More information

COCA-COLA ENTERPRISES, INC. DIVIDEND REINVESTMENT AND CASH INVESTMENT PLAN

COCA-COLA ENTERPRISES, INC. DIVIDEND REINVESTMENT AND CASH INVESTMENT PLAN COCA-COLA ENTERPRISES, INC. DIVIDEND REINVESTMENT AND CASH INVESTMENT PLAN TABLE OF CONTENTS Principal Features of the Plan 1 How to Enroll in the Plan 1 How to Complete the Enrollment Authorization Form

More information

CONTINUING YOUR BENEFITS

CONTINUING YOUR BENEFITS CONTINUING YOUR BENEFITS A COBRA How-To Guide Under federal law, you have the right to continue your employersponsored health insurance coverage after you lose coverage through your employer. The COBRA

More information

Enrollment Application Instructions 2015 Plan Year

Enrollment Application Instructions 2015 Plan Year Enrollment Application Instructions 2015 Plan Year Please read before completing your enrollment request form. You are eligible to join Care N Care Health Plan(s) HMO if: You are entitled to Medicare Part

More information

Bulletin. Alternative Care (AC) Program Fee Procedures, Billing, Long-Term Care Insurance Policy, and Estate Recoveries TOPIC PURPOSE CONTACT SIGNED

Bulletin. Alternative Care (AC) Program Fee Procedures, Billing, Long-Term Care Insurance Policy, and Estate Recoveries TOPIC PURPOSE CONTACT SIGNED Bulletin NUMBER #15-25-05 DATE OF INTEREST TO County Directors Social Services Supervisors and Staff Alternative Care Program Administrators Tribal Agency Directors County Fiscal Administrative Staff Community

More information

COBRA Participant Guide

COBRA Participant Guide COBRA Participant Guide COBRA Participant Guide 1 Table of Contents Introduction........................................... 3 COBRA Checklist........................................ 3 General Timeline

More information

General Commercial Terms

General Commercial Terms Effective Date: July 15, 2015 General Commercial Terms These Commercial Terms apply to our commercial transactions with you, including your purchase of any paid service from us, your purchase of a product

More information

A Guide to Working with Delta Dental of Minnesota. A Reference Manual for Brokers

A Guide to Working with Delta Dental of Minnesota. A Reference Manual for Brokers A Guide to Working with Delta Dental of Minnesota A Reference Manual for Brokers TABLE OF CONTENTS Welcome to Delta Dental of Minnesota 2 Who To Contact 3 Web Site 4 Agent of Record 5 Commissions 6 HIPAA

More information

Memorial Hermann Advantage (HMO)

Memorial Hermann Advantage (HMO) Memorial Hermann Advantage (HMO) 2016 Enrollment Form Follow these easy steps to enroll in a Memorial Hermann Advantage Health Maintenance Organization (HMO). 1. Each applicant must fill out a separate

More information

Eligibility, Enrollment, Disenrollment & Grace Period

Eligibility, Enrollment, Disenrollment & Grace Period Section 2. Eligibility, Enrollment, Disenrollment & Grace Period Enrollment Enrollment in Ohio s Marketplace Program The Centers for Medicare and Medicaid Services (CMS) is the program which implements

More information

COBRA & Billing Administration Administration Services Guide. Welcome!

COBRA & Billing Administration Administration Services Guide. Welcome! Welcome! V4.4/2009 Table of Contents: Welcome Message COBRA & Billing Administrator Contact Information COBRA & Billing Administration Overview COBRA Administration Functions Procedures for Full COBRA

More information

PROCEDURE. Part 5.9: Settlement Payment Methods and Schedule PUBLIC. Market Manual 5: Settlements. Issue 17.0 MDP_PRO_0036

PROCEDURE. Part 5.9: Settlement Payment Methods and Schedule PUBLIC. Market Manual 5: Settlements. Issue 17.0 MDP_PRO_0036 PUBLIC MDP_PRO_0036 PROCEDURE Market Manual 5: Settlements Part 5.9: Settlement Payment Methods and Schedule Issue 17.0 This procedure describes the activities and schedule required by the IESO and Market

More information

Cigna Health and Life Insurance Company (Cigna) Georgia Individual and Family Plan Enrollment Application / Change Form

Cigna Health and Life Insurance Company (Cigna) Georgia Individual and Family Plan Enrollment Application / Change Form Section A. Type of Application Primary Applicant Name Enrollment Form ID Cigna Health and Life Insurance Company (Cigna) Georgia Individual and Family Plan Enrollment Application / Change Form New Enrollment

More information

"You" and "your" mean the account holder(s) and anyone else with authority to deposit, withdraw, or exercise control over the funds in the account.

You and your mean the account holder(s) and anyone else with authority to deposit, withdraw, or exercise control over the funds in the account. FIRST BANK KANSAS Information about Electronic Fund Transfers The Electronic Fund Transfer Act and Regulation E require banks to provide certain information to customers regarding electronic fund transfer

More information

Molina Healthcare of Ohio, Inc. PO Box 22712 Long Beach, CA 90801

Molina Healthcare of Ohio, Inc. PO Box 22712 Long Beach, CA 90801 Section 9. Claims As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your

More information

PRODUCERS QUICK REFERENCE GUIDE Agent Marketing Support Toll Free: 866-280-0766 In Columbia: 803-382-5976 www.bluechoicesc.com

PRODUCERS QUICK REFERENCE GUIDE Agent Marketing Support Toll Free: 866-280-0766 In Columbia: 803-382-5976 www.bluechoicesc.com PRODUCERS QUICK REFERENCE GUIDE Agent Marketing Support Toll Free: 866-280-0766 In Columbia: 803-382-5976 www.bluechoicesc.com Group Size and Proposal Rating: BusinessADVANTAGE Plans 1/1/2014 2 50 Adjusted

More information

Table of Contents. 18.01.65 - Rules for the Surplus Line Brokers

Table of Contents. 18.01.65 - Rules for the Surplus Line Brokers Table of Contents 18.01.65 - Rules for the Surplus Line Brokers 000. Legal Authority.... 2 001. Title And Scope.... 2 002. Written Interpretations.... 2 003. Administrative Appeals.... 2 004. -- 010. (Reserved)...

More information

for paying off your mortgage faster and reducing your total interest costs.

for paying off your mortgage faster and reducing your total interest costs. Bi-Weekly Payment Program Guide for paying off your mortgage faster and reducing your total interest costs. Just enroll in the PNC Mortgage Bi-Weekly Payment Program As a PNC mortgage borrower, you have

More information

New Horizon Bank Online Banking Agreement/Disclosure

New Horizon Bank Online Banking Agreement/Disclosure New Horizon Bank Online Banking Agreement/Disclosure This Agreement governs the use of the New Horizon Bank Online Banking Services and is made and entered into by and between New Horizon Bank ("Bank"),

More information

Plan Administrator s Quick Reference Guide

Plan Administrator s Quick Reference Guide FOR EMPLOYERS Plan Administrator s Quick Reference Guide It s easy to administer your health plan... 2 Online tools for plan administration... 3 Helpful Web tips... 5 Eligibility and enrollment... 6 Special

More information

Electronic Payment Instructions and Tutorial TABLE OF CONTENTS. Getting Started 2. Making a One Time Payment 3. Creating an Account 4

Electronic Payment Instructions and Tutorial TABLE OF CONTENTS. Getting Started 2. Making a One Time Payment 3. Creating an Account 4 TABLE OF CONTENTS TOPIC PAGE Getting Started 2 Making a One Time Payment 3 Creating an Account 4 Setting Up Recurring Payments 8 Change Recurring Payments 13 Setting Up Additional Bank Accounts 16 Adding

More information

Health Benefits Coverage for Noncareer Employees

Health Benefits Coverage for Noncareer Employees Health Benefits Coverage for Noncareer Employees The Federal Employees Health Benefits (FEHB) Program permits health insurance enrollment for certain noncareer (temporary) employees provided these employees

More information

UCA GENERAL INSURANCE SERVICES, INC. SERVICE IS OUR STRENGTH. UCA EZ-Pay. Direct Bill System. Broker Manual

UCA GENERAL INSURANCE SERVICES, INC. SERVICE IS OUR STRENGTH. UCA EZ-Pay. Direct Bill System. Broker Manual UCA GENERAL INSURANCE SERVICES, INC. SERVICE IS OUR STRENGTH UCA EZ-Pay Direct Bill System Broker Manual **This document is intended to serve as a guide and will be revised or replaced as new information

More information

The Commonwealth Health Insurance Connector Authority Brokerage Terms and Conditions

The Commonwealth Health Insurance Connector Authority Brokerage Terms and Conditions The Commonwealth Health Insurance Connector Authority Brokerage Terms and Conditions These Terms and Condittions (also referred to as the Agreement ) are made as of the day of, ; between The Commonwealth

More information

133 Center Street, Bangor, Maine 04401-5097 (207)942-8815. Owners of Brookings-Smith are Gary W. Smith, Holly Smith Fernald and James R.

133 Center Street, Bangor, Maine 04401-5097 (207)942-8815. Owners of Brookings-Smith are Gary W. Smith, Holly Smith Fernald and James R. 133 Center Street, Bangor, Maine 04401-5097 (207)942-8815 Owners of Brookings-Smith are Gary W. Smith, Holly Smith Fernald and James R. Fernald CFSP Maine Mortuary Trust Agreement For the benefit of 1.

More information

Business Online Bill Pay Terms and Conditions

Business Online Bill Pay Terms and Conditions Business Online Bill Pay Terms and Conditions This Online Bill Pay Terms and Conditions ("Agreement") is between Customer and Spring Bank for the delivery of Business Online Bill Pay as described below:

More information

NACHA Return Codes. The available and/or cash reserve balance is not sufficient to cover the dollar value of the debit entry.

NACHA Return Codes. The available and/or cash reserve balance is not sufficient to cover the dollar value of the debit entry. NACHA Return Codes R01 Insufficient Funds The available and/or cash reserve balance is not sufficient to cover the dollar value of the debit entry. R02 Account Closed A previously active account has been

More information

HBF ANCILLARY PROVIDER REQUIREMENTS

HBF ANCILLARY PROVIDER REQUIREMENTS HBF ANCILLARY PROVIDER REQUIREMENTS CONTENTS 1. Registration and Provider Numbers 1.1. Your Provider Number(s) 2 1.2. Eligibility for Registration with HBF 2 1.3. Processing Time for Registration 2 1.4.

More information

TOWNSHIP OF WHITEWATER REGION ACCOUNTS RECEIVABLE POLICY

TOWNSHIP OF WHITEWATER REGION ACCOUNTS RECEIVABLE POLICY TOWNSHIP OF WHITEWATER REGION ACCOUNTS RECEIVABLE POLICY POLICY STATEMENT AND RATIONALE: Council wishes to ensure prompt, effective and efficient delivery of billing and collection for all general Accounts

More information

Bill Payment Agreement

Bill Payment Agreement Bill Payment Agreement Service Provider You authorize Altra Federal Credit Union (Altra) to utilize ipay Solutions (or another processor of our choice) to provide this service to you on the Credit Union

More information

Questionnaire/Compliance Form for COBRA Administration

Questionnaire/Compliance Form for COBRA Administration Form for COBRA Administration Questionnaire/Compliance 1. General Information 1.1 Total number of employees in your company. 1.2 Your company shall submit renewal fees to the district no later than February

More information

Consumer Bill Pay. Quick Step User Guide

Consumer Bill Pay. Quick Step User Guide Consumer Bill Pay Quick Step User Guide Overview Consumer Bill Pay is a service that allows you to pay virtually anyone or any company through your online banking account. You determine who you want to

More information

Online Bill Payment & Presentment User Guide

Online Bill Payment & Presentment User Guide Table of Contents Alerts and Notifications... 4 Add an email Notification...4 Cancel an email Notification...5 Automatic Payments... 6 Add a Standard Automatic Payment Rule...6 Add an Automatic Payment

More information

NATIONAL MEDICAL SUPPORT NOTICE PART A NOTICE TO WITHHOLD FOR HEALTH CARE COVERAGE

NATIONAL MEDICAL SUPPORT NOTICE PART A NOTICE TO WITHHOLD FOR HEALTH CARE COVERAGE NATIONAL MEDICAL SUPPORT NOTICE PART A NOTICE TO WITHHOLD FOR HEALTH CARE COVERAGE This Notice is issued under section 466(a)(19) of the Social Security Act, section 609(a)(5)(C) of the Employee Retirement

More information

ELECTRONIC SERVICES AGREEMENT

ELECTRONIC SERVICES AGREEMENT ELECTRONIC SERVICES AGREEMENT Electronic Disclosure and Consent To the extent that you have given your e-sign consent, if such consent is required, you agree to receive this covering consumer online banking

More information

Champion Credit Union, Inc. PayIt Bill Payment Services Agreement & Disclosure

Champion Credit Union, Inc. PayIt Bill Payment Services Agreement & Disclosure Champion Credit Union, Inc. PayIt Bill Payment Services Agreement & Disclosure Welcome to Champion Credit Union s Virtual Branch Bill Pay Service. Use of PayIt Bill Pay Service indicates acceptance of

More information

Cigna Health and Life Insurance Company (Cigna) Florida Individual and Family Plan Enrollment Application / Change Form

Cigna Health and Life Insurance Company (Cigna) Florida Individual and Family Plan Enrollment Application / Change Form Cigna Health and Life Insurance Company (Cigna) Florida Individual and Family Plan Enrollment Application / Change Form Our medical plans are only available in the following services areas/counties: Tampa:

More information

Cigna Health and Life Insurance Company (Cigna) California Individual and Family Plan Enrollment Application / Change Form

Cigna Health and Life Insurance Company (Cigna) California Individual and Family Plan Enrollment Application / Change Form Section A. Type of Application New Enrollment Application: Applicant Only Applicant and Dependent(s) Child(ren) Only Existing Individual Plan Policy Member requesting a change in coverage: Add Family Member(s)

More information

Consumer ebanking for Business Set-Up Form

Consumer ebanking for Business Set-Up Form Consumer ebanking for Business Set-Up Form PRINT, SIGN and MAIL to American Savings Bank, Customer Service Center, P.O. Box 2300, Honolulu, HI 96804-2300 or DROP OFF this set-up form at your nearest American

More information

FIRST GENERAL CREDIT UNION ONLINE BANKING AND BILL PAYMENT AGREEMENT

FIRST GENERAL CREDIT UNION ONLINE BANKING AND BILL PAYMENT AGREEMENT FIRST GENERAL CREDIT UNION ONLINE BANKING AND BILL PAYMENT AGREEMENT This Agreement describes your rights and obligations as a user of the Online Banking service and/or the Bill Payment service (collectively

More information

Online Banking Agreement

Online Banking Agreement Online Banking Agreement Please read the Terms and Conditions below and "sign" below, by checking the box below and click submit. We recommend that you print a copy of this document and maintain a copy

More information

PATIENT FINANCIAL RESPONSIBILITY STATEMENT

PATIENT FINANCIAL RESPONSIBILITY STATEMENT PATIENT FINANCIAL RESPONSIBILITY STATEMENT Thank you for choosing Medical Associates Clinic, P.C., as your healthcare provider. The medical services you seek imply an obligation on your part to ensure

More information

BENEFIT PLAN CLIENT: CLIENT ID: EFFECTIVE DATE: MONTHLY PAYMENT DUE DATE:

BENEFIT PLAN CLIENT: CLIENT ID: EFFECTIVE DATE: MONTHLY PAYMENT DUE DATE: BENEFIT PLAN CLIENT: CLIENT ID: EFFECTIVE DATE: MONTHLY PAYMENT DUE DATE: ON THE FIRST PAY ENDING DATE OF EACH MONTH, IN THE MONTH PRIOR TO THE BILLING DATE [ 1ST OF EACH MONTH ] RENEWAL DATE: TABLE OF

More information

SMALL EMPLOYER GROUP APPLICATION

SMALL EMPLOYER GROUP APPLICATION SMALL EMPLOYER GROUP APPLICATION EmblemHealth insurance programs are underwritten by (GHI)Group Health Incorporated and (HIP) HIP Health Plan of New York. PRINT IN INK SECTION I: GROUP INFORMATION Company

More information

KEMBA ONLINE BILL PAY AGREEMENT AND DISCLOSURE

KEMBA ONLINE BILL PAY AGREEMENT AND DISCLOSURE KEMBA ONLINE BILL PAY AGREEMENT AND DISCLOSURE BILL PAYMENT OVERVIEW KEMBA Peoria Credit Union offers bill pay services for Internet Banking users from ipay Solutions. Bill Payment provides the capability

More information

MyPOMCO.com New Online Features for FSA Online Set-Up Instructions

MyPOMCO.com New Online Features for FSA Online Set-Up Instructions MyPOMCO.com New Online Features for FSA Online Set-Up Instructions It s now even easier to manage your flexible spending account (FSA) with these new online features: Direct deposit of reimbursements into

More information

EMBLEMHEALTH FOR SMALL GROUPS

EMBLEMHEALTH FOR SMALL GROUPS Print In Ink EMBLEMHEALTH FOR SMALL GROUPS EmblemHealth insurance programs are underwritten by Group Health Incorporated (GHI), HIP Health Plan of Greater New York (HIP) and HIP Insurance Company of New

More information

General Terms Applicable to Bill Payment and Transfer Services

General Terms Applicable to Bill Payment and Transfer Services Please read this document carefully and print a copy for your reference. You may refer back to it at any time on this website. General Terms Applicable to Bill Payment and Transfer Services Your use of

More information

We are happy to report that premiums will remain the same in 2015 as they were last year with no increases.

We are happy to report that premiums will remain the same in 2015 as they were last year with no increases. DATE: December 22, 2014 TO: ARS Chapters and Affiliated Societies FROM: Jeff Ware, Executive Director RE: IMPORTANT INFORMATION: Event Liability Insurance Program We are happy to report that premiums will

More information

online banking, billpay & electronic services agreement

online banking, billpay & electronic services agreement online banking, billpay & electronic services agreement Password and Security You agree not to give or make available your Online Banking access password to any unauthorized individuals. You are responsible

More information

Eligibility and Enrollment for Small Business Health Option Program (SHOP) Participant Guide. Version 2.0

Eligibility and Enrollment for Small Business Health Option Program (SHOP) Participant Guide. Version 2.0 Eligibility and Enrollment for Small Business Health Option Program (SHOP) Participant Guide Version 2.0 Course Name: Eligibility and Enrollment for SHOP Version 2.0 TABLE OF CONTENTS 1 INTRODUCTION...

More information

First Financial Bank Online Banking Bill Pay User Guide

First Financial Bank Online Banking Bill Pay User Guide First Financial Bank Online Banking Bill Pay User Guide First Financial Online Banking Bill Pay User Guide Table of Contents ACCESSING BILL PAY...4 Enrolling in Bill Pay...4 Launching Bill Pay...5 Getting

More information

Franklin County Clerk 2013 Tax Bill Sale Timeline. Notice in The State Journal that certificates of delinquency will be advertised

Franklin County Clerk 2013 Tax Bill Sale Timeline. Notice in The State Journal that certificates of delinquency will be advertised Franklin County Clerk 2013 Tax Bill Sale Timeline April 15, 2014 June 15, 2014 June 22, 2014 July 25, 2014 Sheriff turns unpaid tax bills over to county clerk at the close of business Notice in The State

More information

Visa Liability Waiver Program. Security and coverage when providing Visa Commercial and Business cards to employees

Visa Liability Waiver Program. Security and coverage when providing Visa Commercial and Business cards to employees Visa Liability Waiver Program Security and coverage when providing Visa Commercial and Business cards to employees Security. Coverage. Confidence. Now you can provide Visa Commercial and Business cards

More information

Section 9. Claims Claim Submission Molina Healthcare PO Box 22815 Long Beach, CA 90801

Section 9. Claims Claim Submission Molina Healthcare PO Box 22815 Long Beach, CA 90801 Section 9. Claims As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your

More information

Transitional Reinsurance Program Fees

Transitional Reinsurance Program Fees Transitional Reinsurance Program Fees Submission of Annual Enrollment and Contributions The Patient Protection and Affordable Care Act (Affordable Care Act) fundamentally changed the way health insurance

More information

Health Reimbursement Account (HRA) Frequently Asked Questions

Health Reimbursement Account (HRA) Frequently Asked Questions Health Reimbursement Account (HRA) Frequently Asked Questions Q. What is a Health Reimbursement Account (HRA)? A. A Health Reimbursement Account (HRA) is part of the benefit plan offered to you by Brookhaven

More information

Rollstone Bank & Trust Business Online Bill Pay Agreement

Rollstone Bank & Trust Business Online Bill Pay Agreement Rollstone Bank & Trust Business Online Bill Pay Agreement By choosing to use the Rollstone Bank & Trust Online Bill Pay, you agree to the terms and conditions in this Agreement. Please read this Agreement

More information

User Guide. COBRA Employer Manual

User Guide. COBRA Employer Manual Experience Excellence COBRA Manual User Guide COBRA Employer Manual COBRA Responsibilities and Deadlines Under COBRA, specific notices must be provided to covered employees and their families explaining

More information

Post Retirement Medical Plan & Trust a single employer plan sponsored by Truckee Meadows Water Authority

Post Retirement Medical Plan & Trust a single employer plan sponsored by Truckee Meadows Water Authority 8-23-11 PRMT Agenda Item 7 a single employer plan sponsored by Truckee Meadows Water Authority TO: Board of Trustees of the FROM: Nanette Quitt, TMWA Human Resources Manager DATE: August 1, 2011 SUBJECT:

More information

MANDATORY CUSTOMER CREDIT APPLICATION

MANDATORY CUSTOMER CREDIT APPLICATION MANDATORY CUSTOMER CREDIT APPLICATION Dupal Enterprises LLC Telephone» 718-388-8130 67 Metropolitan Ave Fax back to» 718-388-7008 Brooklyn, NY 11249 *Business Information* Ownership Sole Proprietorship

More information

ALASKA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT

ALASKA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT ALASKA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT 21.79.010. Purpose The purpose of this chapter is to protect, subject to certain limitations, the persons specified in AS 21.79.020(a) against

More information

Online Bill Pay. Quick Reference Guide

Online Bill Pay. Quick Reference Guide Online Bill Pay Quick Reference Guide What is Online Bill Pay?... 2 What are the benefits of Online Bill Pay?... 2 How to Make a Payment... 3 Make a Single Payment... 3 Make a Recurring Payment... 5 How

More information

Application for Medicare Supplement Coverage

Application for Medicare Supplement Coverage Application for Medicare Supplement Coverage Complete application in full Use ballpoint pen Print legibly Plan Selection Plan A Plan D Plan N Requested Effective Plan C Plan F Date: / / Applicant Information

More information

I O W A H B E P M O P R O J E C T P L A N N I N G F O R T H E S M A L L B U S I N E S S H E A L T H O P T I O N S P R O G R AM

I O W A H B E P M O P R O J E C T P L A N N I N G F O R T H E S M A L L B U S I N E S S H E A L T H O P T I O N S P R O G R AM I O W A H B E P M O P R O J E C T P L A N N I N G F O R T H E S M A L L B U S I N E S S H E A L T H O P T I O N S P R O G R AM V E R S I O N 1. 0 S T A T U S : F I N A L N O V E M B E R 3 0, 2 0 1 2 180

More information

20 CSR 100-1.040 Standards for Prompt Investigation of Claims (Rescinded July 30, 2008)...4

20 CSR 100-1.040 Standards for Prompt Investigation of Claims (Rescinded July 30, 2008)...4 Rules of Department of Insurance, Financial Institutions and Professional Registration Chapter 1 Improper or Unfair Claims Settlement Practices Title Page 20 CSR 100-1.010 Definitions...3 20 CSR 100-1.020

More information

COVENTRY HEALTH AND LIFE INSURANCE COMPANY

COVENTRY HEALTH AND LIFE INSURANCE COMPANY COVENTRY HEALTH AND LIFE INSURANCE COMPANY SMALL GROUP POLICY AVAILABLE OUTSIDE OF THE HEALTH INSURANCE MARKETPLACE THIS CONTRACT is made by and between Coventry Health and Life Insurance Company (hereinafter

More information

Only checking accounts can be used for Bill Payment purposes.

Only checking accounts can be used for Bill Payment purposes. INTERNET BILL PAYMENT SERVICE AGREEMENT The Internet Bill Payment service allows you to pay your bills electronically through a personal computer, rather than manually writing and mailing checks. You can

More information

The No Glitch Switch Kit

The No Glitch Switch Kit The No Glitch Switch Kit INSTRUCTIONS Southern Heritage Bank can show you how easy it is to switch banks! Everyone looks for a hassle free way of moving current personal or business accounts, now the switch

More information

HealthWave Premium Billing and Payment Services. Kansas Health Policy Authority / HP Kansas Team

HealthWave Premium Billing and Payment Services. Kansas Health Policy Authority / HP Kansas Team HealthWave Premium Billing and Payment Services Kansas Health Policy Authority / HP Kansas Team New Premium Billing Administrator HP Enterprise Services assumes responsibility from MAXIMUS effective 1/1/2010.

More information

Online Banking Agreement

Online Banking Agreement Online Banking Agreement If you would like to have a paper copy of this Agreement sent to you, please send us an e-mail at netteller@usbhazen.com. This Netteller Online Banking Agreement (this Agreement

More information

Covered California Participant Guide Course Name: Covered California for Small Business Version 4.0 1. COURSE OBJECTIVES... 3

Covered California Participant Guide Course Name: Covered California for Small Business Version 4.0 1. COURSE OBJECTIVES... 3 Covered California Participant Guide Course Name: Covered California for Small Business Covered California for Small Business Participant Guide Version 4.0 Version 4.0 TABLE CONTENTS 1. COURSE OBJECTIVES...

More information

CONSUMER ONLINE BANKING DISCLOSURE AND AGREEEMENT

CONSUMER ONLINE BANKING DISCLOSURE AND AGREEEMENT CONSUMER ONLINE BANKING DISCLOSURE AND AGREEEMENT This Agreement describes your rights and obligations as a user of the Online Banking service and/or the Bill Payment and Presentment service ("Services").

More information

Farmers State Bank Bill Payment Agreement & Disclosures

Farmers State Bank Bill Payment Agreement & Disclosures Farmers State Bank Bill Payment Agreement & Disclosures Welcome to Online Banking Bill Payment Service. Use of the Bill Payment Service indicates acceptance of terms and conditions set forth in the Online

More information

NOTE: Only a checking account may be used, not a Cash Card, savings and/or money market account.

NOTE: Only a checking account may be used, not a Cash Card, savings and/or money market account. Consumer Online Bill Pay Agreement and Disclosure Statement This Consumer Online Bill Pay Agreement and Disclosure Statement (the "Agreement") is between Burke & Herbert Bank (the Bank ) and each customer

More information

San Francisco State University US Bank Personal Liability Travel Card

San Francisco State University US Bank Personal Liability Travel Card POLICY AND PROCEDURES General Information The, commonly known as the Corporate Card/ Travel Card, is an individual liability credit card that is used as a means of expediting payment of travel expenses

More information

BILL PAYING AGREEMENT/DISCLOSURE

BILL PAYING AGREEMENT/DISCLOSURE BILL PAYING AGREEMENT/DISCLOSURE Geauga Credit Union, Inc. Bill Pay Service (ipay Plus) gives you unlimited payment transactions monthly. Enrollees must receive their monthly statements via e mail. Enrolled

More information

Commercial Online Banking Frequently Asked Questions Bryn Mawr Trust Company

Commercial Online Banking Frequently Asked Questions Bryn Mawr Trust Company Commercial Online Banking Frequently Asked Questions Bryn Mawr Trust Company Bryn Mawr Trust Company August 2015 Page 1 of 9 CONTENTS Contents... 2 IMPORTANT NEWS!... 3 Fees and Enrollment... 3 Q&A: Commercial

More information

ADDRESS CITY STATE ZIP CODE CITY STATE ZIP CODE

ADDRESS CITY STATE ZIP CODE CITY STATE ZIP CODE CREDIT AGREEMENT FIRM Originating Location: Please remit application to: DATE TRADE S (If any) COMPANY FEDERAL ID# MAILING PHYSICAL STATE OF INCORPORATION PHONE FAX BUSINESS TYPE # YEARS IN BUSINESS (

More information

EagleBank Online Service Agreement and Electronic Funds Transfer Disclosure

EagleBank Online Service Agreement and Electronic Funds Transfer Disclosure EagleBank Online Service Agreement and Electronic Funds Transfer Disclosure No one from EagleBank will ever contact you in any form (fax, letter, email, phone call, etc.) and ask you to provide your online

More information

Office of Personnel Management

Office of Personnel Management United States Office of Personnel Management The Federal Government s Human Resources Agency Retirement and Insurance Service Benefits Administration Letter Number: 02-306 Date: April 23, 2002 Subject:

More information

Old Dominion National Bank Consumer ebanking Access Agreement and Electronic Fund Transfer Act Disclosure

Old Dominion National Bank Consumer ebanking Access Agreement and Electronic Fund Transfer Act Disclosure Old Dominion National Bank Consumer ebanking Access Agreement and Electronic Fund Transfer Act Disclosure Agreement This Agreement is a contract which establishes the rules governing your electronic access

More information

Chapter 82-60 WAC All Payer Claims Database

Chapter 82-60 WAC All Payer Claims Database Chapter 82-60 WAC All Payer Claims Database WAC 82-60-010 Purpose (1) Chapter 43.371 RCW establishes the framework for the creation and administration of a statewide all-payer health care claims database.

More information

XCEL ENERGY S ebill AND ebill PAYMENT TERMS OF USE

XCEL ENERGY S ebill AND ebill PAYMENT TERMS OF USE XCEL ENERGY S ebill AND ebill PAYMENT TERMS OF USE 1. Introduction CAREFULLY READ ALL OF THESE TERMS OF USE BEFORE PROCEEDING. IF YOU DO NOT ACCEPT SUCH TERMS AND INDICATE YOUR ACCEPTANCE BELOW, THEN YOU

More information

VISA Corporate Liability Insurance

VISA Corporate Liability Insurance VISA Corporate Liability Insurance Another way businesses count on VISA Commercial Card Programs. In addition to the many benefits that corporate clients realize with VISA Commercial Card Programs, they

More information

AGREEMENT FOR JBT ONLINE BILL PAY SERVICE

AGREEMENT FOR JBT ONLINE BILL PAY SERVICE AGREEMENT FOR JBT ONLINE BILL PAY SERVICE INTRODUCTION This is your bill paying agreement with JONESTOWN BANK & TRUST CO. (JBT). JBT Online Bill Pay Service ( Service ) allows you to direct JBT to make

More information

63rd Legislature AN ACT REVISING THE SMALL BUSINESS HEALTH INSURANCE POOL KNOWN AS INSURE MONTANA

63rd Legislature AN ACT REVISING THE SMALL BUSINESS HEALTH INSURANCE POOL KNOWN AS INSURE MONTANA 63rd Legislature HB0048 AN ACT REVISING THE SMALL BUSINESS HEALTH INSURANCE POOL KNOWN AS INSURE MONTANA TO IMPROVE EFFICIENCY; REMOVING IMPEDIMENTS TO FUND TRANSFERS; BASING ELIGIBILITY FOR PREMIUM ASSISTANCE

More information