North and South Florida Regions Administrative Manual
Inside Front Cover
Table of Contents Key Contact Information... 2 Online Account Management SM Useful Tools for Plan Administration... 3 Access Online Account Management... 4 Provider Search Search for Providers in Coventry Health Care of Florida Provider Networks... 5 Get Directions... 6 My Online Services SM... 7 Benefits Schedule of Benefits and Applicable Riders... 8 Certificate of Coverage/Insurance and Group Master Contract About the Certificate of Coverage/Insurance (PPO/HMO/POS) and Group Master Contract... 8 Contractual Agreement About your Contractual Agreement... 9 Enrollment and Termination Procedures Open Enrollment...10 Documentation Required to Enroll...10 Enrollment Documentation...11 Enrolling a Member...11 Disenrolling a Member...12 Copy of Member Status Change Form...12 Premium Billing Accounts Receivable...13 Premium Payments...13 Premiums Due First Day of the Month...13 Billing Cycle...13 Grace Period...13 Termination for Non-Payment of Premium...13 Sample Billing Statement...14 Explanation of Benefits (EOB) Definition of an EOB...15 Sample EOB...16 Claims Prior Authorization...18 Coordination of Benefits...18 Continuation and Medicare Coverages Grievance and Appeals Process...19 Continuation of Coverage...19 Federally Mandated Coverage (COBRA)...19 State-Mandated Coverage...20 Medicare...21 The purpose of this document is to provide general guidance for employer groups that are written under a Coventry Health Care of Florida policy which is administered by Coventry Health Care of Florida, Inc. or Coventry Health and Life Insurance Company. The information contained in this document is not legally binding and may be updated from time to time. References to North and South Florida Regions include sections of the state that are located in Gainesville, Pensacola, Tallahassee, Martin, St. Lucie, Palm Beach, Broward and Miami-Dade. 1
Key Contact Information QUICK REFERENCE GUIDE Customer Service Claims/benefits Member verification Provider status Member appeals Member ID cards Deductible information Phone: 866-847-8235 Care Team (for Coventry Health Care of Florida clients) Coventry Health Care of Florida, Inc. Attn: Florida Enrollment P.O. Box 7171 London, KY 40742 Status of enrollment forms Terminations, additions, changes, corrections Questions about COBRA, HIPAA, & qualifying events Billing invoices Reconciliation questions Payment history Premium payments Online Account Management Phone: 877-274-7919 Fax: 877-548-7647 Website Provider search Plan and benefit information Health information Net support for general website assistance Prescription Drug Benefits Questions about specific prescriptions Phone: 866-847-8279 Prior Authorization Inpatient hospitalizations Out-of-network benefits Other services Phone: 866-410-7620 Behavioral Health Line Mental health and substance abuse information Refer to behavioral health phone number on ID card CLAIMS ADDRESS Coventry Health Care of Florida Claims P.O. Box 7807 London, Kentucky 40742 2
Online Account Management SM Useful Tools for Plan Administration At Coventry Health Care of Florida (Coventry), we know administrative needs are different. Coventry provides a convenient way to manage your group health benefits online. Through a single, password-protected website, employers can perform a variety of functions and access a wealth of account information. Online Account Management is available 24 hours a day. It is easy to: View up to six months of billing statements and invoices View payment history View eligibility information for any employee, and find invoices on which that employee appeared Access online bill payment Add/terminate employee or dependent coverage Update employee demographics Perform a wide variety of functions on behalf of any covered member, including viewing/requesting ID cards and updating address/phone, etc. Request Certificates of Creditable Coverage Ask questions View service request status 3
Online Account Management SM Continued Access Online Account Management Employers can sign up to use Online Account Management through an easy four-step process: Log on to and visit the Employers home page Follow the instructions for the Online Account Management section and read the Coventry Health Care, Inc. Electronic Commerce Agreement online Complete the Web Account Request Form online Once the request is processed, the Employer Administrator will be e-mailed a login ID and password to begin using Online Account Management The Employer Administrator can use Online Account Management to establish access for other Employer Users, including an insurance agent. Security for additional users can be limited to access specific functionality as deemed appropriate. Our dedicated Net Support team is available Monday Friday, 8 a.m. to 6 p.m. (EST) to help with questions using Online Account Management. Simply call toll free 877-274-7919 for personal assistance. 4
Provider Search It s easy for members to find an in-network provider using our electronic provider search tool. It contains the names, addresses and phone numbers of participating providers, hospitals, pharmacies, outpatient facilities and other ancillary providers in Coventry s network. Search for Providers in Coventry Health Care of Florida Provider Networks To search for in-network physicians, hospitals and ancillary providers such as physical therapy and urgent care facilities on our website: Go to Click on Locate a Provider on the right side of the page Click on Enter Provider Search Select a product from the drop-down list (refer to the product identified on the member ID card) Search for a doctor, hospital or ancillary service provider Specify provider name, county or distance/mileage preferences to begin your search 5
Provider Search Continued Select a product from the drop-down list. Get directions Members can obtain a map and driving directions to the provider they ve selected by simply clicking display map next to the chosen health care provider. 6
My Online Services SM Coventry members have access to an electronic personal health assistant, putting them in control of their health and benefits. Within My Online Services, members can find complete, personalized information that is built around a personal health record (PHR). Personal Health Record View, store, track and maintain personal health information Share with a health care provider, family member or caregiver Transactions View medical and prescription claims View or print explanations of benefits (EOB) View, request or print an image of an ID card Send a secure e-mail to Coventry Update personal information Health and Wellness Take a health risk assessment Request an e-mail reminder for screenings and tests Access Coventry WellBeing SM with a wealth of online wellness programs 7
Benefits Schedule of Benefits and Applicable Riders These documents inform employees about their benefits and out-of-pocket costs. Included with the online administrative manual is the Schedule of Benefits and applicable Riders selected by your company. This Schedule of Benefits was previously provided to each employee in the Coventry enrollment package. Contact your account manager for questions regarding the Schedule of Benefits and applicable Riders. Certificate of Coverage/Insurance and Group Master Contract About the Certificate of Coverage/Insurance (PPO/HMO/POS) and Group Master Contract In general, the Certificate of Coverage (COC)/Insurance (COI) explains to your employees how to access their covered services. This document describes the benefits, exclusions and limitations, conditions and scope of coverage.! Important Notice! It is important that you and your employees become familiar with this document. The Florida Department of Financial Services considers the Certificate of Coverage/Insurance to be the legal document your employees and their dependents are bound by law to follow. The Group Master Contract is the legal agreement between the contract holder and Coventry. Your electronic welcome kit contains an attached copy of the Certificate of Coverage/ Insurance that is available to those employees enrolled with Coventry Health Care of Florida. Copies of the Certificate of Coverage/Insurance may also be obtained either through Customer Service or on our website,. 8
Contractual Agreement(s) About your Contractual Agreement(s) The contractual agreement(s) detail the following: Coverage under your health care benefit plan Coverage effective date Eligibility for coverage Group enrollment waiting period When premiums are due How agreement(s) may be terminated 9
Enrollment and Termination Procedures Open Enrollment It is important to understand the difference between an open enrollment period and other enrollment periods. Refer to your COC/COI for details: An open enrollment period is the time period designated by the employer when eligible employees are offered the option to choose, change or reallocate benefits. Open enrollment may occur anytime up to 60 days prior to the plan year renewal and lasts approximately 30 days. Your account manager will help to plan the open enrollment period and is available to conduct onsite educational meetings, distribute enrollment literature, and coordinate the processing of any necessary paperwork. Other enrollment periods are those days not designated by the employer as part of the open enrollment period. Enrollment would only be allowed if a qualifying event occurs. All enrollment forms for dependent changes must be received by Coventry within 31 days of the qualifying event. Refer to your COC/COI for a list of qualifying events. Documentation Required to Enroll Employees and eligible dependents may enroll during the open enrollment period or during one of the other enrollment periods as specified in your COC/COI. Coventry offers two ways to enroll employees and their dependents: OR: 1. Use our convenient online system through Online Account Management. It s free and simple to use! 2. Mail or fax a signed, completed enrollment application to us. Address and fax information is located on page two of this manual (Key Contact Information: Enrollment Department).! Important Notice! Section 111 of the Federal Medicare, Medicaid and SCHIP Extension Act of 2007 carries mandatory reporting requirements with respect to persons who have coverage under a group health plan. Part of the required data to be reported includes enrollee Social Security Numbers (SSNs). Therefore, we seek to collect SSNs for all covered employees and dependents in the event the health plan must report enrollee data. 10
Enrollment and Termination Procedures Continued Enrollment Documentation To enroll employees and their eligible dependents, a completed enrollment application for the employee and his or her eligible dependents must be submitted via fax or mail to the address on page 2 or processed via Online Account Management. The following three common circumstances may require additional documentation during the open enrollment period: 1. When a spouse s last name is different from the employee s. Include a copy of the marriage certificate or applicable court decree as proof of marriage. 2. When the dependent child s last name is different from the employee s. Include either: a. A copy of the dependent child s birth certificate indicating both parents last name(s); or b. For a stepchild, a copy of the first page of the employee s last Federal Income Tax Form 1040 as proof that the dependent child is claimed as a dependent of the employee. Coventry Health Care of Florida may also require the employee to sign and have notarized an affidavit attesting that the stepchild resides permanently in the employee s home. 3. When the employee enrolls a disabled dependent. An additional form may be required to be completed and signed by the disabled dependent s attending physician, describing the disability. Your account manager can provide this form. There may be additional circumstances where documentation may be requested by your Account Manager. We reserve the right to periodically review the eligibility of dependents. Enrolling a Member As the company s benefit administrator, it is important to understand and follow Coventry s enrollment process. Coventry accepts retroactive enrollments up to 31 days from the date the member becomes eligible to enroll. Coventry will provide enrollment packets for all eligible employees to be distributed during the open enrollment period. The enrollment packets contain a group enrollment application and Schedule of Benefits. Please contact your Account Manager for assistance with distributing these packets. The six-step enrollment process is as follows: 1. Employee should review the information in the enrollment packet. 2. The employee completes and submits an enrollment application and any additional documentation required, as explained in the previous section, Enrollment Documentation. The enrollment application must be submitted within 31 days of the employee, or their dependent(s), becoming eligible for coverage. 11
Enrollment and Termination Procedures Continued 3. The enrollment application should be reviewed to ensure its completion. Be sure the employee has signed the enrollment application and any additional required documentation is attached. (Please acknowledge the employee s hire date, group number and group name are listed on the application by initialing the form as specified.) 4. Process the enrollment using Coventry s Online Account Management website. Otherwise, ensure the enrollment application is complete and any additional documentation is attached, submit all documentation to the Enrollment Department (see Key Contact Information page for fax number). Submitting the enrollment application at least three weeks prior to the effective date of coverage will allow enough processing time to ensure the employee receives an identification card prior to seeking services. 5. The Enrollment Department will process the enrollment application if access to Online Account Management is not available. 6. Coventry mails each employee and dependent a member ID card. In the event a member does not have his or her ID card by the first day of coverage, the member may print a temporary ID card through My Online Services. SM Online Account Management also allows you the option to print an ID card for any employee. *Please note: Newborns are automatically covered for the first 31 days. Newborn coverage must be added within 60 days of the birth of the newborn in order for benefits to continue, even when family coverage is already in place. Please refer to your Certificate of Coverage/Insurance for detailed information. Disenrolling a Member The disenrollment may be performed through our Online Account Management website. To disenroll manually, simply provide a completed Member Status Change Form to the Enrollment Department (see Key Contact Information page for fax number) for processing. The Member Status Change Form should clearly indicate the date benefits terminate, which may differ from the individual s employment termination date. Once an employee is terminated, a Certificate of Creditable Coverage is sent to each covered member as required by the Health Insurance Portability and Accountability Act (HIPAA). Please be aware the Coventry Health Care of Florida effective date for employee termination is the last day of the month. Copy of Member Status Change Form An electronic version is included in this manual. Please save this document for use as needed. 12
Premium Billing! Important Notice! Coventry s billing provisions (i.e., the premium due date, billing cycle, grace period and termination provisions) are standard for all clients: Accounts Receivable The address and phone number of our Billing Department is listed in the Key Contact Information under Care Team on page 2 of this manual. A representative is available to answer any questions regarding invoices. Premium Payments Using the Online Account Management tool is the easiest way to pay premiums. Any changes to eligibility may be processed allowing the bill to be automatically adjusted when using the Online Account Management tool. When mailing premium payments, please pay as billed. Payment must be sent with the remittance copy. Employee or dependent terminations must be submitted separately from premium payments when you mail your payment. Submit terminations to the Enrollment Department via mail or fax. Premiums Due First Day of the Month Premiums are due monthly on or before the first day of the upcoming month. Billing Cycle Employer groups typically receive their Premium Invoice by the 10th of each month. Premium is due upon receipt, but no later than the first day of the coverage month for which the group is being billed. Remember, a copy of the invoice should be returned with payment. For any questions regarding billing statements, call the Care Team (the phone number is listed on the Key Contact Information page located on page 2 of this manual). Grace Period Provisions related to the grace period are detailed in the Group Master Contract. Termination for Non-Payment of Premium Details regarding termination for non-payment of premiums are located in the Group Master Contract. 13
Sample Billing Statement 14
Explanation of Benefits (EOB) Definition of an EOB The EOB is a document which provides members a detailed description of how claims are processed. An EOB is not a bill. Members are encouraged to review these carefully and to contact Customer Service with any questions. A subscriber will generally receive an EOB if the following events occur: The provider has been paid for the covered services furnished to the member The member was responsible for payment in the form of copayment, coinsurance, deductible or full payment NOTE: EOBs are available through My Online Services SM. EOBs are not typically generated for services covered in full. Sample EOB A sample EOB is on the following page. The statement provides an explanation of each section. 15
Sample EOB 16
Sample EOB Continued HOW TO READ YOUR MEMBER BENEFIT USAGE A Benefits Header This introductory language precedes the Benefits Accumulation Summary. This date reflects when your claims were processed. B Benefit Period Header This identifies the period (in date form) in which benefits are calculated. This could be by calendar year or contract benefit year. C Benefit Accumulation Summary The information displayed in the columns below is based upon your benefit plan. A The amounts below include claims processed as of February 23, 2009. The information does not reflect any claims received or adjusted after the above mentioned date. B Member Benefit Usage for Dates of Service January 1, 2009 December 31, 2009. Deductible Dollars Out-of-Pocket Dollars C Type In-Network Indiv. Out of Network Indiv. 1 Year-to-Date Satisfied Maximum $ Remaining $ Year-to-Date Satisfied Maximum $ Remaining $ $10.00 $200.00 $190.00 $0.00 $1,000.00 $1,000.00 $0.00 $400.00 $400.00 $0.00 $2,000.00 $2,000.00 2 3 4 5 6 7 1 2 3 4 Type displays the benefit coverage level where dollars have been used or are tracked. If you have different spending limits for different types of benefits, such as in-network or out-of-network, they will be listed as different types. For example, they may be listed as individual or family. Year-to-Date Satisfied total amount spent or credited towards the maximum amount you are required to pay before additional benefits are available. Maximum $ total amount you must spend in the benefit year before your additional insurance benefits are available. Remaining $ total amount you have left to pay on your deductible before the maximum limit is met and your other insurance benefits apply (Maximum minus Year-to-Date Satisfied). 5 6 7 Year-to-Date Satisfied total amount spent or credited towards the maximum amount you are required to pay in the benefit year. Maximum $ total amount you may be responsible for in a benefit year based on your benefit plan design. Remaining $ total amount you have left to pay before the maximum limit is met (Maximum minus Year-to-Date Satisfied). If you have questions, call the customer service number printed on your ID card. 0108 17
Claims Occasionally, employees may have questions about their claims. Employees can review claims online by checking My Online Services or by calling the toll-free customer service number located on the ID card. Members may send questions via secure e-mail through My Online Services. Following are a few helpful hints: Claim status codes Approved An approved claim which has either been or will be paid in full or at a determined partial amount. Members can find detailed claim information available on My Online Services using the View Claims option. Rejected A rejected or denied claim. A claim may be rejected or denied for a number of reasons. Members may refer to their explanation of benefits or call Coventry Customer Service for further explanation. For questions about a status other than those described, members may use the ask a question about this claim function after clicking on the claim in question. Prior Authorization Prior authorization or pre-certification is required for some services. To avoid having claims denied, members should be sure to have providers contact the Medical Management Department before receiving services. A list of services that require a prior authorization can be found on My Online Services. It is the member s responsibility to ensure services are authorized. Coordination of Benefits Coventry does coordinate benefits when a member is covered by two or more insurers. For information regarding benefit determination and coordination of benefit rules please see the Certificate of Coverage/Insurance. When a claim involving coordination of benefits, third party liability or worker s compensation is received, a questionnaire is sent to the subscriber to further investigate details surrounding the claim. Members will receive a letter indicating their claim is being reviewed and will require additional information before being processed. Once the requested information is received, our systems are updated with any relevant information and all related claims are processed accordingly. Failure to return this questionnaire will delay claims processing. 18
Continuation and Medicare Coverages Grievance and Appeals Process If a member is unable to resolve a claim or other problem related to benefits or coverage, an appeal process is available. Please refer to the Certificate of Coverage/Insurance for a complete description of the grievance and appeals process. Continuation of Coverage When an employee s coverage is terminated, the employee may be required to offer the terminated employee, and applicable dependents, federally mandated continuation of group coverage (COBRA) or state-mandated continuation of group coverage. The attached Certificate of Coverage/Insurance summarizes both of these coverage types for employees and their dependents.! Important Notice! The following explanation of COBRA and Florida state continuation of group coverage laws is provided as a courtesy to you. As the employer, the company is responsible for complying with and administrating COBRA or state continuation of group coverage. When an employee is hired, the company is responsible for informing the employee of the availability to continue coverage. In the event group coverage is terminated, the company is responsible for notifying the employee and dependents of their eligibility to continue coverage. Federally Mandated Coverage (COBRA) Under federal law, employers who have 20 or more employees are subject to the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA requires employers to offer the option to continue the company s current group health care benefit plan to members who have one of the following qualifying events: An employee who is terminated for any reason other than gross misconduct, who is laid off or whose hours are reduced. Coverage may be continued for the employee and his or her dependents for up to 18 months. A dependent whose coverage ceases under the terms of the Group Master Contract, or because of divorce, legal separation, the subscriber s death or the subscriber becoming eligible for Medicare, or if there is a loss of a child s dependent status under the terms of the plan. Coverage for dependents may be continued for up to 36 months if there is a legal separation or if the subscriber has died, or for a dependent child, if he or she ceases to meet the plan s rules for dependent status. Coverage for the employee and his or her dependents may be continued for 29 months if the Social Security Administration determines the employee was disabled at the time during the first 60 days of the COBRA continuation coverage. The employee must notify the plan administrator of the determination within 60 days of the date of the determination and within the initial 18-month COBRA continuation period. 19
Continuation and Medicare Coverages Continued The employer must notify the COBRA administrator of a qualifying event within 30 days of when the employer obtains knowledge of the event. Please refer to your COC/COI for a list of qualifying events and details. If the employer is the COBRA administrator, the employer must send a COBRA notice and election form to the employee and their dependents within 44 days of the event. The employee must notify the administrator of qualifying events that are not within the employer s knowledge within 60 days of the event. The plan administrator must notify the individual of his or her right to continue coverage under COBRA by providing an Member Status Change Form and the applicable COBRA rates and the notice required under COBRA. Note: Coventry does not administer COBRA coverage and is not the Plan Administrator. The member has 60 days from either the date coverage is lost or, if it is later, the date he or she receives notification from you to elect COBRA coverage. Even if the covered employee rejects COBRA, each family member has an independent right to elect continuation of coverage. The employer may require the member to pay the full cost of the COBRA coverage. Premiums may not exceed 102% of the premiums being paid by similarly situated employees. Once a member is no longer eligible to receive COBRA coverage the member must be notified of the COBRA termination. Employees who elect to continue coverage under COBRA should submit the Member Status Change Form with the first month s premium to the plan administrator within the specified time. When the individual wishes to discontinue coverage or coverage expires, the plan administrator should submit an Member Status Change Form terminating the individual from the coverage. Reminder: Employers are obligated to provide members with an initial COBRA notice upon plan enrollment. When the coverage ends, this must be sent prior to the termination date. It is important to note the Federal Government may change or amend COBRA from time to time. Failure to offer COBRA may result in fines and the loss of a business tax deduction for plan contributions. State-Mandated Coverage Any state-mandated coverage applicable for employees and their families is explained in the Certificate of Coverage/Insurance. 20
Continuation and Medicare Coverages Continued Medicare Medicare is the federal program that provides health insurance to the aged and disabled. Within the three months prior to an American citizen s 65th birthday, the Social Security Office will send the individual information concerning enrollment in Medicare.! Important Notice! This explanation of Medicare is provided to you as a courtesy. As the employer, you are responsible for complying with and administrating Medicare. For further information, contact your local Social Security Office. Companies with 20 or More Employees For employers with 20 or more employees, the actively working Medicare-eligible employee or his or her spouse is covered by the company s group health care benefit plan as the primary payor of covered health care services. Therefore, Medicare is the secondary payor if the Medicare-eligible employee elects to participate in Medicare. Companies with 19 or Fewer Employees For employers with 19 or fewer employees, Medicare is the primary payor of the covered health care services for an actively working Medicare-eligible employee or spouse. The Medicareeligible employee or spouse may have secondary coverage through the company s benefit plan. Medicare-eligible employee or spouse must provide proof of Medicare participation. Should you have questions or need further assistance, please visit our website at or contact your account manager. 21
Blank (back of page 21)
MEMBER STATUS CHANGE FORM ANY CHANGES MUST BE REPORTED WITHIN THIRTY (30) DAYS OF THE EVENT. A EMPLOYER INFORMATION: To Be Completed by Employer: Company Name: Sub-Group Number: Reason for Change: * Incomplete information may d elay the processing of your request Effective Date of Change: Termination of Employee Coverage PCP Change Termination of Dependent Coverage Name Change or Address Change B SUBSCRIBER INFORMATION: To Be Completed by Employee Last Name: First Name: MI: Male Female PCP Name: PCP ID Number: Gender : Birth Date: Social Security Number: C MEMBER INFORMATION: Family Members to be Updated with Requested Change Last Name: First Name: MI: 1 Gender: Birth Date: Social Security Number: Male Female PCP Name: PCP ID Number: Last Name: First Name: MI: 2 Gender: Birth Date: Social Security Number: Male Female PCP Name: PCP ID Number: Last Name: First Name: MI: 3 D Gender: Birth Date: Social Security Number: Male Female PCP Name: PCP ID Number: NAME CHANGE OR ADDRESS CHANGE: Please attach appropriate legal documents, (i.e., marriage certificate, driver s license, court order). If address and phone numbers of covered dependents are different from that of policyholder, please attach the information on a separate sheet of paper. Name Changed From: Name Changed To: Telephone Number: Current Home Address: City: State: Zip Code: I hereby represent to you that all information furnished by me is true and complete to the best of my knowledge. I acknowledge and accept the provisions of this form. I understand that the information provided is subject to verification by Coventry Health Care of Florida, Inc. and Coventry Health Plan of Florida, Inc. (hereinafter referred to collectively as Coventry). Failure to provide timely information on removing of an employee or dependent may result in an adjustment to the requested effective date of termination of the applicable coverage at the discretion of Coventry. I understand that any change resulting in an adjustment of the premium must be approved by the employer before submitting to Coventry. I understand that any change approved by Coventry will not alter the rights or responsibilities of the member under the Group Agreement/Certificate of Coverage. Any person who knowingly and with intent to injure, defraud or deceive an insurer files a statement of claim or an application containing any false, incomplete or misleading information may be guilty of a felony of the third degree. Employee Signature: Employer/Benefit Administrator Approval: Date: Date: CHC.CHP.MbrChng (4/10) Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Coventry Health and Life Insurance Company 1340 Concord Terrace, Sunrise, FL 33323 Fax: 877-548-7647
Blank (back of form)
Inside Back Cover
CHGF2271 (02-11)