1. health and fitness

Employer Administrative Manual
Alive with Possibilities
REV Jan 2014
Ta b l e o f C o n t e n t s
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Important Contact Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
• Phone Numbers & Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
• Prescription Drug Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
• 24-Hour NurseLine / Health Information Line. . . . . . . . . . . . . . . . . . . . . . . . . . 8
• First Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Saint Mary’s Health Plans Online / www.saintmaryshealthplans.com . . . . . . . . 9
• Employer Online Tools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
• Member Online Tools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Member Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
• Authorization for Disclosure of Protected Health Information . . . . . . . . . . 11
Eligibility and Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
• Eligibility Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
• Enrolling New or Newly Eligible Employees. . . . . . . . . . . . . . . . . . . . . . . . . . . 13
• Enrolling Dependents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
• Additional Documentation and Requirements. . . . . . . . . . . . . . . . . . . . . . . . . 14
• Open Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
• Enrollment Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
• Waiving Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
• Identification Cards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Special Enrollment and Qualifying Events. . . . . . . . . . . . . . . . . . . . . . . . . . . 17
• Certificate of Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Renewal Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
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Ta b l e o f C o n t e n t s
Premium Billing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
• Billing Invoice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
• Pay as Billed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
• Wire Transfer Instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
• Payments Due. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
• Premium Effective Date. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
• Credits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Urgent Care / Emergency Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
• Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
• Emergency Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
• In-Area Emergency Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
• Out-of-Area Emergency Services through First Health Network. . . . . . . . . 27
• Member Travel Allowance Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Health Care Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
• Primary Care Practitioner (PCP) (Required for SMHP HMO &
POS plans). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
• Secondary PCP (Northern Nevada SMHP HMO & POS plans). . . . . . . . . . 29
• Changing a PCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
• Referral to a Specialist (SMHP HMO & POS plans). . . . . . . . . . . . . . . . . . . . . 30
• Prior Authorizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
• Coordinating All Health Plan Coverages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
• Coordinating Benefits with Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
• Subrogation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
• Workers’ Compensation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
• Coordination of Benefits (COB) Employee Questionnaire. . . . . . . . . . . . . . 36
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Ta b l e o f C o n t e n t s
Federal COBRA (Employers with 20+ Employees) . . . . . . . . . . . . . . . . . . . . . 37
• Disability Extension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
• Medicare Entitlement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
• Notification Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
• COBRA Elections and Payments by Employees Electing COBRA . . . . . . . 43
• Notifying SMHP of a Termination of Coverage . . . . . . . . . . . . . . . . . . . . . . . . 44
• Payment of COBRA Premiums by Employer to SMHP . . . . . . . . . . . . . . . . . 44
• SMHP Federal COBRA Administration through CDS Group Health. . . . . 45
Mini COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Claims Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
• How to File a Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
• Where to Send a Claim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
• Payment of Claim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
• When a Claim is Denied. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Member Complaint and Appeals Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
• Appealing a Denied Claim for Plan Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . 50
• Appeal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
• Time Limit for Filing Lawsuits Concerning Denied Benefits . . . . . . . . . . . . 53
• Notice of Appeal Rights Under Nevada Law. . . . . . . . . . . . . . . . . . . . . . . . . . . 54
• Claim Denial Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
• The Notice of Appeal Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
• External Review of Denied Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Forms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
• Member Enrollment/Change and Termination Form . . . . . . . . . . . . . . . . . . 57
• Authorization for Disclosure of Protected Health Information (ADPHI). . 58
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Introduction
Thank you for choosing Saint Mary’s Health Plans
Designed to serve as a guide for administering your company’s insurance coverage
for your employees, this manual provides answers to questions about your Saint
Mary’s Health Plans (SMHP) health plan and explains benefit administration
procedures in an easy-to-use format.
If you have specific questions not covered in this publication, your SMHP account
manager is available to assist you Monday through Friday, 8 a.m. to 5 p.m., PST.
About Saint Mary’s Health Plans
Saint Mary’s Health Plans is a proud member of Dignity Health, the fifth largest
hospital system in the nation with more than 40 hospitals and medical centers in
California, Nevada and Arizona, and is the home to more than 55,000 employees.
Saint Mary’s Health Plans embodies the same standards of commitment to
excellence that the Dignity Health name embraces. We believe in ensuring
compassionate, high-quality, affordable health services; strong relationships with
our brokers, employers and health care providers; and a level of quality recognized
by the National Committee for Quality Assurance (NCQA).
Saint Mary’s Health Plans is comprised of Saint Mary’s HealthFirst, which
includes our HMO and POS products; and Health Choice, which includes our
PPO, Beyond PPO, FlexFit PPO and HDHP products.
Saint Mary’s Health Plans offers the kind of coverage and service that our members
deserve – service from local people who live and work in the same communities as
our members and who put the health of you and your employees first.
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Important Contact Information
Sales
888.840.9080
Monday through Friday, 8 a.m. to 5 p.m. PST
Northern Nevada
1510 Meadow Wood Lane
Reno, NV 89502
775.770.6065
Southern Nevada
2475 Village View Drive, Ste. 100
Henderson, NV 89074
702.260.3012
Premium Billing
775.770.6474
Monday through Friday, 8 a.m. to 5 p.m. PST
For more information regarding Premium Billing, including invoice information
and payment instructions, please see the Premium Billing section beginning on
page 22.
Member and Customer Service Call Centers
Saint Mary’s Health Plans Member Services
775.770.6060 or 800.863.7515 for Saint Mary’s HealthFirst HMO & POS
775.770.6900 or 800.433.3077 for Health Choice PPO & HSA
Monday through Friday, 8 a.m. to 5 p.m. PST
Contact our SMHP Member Services team for customer service issues including
eligibility, benefit or claims questions. Your employees also contact Member Services
to change primary care practitioners, update an address or order a new ID card.
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Prescription Drug Services
Catamaran
866.358.9534
www.mycatamaranrx.com
Saint Mary’s Health Plans partners with Catamaran (formerly Catalyst Rx) to
provide pharmacy benefits. If you or your employees have questions regarding your
prescription drug plan, please call the Catamaran Member Services Department.
Representatives are available 24/7 to assist you.
Catamaran Home Delivery
866.814.7105
www.mycatamaranrx.com
Saint Mary’s Health Plans members have access to a convenient, quality-focused,
and easy-to-use prescription mail service benefit that is matched with exceptional
customer service and designed to ensure our members receive mail service
medications both quickly and accurately.
Diplomat
877.977.9118
www.diplomatpharmacy.com
For Specialty Pharmacy care, Saint Mary’s Health Plans partners with Diplomat
Specialty Pharmacy, the largest independent specialty pharmacy in the nation that
has been serving patients for more than 35 years.
24-Hour NurseLine / Health Information Line
800.243.5495
Members can call Saint Mary’s NurseLine 24/7 and speak to experienced health
specialists and registered nurses about symptoms, accidents or to ask healthrelated questions. Health staff use sophisticated software to assist members in
determining the safest, most appropriate level of care for their needs, including
self-care steps.
First Health
800.226.5116
Monday through Friday from 7 a.m. to 7 p.m., CST
Saint Mary’s Health Plans has selected First Health as the national PPO network
for use outside of Nevada for all PPO members. First Health is an expansive
national network that includes more than 5,000 hospitals, 550,000 physicians and
64,000 ancillary providers.
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All SMHP members have access to the First Health Emergency Travel Network
when traveling outside of Nevada for emergent or urgent medical care only. For
a current list of providers, please go to www.saintmaryshealthplans.com. Click
the First Health Network in the Quick Links sections located at the bottom of the
Home Page.
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S a i n t M a r y ’s H e a l t h P l a n s O n l i n e
w w w. s a i n t m a r y s h e a l t h p l a n s . c o m
What can you do on saintmaryshealthplans.com?
Important information about Saint Mary’s Health Plans is available with just a few
clicks of a mouse and the best part is that everything can be done on your schedule,
not ours.
Employer Online Tools
Visit www.saintmaryshealthplans.com today to view the most current benefit
plans, download forms, order temporary ID cards for employees and more.
Some functions will require a user name and password to access. If you are not a
registered user and would like to become one, please contact Stephanie Monette at
[email protected].
There are two components to the Employer Portal:
Features of Online Services (HealthX):
• View member eligibility and plan selection
• View plan summaries
• Print Temp ID Cards and request replacement ID Cards
• Forms library
Features of Online Enrollment (Auto-Bene):
• Add or delete members
• Update member demographic information
• Change PCP selections (for HMO members)
Member Online Tools
Saint Mary’s Health Plans provides an online member portal to allow our members
to make changes, view information and remain current with their personal health
plan. The following tools and information are provided to Saint Mary’s Health Plan
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members without a secure log-in:
• Read current and past member newsletters
• Download and print Provider Directories
• View Preferred and Specialty Drug Lists
• Link to prescription drug management website
• View prior authorization lists
• Link to Flexible Spending Account calculator
The following tools and information must be accessed behind a secure firewall:
• Copay amounts for selected benefits
• Print temporary ID cards and/or request permanent ID cards
• View member claims
• View member authorizations
• Change address
• Change PCP
If members would like to become a registered user, they should visit
www.saintmaryshealthplans.com > Members > Member Log-in and follow the
prompts on the member login homepage.
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Member Services
The primary goal and responsibility of the Saint Mary’s Health Plans (SMHP)
Member Services Department is to provide members with ongoing education
about their SMHP health plans coverage and help them understand the benefits,
guidelines and procedures of their health plan.
Encourage your employees to call a Member Services Representative whenever
they need assistance. English and Spanish speaking representatives are available
Monday through Friday from 8 a.m. to 5 p.m., PST.
Member Service Representatives are available to:
• Explain benefits
• Clarify co-payments, deductibles and co-insurance
• Provide guidance about the prior authorization process
• Verify enrollment
• Order replacement ID cards
• Record demographic changes (e.g. address, telephone number, etc.)
• Furnish updated copies of plan materials
• Change Primary Care Providers (PCP)
• Verify contracted providers
775.770.6060 or 800.863.7515 for Saint Mary’s Health Plans HMO & POS
775.770.6900 or 800.433.3077 for Health Choice PPO & HSA
Monday through Friday, 8 a.m. to 5 p.m., PST
Authorization for Disclosure of Protected Health Information
As a health insurance company, Saint Mary’s Health Plans has access to medical
information concerning our members that is deemed to be “Protected Health
Information” (PHI) by the Health Insurance Portability and Accountability Act of
1996 (HIPAA). The member information is confidential and can only be shared
with the member, the member’s provider or a designated person(s) shown on an
Authorization for Disclosure of Protected Health Information (ADPHI) form. There
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is a separate form for Protected Mental Health Information. ADPHI forms can be
found online at www.saintmaryshealthplans.com > Health Plans Members > Forms.
Once completed, members can fax the ADPHI form to Member Services at
775.770.3820 and it will be attached to the member’s file for future reference.
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Eligibility and Enrollment
Fax 775.770.3820
Enrollment Representatives process your employees’ enrollment forms and
issue member information packets and ID cards. They are also available for any
questions you may have concerning your group’s eligibility and enrollment.
Eligibility Requirements
Your group contract contains a section entitled Eligibility and Enrollment.
Enrollment of your employees and their dependents will be based on the eligibility
requirements established by you, the employer, and as described in the Group
contract. This criteria will be reviewed annually.
Enrolling New or Newly Eligible Employees
Employees and their eligible dependents may enroll in the health plan once they
have met eligibility criteria agreed upon between Saint Mary’s Health Plans and
the group.
Each employee should complete an Enrollment/Change and Termination form
within 31 days of eligibility (see Forms page 57). If an Enrollment form is not
completed and submitted to Saint Mary’s Health Plans within 31 days, eligible
employees and their dependents will be required to wait for coverage until the
group’s open enrollment period.
Enrolling Dependents
New or newly eligible employees should include any eligible dependents that the
employee wishes to cover on the Enrollment/Change and Termination form when
the employee initially enrolls with Saint Mary’s Health Plans.
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Dependents may enroll if they meet the eligibility requirements specified in
the Eligibility and Enrollment section of the Group Contract. Standard eligibility
provisions include:
• Employee’s lawful spouse.
• An unmarried child under the age of 26 who is primarily supported by the
employee. This includes:
a. Newborns of subscribers or their spouse will be covered from the date of
birth for 31 days. Coverage after the 31st day will be provided only if the
newborn is enrolled within 31 days from the date of birth.
b. Step-children.
c. Children for whom the employee and/or the spouse has been court
appointed permanent legal guardian.
d. Adopted children.
• Requested Birth Certificates, Marriage License, Court Orders or other items
(e.g. Certificates of coverage, Credible Coverage) must be furnished by the
member to Saint Mary’s Health Plans within 30 days of receipt of request.
Failure to furnish the requested documents will result in ineligibility.
• Unmarried children over the age of 25 who are chiefly dependent upon
employee for support due to mental illness, developmental disability, mental
retardation or physical handicap if the condition occurred before age 19.
Disability verification is required via a form from family doctor and evidence
that the dependent is on the subscriber’s tax documents.
• Domestic Partner coverage is available as a rider. As the employer, you must have
a written policy defining domestic partner coverage in order to request this rider.
All Domestic Partners that wish to enroll are required to provide a Certificate of
Registered Domestic Partnership from the Nevada Secretary of State.
Additional Documentation and Requirements
The following documents should be submitted with Enrollment/Change and
Termination forms:
• Marriage Certificates – required for spouse or dependents enrolling with
different last names (first enrollment only) or if coming on due to marriage
(qualifying event)
• Birth Certificates – required for all under 26 dependents with different last
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names (birth record is usually included with the enrollment forms)
• Domestic Partnership – State of Nevada certification required for all domestic
partner enrollment requests
• Court Documents Required for the following events:
a. Adoption
b. Divorce
c. Court Ordered Medical Coverage
• Name Change requires either a marriage certificate or divorce decree and a
driver’s license or social security card.
If any of the documents submitted at the time of enrollment are completed
incorrectly, we require a driver’s license or other back-up documentation for
verification and correction.
Open Enrollment
Every year, approximately two months prior to the expiration of your Saint Mary’s
Health Plans contract, you will receive a notice regarding your upcoming renewal
and annual open enrollment period.
An open enrollment period shall be held at least once every 12 months for a period
of at least 15 days during which time eligible employees may enroll themselves and
their eligible dependents.
Employees and COBRA participants currently enrolled may use the open
enrollment period to add eligible dependents that were not enrolled at the time of
initial eligibility.
The recommended open enrollment period is during the month preceding the
effective date of your group’s contract renewal. The effective date for changes
made during open enrollment is generally the contract renewal date.
Enrollment Changes
It is the employer’s responsibility to notify Saint Mary’s Health Plans, in writing, of
any changes that affect a member’s eligibility or the eligibility of their dependents
within 31 days of the event. Please notify Saint Mary’s Health Plans immediately of
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a member’s change in enrollment, including additions or deletions, by completing
the Enrollment/Change and Termination form (see Forms page 57) and submit
to Saint Mary’s Health Plans Enrollment Department. A request to terminate
a subscriber’s coverage automatically cancels coverage for all dependents.
SMHP recommends keeping copies of fax confirmations or online enrollment
submissions as back-up, if needed.
Waiving Coverage
Any employee who chooses not to enroll in Saint Mary’s Health Plans coverage
should complete should complete sections A and H of the Member Enrollment/
Change and Termination form. By completing these portions of the form, the
employee acknowledges that the opportunity to apply for coverage was declined.
An employee who declines coverage for him/herself and/or any dependents may
not enroll until the next open enrollment period, unless they are eligible for a
special enrollment.
Identification Cards
A member identification card and the Certificate of Coverage (COC) or Evidence
of Coverage (EOC) will be mailed to the employee’s home address upon
enrollment. Each covered dependent will receive an individual identification card
with his/her name on it. Coverage will not be effective until the date shown on the
identification card.
The identification card contains the following information:
• Member or Dependent(s) name
• ID Number
• Group Name
• Effective date of coverage
• Deductible
• Copay information (hospital, specialist, Rx, lab, etc.)
• Coinsurance
• Primary Care Practitioner (PCP) (for HMO/POS members only)
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Special Enrollment and
Qualifying Events
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 regulates
employer-sponsored health benefits and health insurance. HIPAA requires Saint
Mary’s Health Plans (SMHP) to offer eligible employees or their dependents a
special enrollment opportunity to allow individuals who previously declined health
coverage to enroll for coverage.
What is a special enrollment opportunity?
There are two types of special enrollment – upon loss of eligibility for other
coverage and upon certain life events. Under the first, employees and dependents
who decline coverage due to other health coverage and then lose eligibility or lose
employer contributions have special enrollment rights. For instance, an employee
turns down health benefits for herself and her family because the family already
has coverage through her spouse’s plan. Coverage under the spouse’s plan ceases.
That employee then can request enrollment in her own company’s plan for herself
and her dependents.
Under the second, employees, spouses, and new dependents are permitted to
special enroll because of marriage, birth, adoption, or placement for adoption. For
both types, the employee must request enrollment within thirty-one (31) days of
the loss of coverage or life event triggering the special enrollment.
What are some examples of the events that can trigger a loss of
eligibility for coverage?
Loss of eligibility for coverage may occur when:
• Divorce or legal separation results in you losing your spouse’s health insurance;
• A child dependent, because of age, is no longer an eligible dependent under a
parent’s plan;
• Your spouse’s death leaves you without coverage under his or her plan;
• Your spouse’s employment ends, as does coverage under his or her employer’s
health plan;
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• Your employer reduces your work hours to the point where you are no longer
covered by the health plan;
• Your plan decides it will no longer offer coverage to a certain group of
individuals (for example, those who work part time);
• You no longer live or work in the HMO’s service area;
These should give you some idea of the types of situations that may entitle your
employees to a special enrollment right.
How long do I have to request special enrollment?
As an employer, you must submit enrollment documents to Saint Mary’s Health
Plans within thirty-one (31) days after an employee loses eligibility for coverage or
after a marriage, birth, adoption, or placement for adoption.
After I request special enrollment, how long will I wait for coverage?
It depends on what triggers your right to special enrollment. Those taking
advantage of special enrollment as a result of marriage/domestic partnership, a
birth, adoption, or placement for adoption begin coverage no later than the day of
the event.
For special enrollment due to loss of eligibility for other coverage, your new
coverage will be effective retroactively to the day following the loss of the
qualifying coverage. SMHP must be provided with proof of previous qualifying
coverage and an enrollment form within 31 days of the date of the qualifying event.
What coverage will I get when I take advantage of a special
enrollment opportunity?
Special enrollees must be offered the same benefits that are available to other Saint
Mary’s Health Plans members. Special enrollees cannot be required to pay more for
the same coverage.
Certificate of Coverage
HIPAA requires Saint Mary’s Health Plans (SMHP) to issue a certificate of coverage
to any enrollee upon request, or upon loss of coverage. This certificate provides
verification of prior credible coverage. See sample document on page 20.
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Timing of certificates
The certificate of coverage will be provided to an individual at three points in time:
• Upon termination of employment or eligibility for benefits under the group
health plan. For example, at the time of a COBRA qualifying event, not later
than the end of the period for providing a COBRA election notice (generally
44 days).
• Upon termination or exhaustion of COBRA continuation coverage
• At any time that the employee or covered dependents of the employee
requests a certificate of coverage.
A certificate of coverage is not required to be provided for more than 24 months
following termination of coverage under the plan.
If an employee wishes to take advantage of a special enrollment opportunity
due to one of the events described above, a completed enrollment form must
be submitted to Saint Mary’s Health Plans in order to enroll within 31 days of
the event. The completed special enrollment form must include a copy of the
employee’s most recent certificate of credible coverage evidencing the employee’s
prior health coverage.
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JOHN DOE
1234 SMITH STREET
RENO NV 89502
CERTIFICATE OF GROUP HEALTH COVERAGE
Important - This certificate provides evidence of your prior health coverage. You may need to furnish this
certificate, if you become eligible under a group health plan that excludes coverage for certain medical
conditions that you have before you enroll. This certificate may need to be provided if medical advice,
diagnosis, care, or treatment was recommended or received for the condition within the 6-month period
prior to your enrollment in the new plan. If you become covered under another group health plan, check
with the plan administrator to see if you need to provide this certificate. You may also need this certificate to
buy, for yourself or your family, an insurance policy that does not exclude coverage of medical conditions
that are present before you enroll.
1. Date of this certificate: 12/30/2013
2. Name of group health Plan: Saint Mary's HealthFirst
3. Members to whom this certificate applies:
Member Name
JOHN DOE
Member Card Id
000012345678
Eff Date
4/1/2011
Term Date
11/30/2013
4. Name, address, and telephone number of issuer responsible for providing this certificate:
SAINT MARY'S HEALTHFIRST
1510 MEADOW WOOD LANE
RENO, NEVADA 89502
(775) 770-6060 or (800) 863-7515
5. For further information, call: (775) 770-6060 or (800) 863-7515
6. If the individual(s) listed has at least 18 months of creditable coverage (disregarding periods of coverage
before a 63-day break), check here ___ and skip lines 7 and 8.
7. Date waiting period or affiliation period (if any) began:
8. Check here ___ if coverage is continuing as of the date of this certificate.
Note: Separate certificates will be furnished if the information is not identical for the participants and each
beneficiary.
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Renewal Process
Approximately 60 days prior to your group’s effective renewal date, Saint Mary’s
Health Plans will send via US Mail information to your group contact specifically
detailing steps essential to your group renewal process and any applicable rate
adjustments.
Paperwork to complete and return to your broker or SMHP account manager
can include:
• Renewal Election form
• Compliance Verification requirement
Important Note! It is SMHP policy that a group is considered delinquent if the
contract renewal has not been received by the last day of the contract. All medical
and pharmacy claims will be pended as of the first of the month of your
renewal date unless we receive confirmation to renew.
If your group grandfathered a plan during last renewal (same plan design that
was provided on March 23, 2010) and wish to continue the grandfathered plan
status, you will need to continue with your current plan of benefits with no plan
changes. If your contributions to a grandfathered plan become less favorable to
your employees, you could lose your grandfathered status. If you wish to continue
coverage under your existing grandfathered plan, you will need to request
those rates through your broker or SMHP account manager.
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Premium Billing
775.770.6474
Billing Invoice
On or about the 15th of each month, your group will receive an invoice for the next
month’s coverage. Your account ID, invoice number, invoice date and due date are
listed at the top of the statement.
Billing invoices are divided into four sections:
• Invoice Summary is the first section of your invoice and it summarizes
payments received and premium amount due. Any manual adjustments will
also appear in this section.
• Current Billing Detail is the second section of your invoice and lists active
employees for the current period and the amount due for each employee. This
section may contain more than one page. Each employee is listed individually
with a total billed or all selected benefits including Rx and any dental, vision
or family planning coverage.
• Retro Detail is the third section of your invoice and explains retroactive
charges and credits to your group’s account that did not appear on previous
invoices. If there are no changes in your enrollment from the previous period,
you will not receive this section.
• Site Summary is the last section of your invoice and displays the total,
current and retro charges by policy.
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•
How To Read an Invoice
This guide has been developed to help you understand the new invoices
generated from Saint Mary’s Health Plans’ current operations system. A key
difference on the new invoice is that the summary of the current month’s
premiums and the summary of retroactive transactions are displayed on the
last page of the invoice under the Site Summary section. For additional invoice
details, please see below.
1
For questions regarding your Saint Mary’s Health Plans invoice, please contact
your Account Manager or Premium Billing representative.
Account ID: ARID0001000 Invoice #:
Date Billed: 09/01/2011
Date Due:
Phone: 775-770-6474 Email: [email protected]
**000000
Attn: DOE, JOHN Q
09/01/2011
ARINV0000001000
Payment Due:
INVOICE
Date Billed: 09/01/2011
Date Due:
ABC CORPORATION
123 ANY STREET
9
4
INVOICE DATE
BILLING PERIOD
ORIGINAL AMOUNT
09/01/2011
10/01/2011
09-01-11 To 09-30-11
10-01-11 To 10-31-11
RECEIPTS AND MANUAL ADJUSTMENTS FOR THIS PERIOD
10
11
09/01/2011
Payment Due:
$3,132.26
5
$1205.90
$1926.36
6
7
INVOICE AMOUNT PAYMENT AMOUNT
$2411.80
$1926.36
12
8
Invoice Amount – Original amount owed in
addition to Manual Adjustments. See #7
6
Payment Amount – Payments applied to the AR
account for the period. Note: Payments are always
applied to the oldest AR account first. Payments
received after the billing is run (around the 10th of
the month) will not be reflected on invoice.
7
Manual Adjustment – Manual adjustments are
adjustments that cannot be made to your account
through normal membership transactions. For
example: adjustments needed to be made to your
account during the transition of the previous
SMHP operating system to the new operating
system.
8
Invoice Balance – Total amount due minus
payment amount.
9
Receipts and Manual Adjustments for
this period – Contains a list of payments and
adjustments.
11 Transaction – Type of transaction received, either
“check” signifying payment or “adjustment” for
any manual adjustments made to the account.
Page 1 of 2
MANUAL ADJUSTMENT
INVOICE BALANCE
$1205.90
$0.00
$1205.90
$1926.36
$1205.90
$0.00
13
DATE
TRANSACTION
AMOUNT
REFERENCE #
09/09/2011
CHECK
$1205.90
1000
12 Amount – Amount paid, credited or debited from
the transaction.
14
13 Reference # - Check number or other accounting
identification number for the transaction.
REC/ADJ CODE
14 Rec/Adj Code – Any notes or comments
regarding the transaction.
$3132.26
$0.00
15 Summary – Section summarizes entire invoice.
ACCOUNT BALANCE
PLEASE PAY
5
10 Date – Date of adjustment.
Amount Enclosed: $ __________
SUMMARY
TOTAL FOR ALL INVOICES
TOTAL UNAPPLIED CASH
Original Amount – Current month’s premium
(based on membership) plus premium for previous
months’ activity that was reported retrospectively,
commonly called retroactivity.
ARINV0000001000
Billing Phone: 775-770-6474 Email: [email protected]
3
INVOICE NUMBER
ARINV0000001000
ARINV0000001000
15
16
17
18
19
4
Saint Marys Health Plans
Dept 33396
P.O.BOX 39000
SAN FRANCISCO CA 94139-3396
Account ID: ARID0001000 Invoice #:
2
Billing Period – The first and last day of the
month in the billing period.
$3,132.26
PLEASE REMIT COUPON W ITH PAYMENT
1
Invoice Date – Applicable dates for each invoice.
3
Amount Enclosed: $ __________
Y
1oz - 000 - 000
ABC CORPORATION
123 ANY STREET
ANYTOWN US 12345-6789
Invoice Number – The identification number
used to refer to each invoice.
2
$3132.26
16 Total for all invoices – Combined amounts of all
open invoices.
17 Total Unapplied Cash. – Overpayments or
credits, will show in unapplied cash until
another bill is generated and payment can
be applied.
21
18 Account Balance.
19 Please Pay – The specific amount due to SMHP
Accounts Receivable.
20
How To Read an Invoice
INVOICE
1oz - 000 - 000
Page 2 of 2
20 C U R R E N T D E T A I L
Site Type: HOME
Policy Holder Name
Policy Holder #
Contract
Eff_Date
Policy Package
Billing Date
Desc
DOE, JOHN Q
000001000000
09/01/2011
Site Type: MANAGEMENT
Policy Holder Name
Policy Holder #
Contract
Eff_Date
1XHD014
10/01/2011
CHARGE
Policy Package
Billing Date
Desc
DOE, JOHN Q
DOE, JANE Q
000001000000
000001000000
09/01/2011
09/01/2011
1XHD014
1XHD014
10/01/2011
10/01/2011
CHARGE
CHARGE
21
22
23
Billing Tier
Count
Charge
1
$360.23
Total
$360.23
EM
24
Billing Tier
EM
FAM
Count
Charge
1
4
$147.03
$1058.87
Total
$1205.90
Policy Holder #
Contract
Eff_Date
Policy Package
Billing Date
DOE, JOHN Q
000001000000
09/01/2011
1XHD014
9/01/2011
26 S I T E S U M M A R Y
Group/SiteSummary
Policy
ARID0001000
1XHD014
Total
Charge
RetroActivity
$1566.13
$1566.13
$360.23
$360.23
21 Billing Tier – An abbreviated indication of the
bill type (Employee, Employee + Spouse, Family,
Employee + Dependents).
22 Count – Number of individuals enrolled on the
contract (subscriber and all dependents).
23 Charge – Total amount due for the contract.
24 Total – The invoice will sub-total each plan, if
applicable.
25 R E T R O D E T A I L
Site Type: HOME
Member Name
20 Current Details – A list of all members enrolled in
your employer group plan(s) for the current month.
The membership is rolled up to the Subscriber
level.
Desc
CHARGE
Billing Tier
EM
Count
Charge
1
$360.23
Total
$360.23
25 Retro Detail (formally known as Adjustments)
– Detailed list of all individual members who were
added or terminated with effective or termination
date in a prior billing period (up to 60 days back
according to group contract). It also will reflect
rate changes that affect premiums in prior billing
periods. Only members on a contract affected
by the activity are displayed. The Count column
contains the count of the contract, not 1 for the
individual.
26 Site Summary – Lists current month’s total
premium (based on active members as of the
month) and total retroactivity in separate columns.
These dollar amounts are listed according to each
company entity/division. Dollar amounts are
totaled.
1oz - 000 - 000
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Pay as Billed
Regardless of the changes not yet reflected on your billing statement, the group
is required to PAY AS BILLED, that is, pay the amount indicated on the invoice
summary which states: “PLEASE PAY: _______.”
Any open enrollment change or payments received after the 10th of the month
will not be reflected on the following month’s invoice. To ensure the correct
department receives your payment, a return addressed envelope is provided with
each monthly invoice. If your company uses multiple accounts for payment please
mark each check with the intended account number(s).
If you are unable to use the enclosed envelope, please remit payment to the address below:
Saint Mary’s Health Plans
Dept. 33396
P.O. Box 39000
San Francisco, CA 94139-3396
Wire Transfer Instructions
Please note the following wire instructions into Saint Mary’s HealthFirst:
Account Name to Credit:
Saint Mary’s HealthFirst
Account Number to Credit:4159567130
Bank ABA Number:121000248
Bank Name:
Wells Fargo Bank
P.O. Box 300
Reno, NV 89504-0300
Bank Contact Number:415-243-7596
Payments Due
Saint Mary’s HealthFirst and Health Choice are prepaid programs. Premium
payments are due on the 1st of each month for that month’s coverage. If payment
is not received by the 20th of the month, a delinquent notice will be sent to you via
mail. A copy of the delinquent notice will be sent to your broker, if applicable.
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If payment is not received 30 days from the due date, your group’s coverage will be
canceled retroactive to the last day of the month for which premiums were paid.
Premium Effective Date
• Additions
Members added on or before the 15th of the month will be charged the full
premium for that month. Members added on or after the 16th of the month
will not be charged premium for that month.
• Terminations/Deletions
Members terminated on or after the 16th of the month will be charged the full
premium for that month. Members terminated on or before the 15th of the
month will not be charged premium for that month.
Credits
The group must submit to Saint Mary’s Health Plans’ Enrollment Department all
enrollment additions and terminations within thirty-one (31) days of the event.
The group will be credited with a premium payment made for a non-eligible
enrollee only after Saint Mary’s Health Plans is notified and only if the enrollee
has not received covered services during the period in question. In no event
will premium adjustment credits be given for a period of more than 60 days, as
outlined in your group contract.
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Urgent Care /
Emergency Services
Urgent Care
In-Area
In the event an employee cannot be seen by their Primary Care Practitioner, urgent
care is the alternative to being treated in the emergency room. All urgent care
services must be obtained through a contracted urgent care provider.
Urgent care services are defined as care for an injury, illness or another type of
condition, which should be treated within 24 hours. Routine or follow-up care is not
considered urgent care and must be provided by your Primary Care Practitioner.
Out-of-Area
Out-of-area urgent care services are covered for medically necessary services.
For follow-up care, please contact your Primary Care Practitioner. Since out-ofarea providers are not contracted with Saint Mary’s Health Plans, the member
may be required to pay at the time of service. The applicable copay or deductible/
coinsurance applies.
Emergency Services
Medically necessary emergency services are health care services provided to a
member by a provider of health care after the sudden onset of a medical condition
that manifests itself by symptoms of sufficient severity that a prudent person would
believe the absence of immediate medical attention could result in:
• Serious jeopardy to the health of the member;
• Serious jeopardy to the health of an unborn child;
• Serious impairment of a bodily function or
• Serious dysfunction of any body organ or part.
Examples include, but are not limited to, heart attacks, severe chest pains, burns
and loss of consciousness. Criteria is based on signs and symptoms at the time
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of treatment, and verified by the treating physician. If the services received are
determined not medically necessary, the member may be financially responsible.
Follow-up care should be coordinated through a Primary Care Practitioner.
Follow-up care cannot be obtained through an emergency room or urgent care
center. Prior authorization for follow-up care must be obtained for Saint Mary’s
Health Plans HMO/POS members.
If a member is hospitalized in a non-contracted or out-of-area hospital, Saint
Mary’s Health Plans may require the member to be transferred to a contracted
hospital in the service area, as soon as medically possible.
In-Area Emergency Services
Coverage for emergency services is available 24/hours a day, seven days a week
at a plan provider. Follow-up care should be coordinated through a Primary Care
Practitioner. Follow-up care obtained through an emergency room or urgent care
center will not be covered. Prior Authorization for follow-up care must be obtained
for Saint Mary’s Health Plans HMO/POS members.
Out-of-Area Emergency Services through First Health Network
All SMHP members traveling outside of Nevada have access to a First Health
provider for emergent or urgent medical need while reducing out-of-pocket
expenses. This is available for HMO, POS and PPO SMHP members.
Medically necessary, covered emergency services at a non-contracted provider will
be covered worldwide at the in-network benefit level. In the case of an emergency
resulting in a hospital admission, it is the member’s responsibility to ensure that
Saint Mary’s Health Plans is notified within 48 hours, the next business day after
the admission, or as soon as reasonably possible.
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Member Travel Allowance Policy
To support SMHP members and/or their support person or family members who
fully utilize care at Centers of Excellence (COE) facilities, a $3,000 member travel
allowance (related to a single episode of care) is offered. This travel benefit applies
only to expenses incurred related to COE evaluation and/or treatment. All trips
and means of transportation must be approved by a SMHP case manager prior to
commencing the trip.
The allowance will reimburse living expenses (see below) up to a daily maximum
of $200 per day with a trip maximum (related to a single episode of care) of $2,000.
In addition, travel expenses (see below) will be paid up to $1,000 per trip (related
to a single episode of care). The $2,000 living expenses and $1,000 for travel total
the $3,000 per single episode of care. The calendar year limit on all eligible travel
expenses is $10,000. Travel reimbursement will be made to the SMHP policy
holder.
Covered Travel Expenses include:
• Airfare for patient and one support person (primary caregiver) or both parents
if patient is a dependent.
• Rental car and mileage allowance for mileage recorded on the rental car receipt.
• Mileage to and from the COE facility if a member is driving / driven from
home will be paid.
Covered Living Expenses include:
• Lodging expenses
• Meals for the patient and support person / caregiver or parents
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Health Care Providers
Primary Care Practitioner (PCP) (Required for Saint Mary’s HealthFirst HMO & POS plans only)
Primary Care Practitioner (PCP) refers to a general or family practice doctor,
internist, or pediatrician who is chosen by the member from the Saint Mary’s
Health Plans HMO Provider Directory.
The PCP is responsible to provide, arrange or coordinate all of a member’s health
care services to assure continuity of care. The PCP initiates any Referrals and Prior
Authorization for specialized care the member may require.
When a member enrolls into Saint Mary’s Health Plans HMO or POS products, adult
members must designate a PCP from the Family Practice or Internal Medicine
categories. A child’s PCP can be chosen from the Family Practice or Pediatrician
categories. If a PCP is not designated during enrollment, Saint Mary’s Health Plans will
select one for the member.
Secondary PCP
(Northern Nevada Saint Mary’s HealthFirst HMO & POS plans only)
Female members in Northern Nevada have the option to select an Obstetrician/
Gynecologist as a Secondary PCP. The member can access her Secondary PCP
without a referral for any female related condition. This does not replace the
member’s PCP’s responsibilities related to their total health care.
Changing a PCP
A member may change their PCP at any time by calling the Saint Mary’s Health
Plans Member Services Department at 775.770.6060 or 800.863.7515.
PLEASE NOTE: PCP Changes for southern Nevada HMO Members
PCP changes must be made prior to the 15th of the month in order for that change to be
effective immediately. PCP changes made after the 15th of the month will be effective the
first of the following month. Members must see their currently assigned PCP in order for
claims to be paid. Member Services will confirm the effective date of their change.
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Referral to a Specialist
(Saint Mary’s Health Plans HMO & POS plans only)
Prior to seeking treatment from a specialist, a member must obtain the initial
referral from their PCP. All referrals must be to a contracted provider/facility
unless otherwise authorized. All services must be medically necessary and a
covered benefit.
There may be times when a particular service is required but not available in the
Saint Mary’s Health Plans service area. In these situations, the PCP and Saint
Mary’s Health Plans will work together to arrange for the appropriate service at the
nearest contracted Center of Excellence.
Prior Authorizations
Saint Mary’s HealthFirst HMO/POS Plans
The member’s PCP will contact Saint Mary’s Health Plans to obtain the initial
authorization to the specialist. If additional services are required, the specialist will
contact Saint Mary’s Health Plans for additional authorizations.
Prior Authorizations are required on some HMO/POS services. For benefits,
limitations, referral/authorization requirements please contact Member Services
prior to obtaining services. A current Saint Mary’s HealthFirst Prior Authorization
list can be found on our website at www.saintmaryshealthplans.com > Health Plans
Members > Prior Authorizations/Pre-Certifications. Select southern or northern
Nevada for the appropriate list.
All inpatient and outpatient hospital stays require Prior Authorization. All
services must be medically necessary and a covered benefit.
Health Choice PPO Plans
Prior Authorizations are required on some PPO services. For benefits, limitations,
referral/authorization requirements please contact Member Services prior to
obtaining services. A current Health Choice Prior Authorization list can be found
on our website at www.saintmaryshealthplans.com > Health Plans Members > Prior
Authorizations/Pre-Certifications.
All inpatient and outpatient hospital stays require Prior Authorization. All
services must be medically necessary and a covered benefit.
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Coordination of Benefits
Coordinating All Health Plan Coverages
Coordination of Benefits (COB) occurs when a member is covered by more than
one group health plan. Saint Mary’s Health Plans will work with the other group
health plan to ensure that a member receives the maximum coverage while
limiting the total benefits payable to 100% of covered expenses.
Health Plans will pay benefits as stated in the Certificate of Coverage (COC) /
Evidence of Coverage (EOC).
Saint Mary’s Health Plans will pay its benefits if all State-approved guidelines
are followed which include, but are not limited to, accessing care through Plan
Practitioners/Providers and obtaining Prior Authorizations. Prior to receiving
services under Coordination of Benefits, members should contact the Health
Plans Member Services Department. One company will provide its full benefit
as the primary contract. The other company will be designated as the secondary
contract, if necessary, to the extent of its benefit. This prevents double payment
and overpayment.
In order to determine which company is primary, the following rules apply:
• If the other contract does not have a provision similar to this one, then it is the
primary contract.
• If the person receiving the benefit is the Subscriber belonging to the Group
through which, or to which one contract was issued and is only covered as a
Dependent on the other contract, the contract under which the person is the
Subscriber shall be primary.
• If two or more contracts cover the person receiving care as a Dependent, then
the contract of the Subscriber whose birthday, month of birth, follows earliest
in the Calendar Year shall be primary unless the other contract uses a rule
based on the Subscriber’s gender and as a result, the contracts do not agree
on the order of benefits. In that case, the other contract shall be primary.
• If the Dependent is the child of divorced or separated parents, then benefits
for the child are determined in the following order:
a. First, the plan of the parent with custody of the child;
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b. Then, the plan of the spouse of the parent with custody of the child;
c. Finally, the plan of the parent not having custody of the child; and
Notwithstanding a., b., and c., above, if the specific terms of a court decree state
that one of the parents is responsible for the health care expenses of the child, and
the entity obligated to pay or provide the benefits of the plan of that parent has
actual knowledge of those terms, the benefits of that plan are determined first.
This paragraph does not apply with respect to any claim determination period or
plan year during which the benefits are actually paid or provided before the entity
has that actual knowledge.
• If none of the above applies, then the contract which has covered the member
or the person receiving services for the longest time shall be primary.
• Members are required to cooperate with SMHP in the administration of this
provision. The plan EOC/COC requires that benefits be paid for by another
source and members have failed to seek payment from that source, SMHP will
reduce the payments under this EOC/COC by the amount to which members
are entitled from that source. In some cases, SMHP may ask members to sign
documents or cooperate with Saint Mary’s Health Plans to seek payment from
another source. Members are required to cooperate in such cases.
• None of the above rules as to Coordination of Benefits will serve as a barrier
to members.
Coordinating Benefits with Medicare
If an individual has Medicare and other health insurance or coverage, each
type of coverage is called a payer. When there is more than one payer, there are
coordination of benefits rules that decide which one pays first.
The primary payer pays what it owes on their bills first, and then sends the rest to
the secondary payer to pay. In some cases, there may also be a third payer.
Whether Medicare pays first depends on a number of things, including the
situations listed in the chart on the next two pages. However, this chart doesn’t
cover every situation. Be sure to tell your doctor and other providers if you have
coverage in addition to Medicare. This will help them send your bills to the
correct payer to avoid delays. If you have questions about who pays first or if your
insurance changes, call the Medicare Coordination of Benefits Contractor (COBC)
at 800.999.1118. TTY users should call 800.318.8782.
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If you...
Are 65 or older and covered
by a group health plan
because you or your spouse
is still working
Have an employer group
health plan after you retire
and are 65 or older
Are disabled and covered
by a large group health plan
from your work, or from
a family member who is
working
Have End-Stage Renal
Disease (permanent kidney
failure) and group health
plan coverage (including
retirement plan)
Have End-Stage Renal
Disease (permanent
kidney failure) and COBRA
coverage
Are 65 or over OR disabled
and covered by Medicare
and COBRA coverage
Situation
Pays first
Pays second
Group Health
Plan
Medicare
The employer has less than
20 employees*
Medicare
Group Health
Plan
Entitled to Medicare
Medicare
Retiree
Coverage
Large Group
Health Plan
Medicare
Entitled to Medicare
The employer has 20 or
more employees
Entitled to Medicare
The employer has 100 or
more employees
The employer has less than
100 employees
Medicare
Group Health
Plan
First 30 months of eligibility
or entitlement to Medicare
Group Health
Plan
Medicare
After 30 months
Medicare
Group Health
Plan
First 30 months of eligibility
or entitlement to Medicare
COBRA
Medicare
After 30 months
Medicare
COBRA
Entitled to Medicare
Medicare
COBRA
*If your employer participates in a plan that is sponsored by two or more employers, the rules are
slightly different.
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If you
Have been in an incident
where no-fault or liability
insurance is involved
Are covered under workers’
compensation because of a
job-related illness or injury
Are a veteran and have
Veterans’ benefits
Situation
Pays first
Pays second
Entitled to
Medicare
No-fault or Liability insurance
for services related to accident
claim
Medicare
Workers’ compensation for
services related to workers’
compensation claim
Usually doesn’t
apply. However,
Medicare
may make a
conditional
payment
Entitled to
Medicare
Entitled to
Medicare
and Veterans’
benefits
Are covered under TRICARE
Entitled to
Medicare and
TRICARE
Have black lung disease and
covered under the Federal
Black Lung Program
Entitled to
Medicare and
Federal Black
Lung Program
Medicare pays for Medicarecovered services.
Veterans’ Affair pays for VAauthorized services.
Note: Generally, Medicare
and VA can’t pay for the same
service.
Medicare pays for Medicarecovered services.
TRICARE pays for services
from a military hospital or any
other federal provider.
Federal Black Lung Program
for services related to black
lung
Usually doesn’t
apply
TRICARE may
pay second
Medicare
Subrogation
If your employee or a covered member of their family is sick or injured as a result
of the act or omission of another person, Saint Mary’s Health Plans (SMHP) will
conditionally advance payment of Medical Plan benefits for their injury or illness.
Subrogation means SMHP has the right to recover SMHP benefit payments
advanced on their behalf, for an injury or illness caused by another person, and
recovered by your employee or their dependent from the person who caused them
harm (or any insurer acting in place of, or on behalf of that person or any third
party’s insurer). Third party means any other person or organization.
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When an employee or a covered member of their family accepts payment of
SMHP benefits for an injury or illness caused, in whole or in part, by a third party
(hereinafter referred to as a “Third-Party Injury”) they agree SMHP has the right
to bring an action for an equitable lien for 100% of the SMHP benefits paid on
their behalf from all recoveries they receive from a third party or third party insurer
(whether by lawsuit, settlement, or otherwise) in connection with the Third-Party
Injury. If the recovery of an employee or their covered family member’s recovery
from the third party is less than the amount of benefits SMHP has paid on their
behalf or on behalf of their covered family member, the members agree SMHP has
a lien on 100% of the amounts recovered.
This lien shall remain in effect until SMHP is repaid. Your employee or their
family member agree to pay to SMHP the benefits paid on their behalf out of any
recovery made from another party or insurer. SMHP’s right to an equitable lien
or a constructive trust shall be given priority over any funds paid by a third party
concerning the injury or sickness, including a priority over any claim for nonmedical or dental charges, attorneys’ fees, or other costs and expenses.
When your employee accepts payment of medical expenses (i.e. benefits) for
an injury or illness caused or contributed to by a third party, they agree to the
following:
• Saint Mary’s Health Plans (SMHP) right to recover benefits paid on their
behalf will not be reduced nor will it be contingent upon your employee being
made whole for the Third-Party Injury.
• Once your employee has received a Third-Party Injury recovery, they agree
to reimburse SMHP for 100% of the benefits paid on their behalf from all
amounts they receive from a third party or third party insurer (whether by
lawsuit, settlement, or otherwise) in connection with the Third-Party Injury.
• If your employee’s recovery from the third party is less than the amount of
benefits SMHP has paid on their behalf, your employee agrees to reimburse
SMHP 100% of the amounts recovered by them.
• If your employee makes any request or demand for payment to a third
party (whether formal or informal) in connection with a Third-Party Injury,
they will notify SMHP in writing within five (5) business days of making
that request. They will also notify SMHP in writing within five (5) business
days of receiving any payment from a third party (or third party insurer) in
connection with a Third-Party Injury.
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• Within five (5) business days of receipt of any payment from a third party
(or a third party insurer) in connection with a Third-Party Injury, your
employee shall deposit 100% of the amounts recovered by them into a bank
account. Amounts owed to SMHP under this Agreement shall be held in
constructive trust for SMHP and shall remain in the bank account until paid
to SMHP pursuant to this Agreement. SMHP shall have the right of equitable
restitution for any medical benefits paid or provided to your employee.
• If your employee fails to bring legal action against a third party (or a third
party insurer) to recover payment of health care expenses incurred in
connection with a Third-Party Injury, SMHP may institute a lawsuit against
such third party in its own name or in your employee’s name. SMHP shall
receive an assignment from your employee of their rights to recover against
any third party (or third party insurer) with respect to any Third-Party Injury.
SMHP shall be entitled to retain from any resulting judgment or settlement
the amount of benefits paid or provided by SMHP, together with all court
costs and attorneys’ fees incurred by SMHP.
• Your employee agrees to take all reasonable measures to help SMHP recover
benefits paid or incurred on their behalf in connection with a Third-Party
Injury. They shall execute and deliver any and all such instruments and
papers as may be required (including, but not limited to, executing an
assignment of their claims in favor of SMHP and will do whatever else is
needed to secure SMHP rights under this Agreement. If they do not comply
with this Agreement, they will be responsible for the medical benefits paid by
SMHP and any legal expenses incurred by SMHP to enforce its subrogation
rights under this Agreement.
Workers’ Compensation
Saint Mary’s Health Plans will not pay for benefits for conditions in which coverage
is available under the workers’ compensation law.
Coordination of Benefits (COB) Employee Questionnaire
You can help us obtain information from your employees about other insurance
coverage by making sure they complete all sections listed on their Enrollment/
Change and Termination form
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Federal COBRA
(Employers with 20+ Employees)
What is COBRA Continuation of Coverage?
Congress passed the landmark Consolidated Omnibus Budget Reconciliation
Act (COBRA) health benefit provisions in 1986. The law amends the Employee
Retirement Income Security Act, the Internal Revenue Code and the Public Health
Service Act to provide continuation of group health coverage that otherwise might
be terminated.
COBRA contains provisions giving certain former employees, retirees, spouses,
former spouses, and dependent children (deemed “qualified beneficiaries”) the
right to temporary continuation of health coverage at group rates. This coverage,
however, is only available when coverage is lost due to certain specific events
(“qualifying events”).
How does a person become eligible for COBRA Continuation Coverage?
To be eligible for COBRA coverage, the employee must have been enrolled in the
employer’s health plan when the employee worked and the health plan must continue
to be in effect for active employees. COBRA continuation coverage is available upon
the occurrence of a qualifying event that would, except for the COBRA continuation
coverage, cause an individual to lose his or her health care coverage.
Under COBRA, what benefits must be covered?
Qualified beneficiaries must be offered coverage identical to that available to
similarly situated beneficiaries who are not receiving COBRA coverage under
the plan (the same coverage that the qualified beneficiary had immediately
before qualifying for continuation coverage). A change in the benefits under the
plan for the active employees will also apply to qualified beneficiaries. Qualified
beneficiaries must be allowed to make the same choices given to non-COBRA
beneficiaries under the plan, such as during periods of open enrollment by the plan.
Which employers are required to offer COBRA Coverage?
Employers with 20 or more employees are usually required to offer COBRA
coverage and to notify their employees of the availability of such coverage. COBRA
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applies to plans maintained by private-sector employers and sponsored by most
state and local governments.
Group health plans for employers with 20 or more employees on more than 50
percent of its typical business days in the previous calendar year are subject to
COBRA. Both full and part-time employees are counted to determine whether
a plan is subject to COBRA. Each part-time employee counts as a fraction of
an employee, with the fraction equal to the number of hours that the part-time
employee worked divided by the hours an employee must work to be considered
full-time.
Who is a qualified beneficiary?
A qualified beneficiary generally is an individual covered by a group health plan
on the day before a qualifying event who is either an employee, the employee’s
spouse, or an employee’s dependent child, and the health plan must continue
to be in effect for active employees. In certain cases, a retired employee, the
retired employee’s spouse, and the retired employee’s dependent children may be
qualified beneficiaries. In addition, any child born to or placed for adoption with a
covered employee during the period of COBRA coverage is considered a qualified
beneficiary. Agents, independent contractors, and directors who participate in the
group health plan may also be qualified beneficiaries.
Each qualified beneficiary may independently elect COBRA coverage. A covered
employee or the covered employee’s spouse may elect COBRA coverage on behalf
of all other qualified beneficiaries. A parent or legal guardian may elect on behalf of
a minor child.
If a COBRA participant adds eligible family members during open enrollment, the
newly enrolled family members are not considered qualified beneficiaries and
therefore are not entitled to the same independent rights as a qualified beneficiary.
What is a qualifying event?
Qualifying events are certain events that would cause an individual to lose
health coverage. The type of qualifying event will determine who the qualified
beneficiaries are and the amount of time that a plan must offer the health coverage
to them under COBRA.
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The qualifying events for employees are:
• Voluntary or involuntary termination of employment for reasons other than
gross misconduct;
• Reduction in the number of hours of employment.
The qualifying events for spouses are:
• Voluntary or involuntary termination of the covered employee’s employment
for any reason other than gross misconduct;
• Reduction in the hours worked by the covered employee;
• Covered employee’s becoming entitled to Medicare;
• Divorce or legal separation of the covered employee; and
• Death of the covered employee.
The qualifying events for dependent children are the same as for the spouse with
one addition:
• Loss of dependent child status under the plan rules.
Is FMLA leave a qualifying event for COBRA Coverage?
The Family and Medical Leave Act, effective August 5, 1993, requires an employer
to maintain coverage under any group health plan for an employee on FMLA leave
under the same conditions coverage would have been provided if the employee
had continued working.
Coverage provided under the FMLA is not COBRA coverage, and FMLA leave
is not a qualifying event under COBRA. A COBRA qualifying event may occur,
however, when an employer’s obligation to maintain health benefits under FMLA
ceases, such as when an employee notifies an employer of his or her intent not to
return to work.
Further information on FMLA is available from the nearest office of the Wage and
Hour Division, listed in most telephone directories under U.S. Government, U.S.
Department of Labor.
How long does COBRA Continuation Coverage last?
COBRA establishes required periods of coverage for continuation health benefits.
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COBRA beneficiaries generally are eligible for group coverage for a maximum of 18
months for qualifying events due to employment termination or reduction of hours
of work.
Certain qualifying events, or a second qualifying event during the initial period of
coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.
Qualifying Event
COBRA Duration
Voluntary or involuntary termination of employment for
reasons other than gross misconduct
18 months
Reduction in the number of hours of employment
18 months
Covered employee’s becoming entitled to Medicare
36 months
Divorce or legal separation of the covered employee
36 months
Death of the covered employee
36 months
Loss of dependent child status under the plan rules
36 months
Termination of employment when totally disabled as
determined by Social Security Administration
29 months
Military leave
24 months
If, during the 18 month maximum coverage period (or 29 month coverage period
in the case of a disability), a qualified beneficiary with COBRA coverage has a
second qualifying event, the maximum coverage period is extended from 18 (or
29) months to 36 months. A second qualifying event applies only to a covered
employee’s spouse and dependent children.
Second qualifying events for spouses and dependent children are:
• Covered employee’s divorce or legal separation from spouse
• Covered employee’s death
• Covered employee’s entitlement to Medicare
• Covered employee’s child’s loss of dependent status under the terms of the plan.
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Coverage begins on the date that coverage would otherwise have been lost by
reason of a qualifying event and will end at the end of the maximum period. It may
end earlier if:
• Premiums are not paid on a timely basis
• The employer ceases to maintain any group health plan
• After the COBRA election, coverage is obtained with another employer group
health plan that does not contain any exclusion or limitation with respect to
any pre-existing condition of such beneficiary. However, if other group health
coverage is obtained prior to the COBRA election, COBRA coverage may
not be discontinued, even if the other coverage continues after the COBRA
election.
• After the COBRA election, a beneficiary becomes entitled to Medicare
benefits. However, if Medicare is obtained prior to COBRA election, COBRA
coverage may not be discontinued, even if the other coverage continues after
the COBRA election.
Disability Extension
Disability can extend the 18 month period of continuation coverage for a qualifying
event that is a termination of employment or reduction of hours. To qualify for
additional months of COBRA continuation coverage, the qualified beneficiary must:
• Have a ruling from the Social Security Administration that he or she became
disabled within the first 60 days of COBRA continuation coverage
• Send the plan a copy of the Social Security Administration’s ruling letter within
60 days of receipt, but prior to expiration of the 18-month period of coverage
If these requirements are met, the entire family qualifies for an additional 11
months of COBRA continuation coverage.
Medicare Entitlement
If, after the COBRA election, a beneficiary becomes entitled to Medicare benefits,
COBRA coverage will end.
However, if Medicare is obtained prior to COBRA election, COBRA coverage may
not be discontinued, even if the other coverage continues after the COBRA election.
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Notification Requirements
Responsible Parties, Notification Requirements, and Deadlines
Employers/Health Plan Administrators:
Notice
Requirement
Deadline
General (Initial)
Notice
A group health plan must notify a covered
employee and spouse of COBRA rights. The notice
can be sent via first class mail to the employee’s
and spouse’s last known address, or it can be
included in the SPD and given to the employee and
spouse within 90 days after coverage begins
Within 90 days after
active employee
coverage begins
Notice of Qualifying
Event – Employer
An employer must notify its plan administrator of:
• A covered employee’s termination of
employment
• A covered employee’s reduction in work hours
• A covered employee’s death
• A covered employee’s Medicare entitlement
• The employer’s Title 11 bankruptcy
proceeding that causes covered retirees and
their dependents to lose substantial coverage
within one year before or after the filing
Within 30 days of the
qualifying event or
the loss of coverage,
whichever occurs later
Election Notice
The employer’s plan administrator must notify a
qualified beneficiary of COBRA rights when there
is a qualifying event
Within 14 days after
receiving notification of
the qualifying event
Notice of
Unavailability of
COBRA
If an employer’s plan administrator receives a
qualifying event notice and determines that an
individual is not entitled to COBRA coverage, the
administrator must provide the individual with a
notice explaining the reasons for the rejection of
COBRA coverage.
Within 14 days after
notification of the
qualifying event
Termination Notice
An employer’s plan administrator must notify
each qualified beneficiary of any termination of
continuation coverage that takes effect earlier
than the end of the maximum coverage period
associated with the qualifying event. The
notification must include the reason the coverage
is being terminated, the coverage termination date,
and any rights to elect alternative coverage (e.g.,
conversion right).
As soon as practical
following the
administrator’s
determination that
continuation coverage
will terminate
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Responsible Parties, Notification Requirements, and Deadlines
Employees/Qualified Beneficiaries:
Notice
Requirement
Deadline
Notice of Qualifying
Event – Qualified
Beneficiary
An employee or qualified beneficiary must notify
the employer’s plan administrator of:
• A covered employee’s divorce or legal
separation
• A covered employee’s child’s loss of
dependent status
Within 60 days of the
qualifying event or
the loss of coverage,
whichever occurs later
Disability Notice
A qualified beneficiary must notify the employer’s
plan administrator of the Social Security
Administration’s determination of disability.
Within 60 days of
the determination of
disability by the Social
Security Administration,
and before the 18
month coverage period
ends
Notice of Qualified
Beneficiary’s Status
Change to NonDisabled
A qualified beneficiary must notify the
employer’s plan administrator of the Social
Security Administration’s determination that the
beneficiary is no longer disabled.
Within 30 days of
the Social Security
Administration’s
determination
COBRA Elections and Payments by Employees Electing COBRA
Qualified beneficiaries have 60 days from the loss of coverage date or the date
the notice was mailed (whichever is later) to decide whether to elect COBRA
continuation coverage.
Qualified beneficiaries must respond to this notice and elect COBRA coverage
by the 60th day after the written notice is sent or the day health care coverage
ceased, whichever is later. Otherwise, qualified beneficiaries will lose all rights to
COBRA benefits.
Coverage begins on the date that coverage would otherwise have been lost by
reason of a qualifying event.
Spouses and dependent children covered under the employee’s health plan have
an independent right to elect COBRA coverage upon the employee’s termination
or reduction in hours. If, for instance, the employee has a covered family member
with an illness at the time the employee is laid off, that covered family member
alone can elect coverage.
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The initial premium payment must be made within 45 days after the date of the
COBRA election by the qualified beneficiary. Payment generally must cover the
period of coverage from the date of COBRA election retroactive to the date of the
loss of coverage due to the qualifying event.
Premiums for successive periods of coverage are due on the date stated in the plan
with a minimum 30-day grace period for payments. Payment is considered to be
made on the date it is sent to the plan.
Notifying Saint Mary’s Health Plans of a Termination of Coverage
The employer should submit an Enrollment/Change and Termination form to Saint
Mary’s Health Plans (SMHP) immediately upon notification of an employee’s
termination from the group plan or a family member’s loss of eligibility, regardless
of whether the member has been offered COBRA continuation coverage. Timely
notification by the employer will help avoid responsibility for premiums past the
termination effective date, should a SMHP member not elect COBRA during the
60 day election period allowed, or fail to pay within 45 days of electing COBRA.
Payment of COBRA Premiums by Employer to Saint Mary’s Health Plans
The employer must submit payment for the qualified beneficiary to Saint Mary’s
Health Plans (SMHP) if COBRA has been elected, whether or not payment has
been made to the employer by the qualified beneficiary. If payment is not made to
the employer within 30 days of the premium due date, the employer may terminate
the qualified beneficiary’s coverage. An Enrollment/Change and Termination form
must be submitted to SMHP as notification of non-payment, terminating the
qualified beneficiary from the plan. Saint Mary’s Health Plans will make retroactive
reimbursement of the premium submitted by the employer as long as it is within
60 days of the termination and no claims have been incurred during that period.
• Terminations/Deletions Occurring On or Before the 15th Day of the Month
The employer will not be charged the qualified beneficiary’s premium under
the group coverage for that month (if no claims have been incurred during
this period). If the qualified beneficiary elects COBRA coverage, the qualified
beneficiary will be responsible for paying the full premium for the month in
which the qualifying event occurred.
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• Terminations/Deletions Occurring On or After the 16th Day of the Month
The employer will be charged the qualified beneficiary’s full monthly
premium under the group coverage. If the qualified beneficiary elects
COBRA coverage, the qualified beneficiary will receive premium credit
toward COBRA for the remainder of the month in which the qualifying event
occurred. The qualified beneficiary’s COBRA payment will then begin on the
first of the following month.
For groups employing 20 or more employees, continuation of coverage is to be paid
on a monthly basis.
Saint Mary’s Health Plans does not administer, notify, or bill for federal
COBRA continuation coverage. If a qualified beneficiary elects this
continuation, the qualified beneficiary must submit payments directly to
the employer, and the employer will then include that payment in the check
submitted to Saint Mary’s Health Plans for all of their covered employees.
Please see the next section for information regarding federal COBRA
administration available through CDS Group Health.
DISCLAIMER: The above information in this section is not intended to be allinclusive or to serve as legal advice. Employers should consult their attorneys and/
or legal advisors to determine their continuation responsibilities under federal
and state laws.
Saint Mary’s Health Plans Federal
COBRA Administration through CDS Group Health
Saint Mary’s Health Plans understands that many employer groups do not
have the time or the resources available to keep up with the complex federal
COBRA regulations. To assist our employer groups in meeting federal COBRA
requirements, federal COBRA administration is offered at no extra cost to groups
through our affiliate company, CDS Group Health.
To set up your group for federal COBRA administration or for more information,
please contact CDS Group Health at 775.352.6900. Highlights of the federal
COBRA administration services that CDS Group Health provides are listed on the
next page.
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CDS Group Health
Federal COBRA Administration
for Saint Mary’s Health Plans Groups
CDS does not mail initial (general) notices, as CDS takes over from the point of
termination. The employer must cancel any coverage the employee may have as an
active employee.
From the occurrence of the qualifying event, CDS Group Health will:
• Mail the COBRA rights letter, election form, and COBRA information packet
to the member.
• Mail a confirmation “welcome” letter and a page of payment coupons to the
member upon receipt of the COBRA Election Form and initial payment.
• Maintain the member’s COBRA file and collect and track premium payments.
• Mail rate change letters to members thirty days prior to rate changes, if the
information is provided by the employer thirty days in advance of the change.
• Mail termination of COBRA coverage letters to members.
• Answer the employer’s and member’s COBRA related inquiries.
• Notify the employer of the member’s COBRA election, change, and
termination.
• Notify carriers of the member’s COBRA election, change, and termination.
• Forward medical premium payments to Saint Mary’s Health Plans, and
forward other carriers’ dental and vision premiums to the employer.
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Mini COBRA
As of January 1, 2014, Saint Mary’s Health Plans (SMHP) will no longer offer state
(mini) COBRA coverage per the Nevada Division of Insurance Commissioner’s
Omnibus Bill.
Please be advised that any of your employees or dependent’s of employees seeking
health care coverage may be eligible for coverage under the Nevada Health
Exchange or Nevada Health Link. Saint Mary’s Health Plans is a participating
carrier and a variety of individual and family health plans are available with the
potential to receive state subsidies to help cover monthly premium costs.
To view plan options, please visit www.saintmaryshealthplans.com and select the
Nevada Health Link logo in the lower right corner of the home page. If you have
any additional questions, please contact your SMHP account manager.
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Claims Information
How to File a Claim
In order to file a claim, a Member must either download a copy of the claim form
from our website www.saintmaryshealthplans.com > Health Plan Members > Forms
> Member Claim Forms or request a claim form from the Subscriber’s employer or
from Saint Mary’s Health Plans within 20 days after charges are incurred, or as
soon as reasonably possible. Saint Mary’s Health Plans will send the claim form to
the Member within 15 days after receiving the request. Saint Mary’s Health Plans
will have the right, at its own expense, to physically examine any Member whose
illness or injury is the basis of a claim. This may occur when and as often as Saint
Mary’s Health Plans may reasonably require.
Where to Send a Claim
Send completed claim forms and the original bills to:
Saint Mary’s Health Plans
1510 Meadow Wood Lane
Reno, Nevada 89502
Telephone: 775.770.6060 / 800.863.7515
Hours of Operation: 8 a.m. to 5 p.m.
Monday through Friday
SMHP HMO members in southern Nevada should send completed claim forms
and the original bills to:
Saint Mary’s HealthFirst
P.O. Box 93927
Las Vegas, NV 89193
Payment of Claim
All benefits will be paid to the Member, or with written direction to the provider of
medical services. Any payment made under this option will completely discharge
Saint Mary’s Health Plans from any further obligation. Saint Mary’s Health Plans
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reserves the right to allocate the Deductible amount to any eligible charges and to
apportion the benefits to the Member and to any assignees. Such actions will be
binding on the Member and on his assignees.
When a Claim is Denied
Every notice of an adverse benefit determination, or denial of claim, will be set
forth in a manner designed to be understood by You, will be provided in writing or
electronically, and will include all of the following information that pertains to the
determination:
• A notice of Adverse Benefit Determination will include information sufficient
to identify the claim involved, including the date of service, health care
provider, claim amount (if applicable), and a statement notifying the claimant
that they may request their diagnosis and treatment code(s) as well as the
code’s corresponding meaning(s). Saint Mary’s Health Plans will provide such
codes and corresponding meanings as soon as practicable after receipt such
requests. Requests for diagnosis and treatment code(s) and corresponding
meaning(s) are merely information requests and will not trigger the start of
an internal appeal or external review,
• The specific reason or reasons for the claim denial;
• Reference to the specific plan provisions upon which the determination is based;
• A statement that You may request access to, and copies of, all documents,
records and all other information relevant to Your claim;
• If an internal rule, guideline, standard, protocol, or other similar criterion was
relied upon in denying Your claim, a statement that a copy of such rule, etc.
will be provided free of charge upon request;
• If the denial is based on a Medical Necessity or Experimental treatment or similar
exclusion or limit, a statement that an explanation of the scientific or clinical
judgment for the determination will be provided free of charge upon request;
• An explanation of the plan’s review procedures and the time limits applicable
to such procedures, including a statement of Your right to bring civil action
under Section 502(a) of ERISA following a denial on Appeal, and;
• In the case of a claim involving Urgent Care, a description of the expedited
review process applicable to such claim.
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Member Complaint
and Appeals Process
A Member Complaint and Appeal procedure has been developed to assure a timely
and appropriate response to a member’s concerns. The Saint Mary’s Health Plans
Member Services Department is available Monday through Friday, between 8 a.m.
and 5 p.m., PST to assist members.
A complaint is defined as an oral or written expression of dissatisfaction filed by a
member. For example, a member’s dissatisfaction may concern, but is not limited
to the following:
• Payment or reimbursement for covered services;
• Availability, delivery or quality of covered services, including an adverse
determination made pursuant to utilization review or;
• The terms and conditions of the plan.
Saint Mary’s Health Plans will do its best to resolve any questions or concerns You
may have on Your initial contact. If it needs more time to review or investigate Your
concern, Saint Mary’s Health Plans will get back to You as soon as possible, but
in any case within 30 calendar days for all non-Urgent Care claims. If You are not
satisfied with the results of a coverage decision, You can begin the Internal Appeals
procedure.
Appealing a Denied Claim for Plan Benefits
An Appeal is defined as a Member’s request for Saint Mary’s Health Plans to
change an Adverse Benefit Determination.
How to File An Appeal: To initiate an Appeal, You (or Your authorized
representative) must submit a request for an Appeal in writing to Saint Mary’s
Health Plans within 180 calendar days after receipt of Your denial notice. Send
completed written appeals to:
Saint Mary’s Health Plans
1510 Meadow Wood Lane
Reno, Nevada 89502
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Urgent care claims may be appealed orally. If you have an Urgent Care Claim you
want to appeal, or if you have any questions about the appeal process, please call
775.770-6900 / 800.433.3077, Monday through Friday, 8 a.m. to 5 p.m, PST.
If you believe that your appeal qualifies as an Urgent Care Claim, you should also
inform Saint Mary’s Health Plans that you believe your appeal should be expedited.
If You fail to Appeal a denial within the 180-day period, Saint Mary’s Health
Plans’ initial claim determination will be final and binding. If You are physically
incapacitated during the Appeal timeline and Your authorized representative was
unable to submit the Appeal on Your behalf, then You are entitled to an additional 60
days to submit Your Appeal. Upon request, Saint Mary’s Health Plans will assign an
Appeal’s Specialist to assist You (or Your Representative) through the appeal process.
The Appeal will be reviewed by the Appeals Review Board. An Appeals Review
Board Member’s compensation, promotional opportunities or other terms and
conditions of employment have no relationship to whether a Member’s appeal
is granted or denied. If You Appeal, You (or Your authorized representative) may
submit comments, documents, records or other information You feel are pertinent
to permit the Appeals Committee to re-examine all facts and make a determination
with respect to the denial.
As a Saint Mary’s Health Plans Member, You may request reasonable access to, and
copies of, all documents, records, and other information relevant to Your claim
at no charge. In addition, You may request reasonable access to all documents
submitted on Your behalf to the Appeals Committee. Upon request, You can
obtain a copy of the benefit provisions, guidelines or protocols on which the denial
decision was based. The member or the member’s designated representative
may appear in person or by teleconference to present information to the Appeals
Review Board.
In order to ensure the prompt and fair processing of Member Appeals, the time
period for filing Appeals and reviewing Appeals is fixed. The beginning date
for Member Appeals is that date on which Saint Mary’s Health Plans receives
notification of a Member’s Appeal and ends on the date Saint Mary’s Health Plans
notifies the Member of its decision. Given the tight time schedules established in
the claims procedures, Saint Mary’s Health Plans cannot extend time deadlines.
Additional materials submitted after the time has expired for submitting Your
Appeal cannot be considered.
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Appeal
Your Appeal will be reviewed and the decision made by someone not involved in
the initial denial of Your claim. The Appeals Review Board will consult with an
appropriate health care professional who was not involved in the initial denial
of Your claim with respect to Appeals involving medical judgment. The Appeals
Review Board will not afford deference to the initial claim denial. In the event new
or additional evidence is considered, relied on or generated by SMHP or Appeals
Review Board in connection with a Member’s claim, then as soon as possible
and at least 14 calendar days in advance of the date of the Appeals Review Board
decision, the Member will be provided, free of charge, with the new evidence or
the new rationale. A Member may respond to the new evidence or rationale before
a decision is made by the Appeals Review Board. The Appeals Review Board will
provide written or electronic notification of its decision within 30 calendar days
after it receives an Appeal for a precertification claim or a post-service claim. In
the case of an Urgent Care Claim Appeal, Saint Mary’s Health Plans will either
respond orally with a decision within 72 hours, followed up by written or electronic
notification, or will provide written confirmation of its decision within 72 hours.
Every notice of an Adverse Benefit Determination on Appeal will be set forth in a
manner designed to be understood by You, and will include all of the following that
pertain to the determination:
• A notice of Adverse Benefit Determination will include information sufficient
to identify the claim involved, including the date of service, health care
provider, claim amount (if applicable), and a statement notifying the claimant
that they may request their diagnosis and treatment code(s) as well as the
code’s corresponding meaning(s). Saint Mary’s Health Plans will provide such
codes and corresponding meanings as soon as practicable after receipt such
requests for diagnosis and treatment code(s) and corresponding meaning(s)
are merely information requests and will not trigger the start of an external
review. The specific reason or reasons for the Adverse Benefit Determination
on Appeal,
• Reference to the specific Plan provisions upon which the determination
is based, a statement that You may request access to, and copies of, all
documents, record and all other information relevant to Your claim,
• If an internal rule, guideline, standard, protocol or other similar criterion was
relied upon in denying Your claim, a statement that a copy of such rule, etc.,
will be provided free of charge upon request,
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• If the Adverse Benefit Determination is based on a Medical Necessity or
Experimental treatment or similar Exclusion or limit, a statement that an
explanation of the scientific or clinical judgment for the determination will be
provided free of charge upon request,
• A statement describing the next level of Appeals procedures offered by the
Plan and Your right to obtain information about such procedures, and
• A statement of Your right to bring a civil action under Section 502(a) of ERISA
(if applicable)
Time Limit for Filing Lawsuits Concerning Denied Benefits
No legal action for benefits under the Saint Mary’s Health Plans (SMHP) may be
brought until You;
• Have submitted a written claim for benefits (including requests for
Authorization) in accordance with the procedures described above, have
been notified by SMHP that the claim is denied, have filed a written Appeal in
accordance with the Appeal procedure described above; or
• The Plan fails to establish and follow its own written procedures unless
the failure was(i) de-minimis, (ii) non-prejudicial, (iii) attributable to good
cause or matters beyond SMHP control, (iv) in the context of an ongoing
good-faith exchange of information, and (v) not reflective of a pattern or
practice of non-compliance. Upon written request, SMHP will provide You
with an explanation of its basis for asserting that the circumstances meet
the exception. If an external reviewer or a court rejects Your request for
immediate review of a claim, on the basis that SMHP met the exception
requirements listed above, You have the right to resubmit Your claim and
pursue an internal appeal. No legal action may be commenced or maintained
against the Plan more than one (1) year after SMHP denies the Appeal or the
Plan fails to establish and follow these procedures.
To file a Complaint with the Secretary to the Consumer Health Assistance You
must submit Your Complaint in writing to:
Consumer Health Assistance
555 East Washington Avenue, Suite 4800
Las Vegas, Nevada 89101
Telephone: 702.486.3587 or 888.333.1597
Fax: 702.486.3586
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Notice of Appeal Rights Under Nevada Law
You have a right to appeal any decision Saint Mary’s Health Plans makes that
denies payment on Your claim or Your request for coverage of a health care service
or treatment. You may request an additional explanation when Your claim or
request for coverage of a health care service or treatment is denied or the health
care service or treatment You received was not fully covered. Contact us at
775.770.6060 or 800.863.7515 when You:
• Do not understand the reason for the denial;
• Do not understand why the health care service or treatment was not fully covered;
• Do not understand why a request for coverage of a health care service or
treatment was denied;
• Cannot find the applicable provision in Your Benefit Plan Document;
• Want a copy (free of charge) of the guideline, criteria or clinical rationale that
we used to make our decision; or
• Disagree with the denial or the amount not covered and You want to appeal.
If Your claim was denied due to missing or incomplete information, You or Your
health care provider may resubmit the claim to us with the necessary information
to complete the claim.
Claim Denial Appeals
All appeals for claim denials (or any decision that does not cover expenses You
believe should have been covered) must be sent to:
Saint Mary’s Health Plans
Member Services
1510 Meadow Wood Lane
Reno, NV 89502
Claim denial appeals must be received within 180 days of the date You receive our
denial. We will provide a full and fair review of Your claim by individuals associated
with us, but who were not involved in making the initial denial of Your claim. You
may provide us with additional information that relates to your claim and You may
request copies of information that we have that pertains to Your claims. We will
notify You of our decision in writing within 30 days of receiving Your appeal. If You
do not receive our decision within 30 days of receiving Your appeal, You are entitled
to file a request for external review.
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The Notice of Appeal Rights
Emergency Experimental or Investigational Medical Conditions: In the
event of emergency experimental or investigational medical conditions, the time
frame for completing the expedited review for urgent claims either internally
or externally do not apply. Emergency medical conditions are those that would
jeopardize the life or health of the Covered Person or would jeopardize the
Covered Person’s ability to regain maximum function. Review for requests of
emergency experimental or investigational medical treatment may be made at the
same time a request for an expedited review of a denied claim has been made both
internally and externally.
If the initial denial of the claim for emergency experimental or investigational
treatment involves a denial of coverage based on a determination that the
recommended or requested health care service or treatment is experimental or
investigational and if the Covered Person’s treating physician certifies in writing
that the recommended or requested health care service or treatment (the subject of
the initial claim denial) would be significantly less effective if not promptly initiated,
then the independent review organization assigned to conduct the expedited
external review will decide whether the Covered Person will be required to complete
the expedited review of the denied claim before medical services are provided.
External Review of Denied Claims
If we have denied Your request for the provision of or payment for a health care
service or course of treatment You may have a right to have our decision reviewed
by independent health care professionals who have no association with us if our
decision involved making a judgment as to the medical necessity, appropriateness,
health care setting, level of care or effectiveness of the health care service or
treatment You requested by submitting a request for external review. SMHP will
send You a denial letter along with information about Your appeal rights and
Nevada’s External Review Request Forms. These forms must be completed and
submitted to the Office for Consumer Health Assistance to initiate an external
review of Your denied claim within four months after receipt of this notice.
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Forms should be sent to:
Office for Consumer Health Assistance
555 East Washington #4800
Las Vegas, NV 89101
702.486.3587 / 888.333.1597
702.486.3586 (fax)
www.govcha.nv.gov
For standard external review, a decision will be made within 45 days of receiving
Your request. If You have a medical condition that would seriously jeopardize
Your life or health or would jeopardize Your ability to regain maximum function if
treatment is delayed, You may be entitled to request an expedited external review
of our denial. If our denial to provide or pay for health care service or course of
treatment is based on a determination that the service or treatment is experimental
or investigational, You also may be entitled to file a request for an expedited
external review of our denial. For details, please review Your Evidence Coverage,
contact us, the Office for Consumer Health Assistance or contact the Nevada
Division of Insurance.
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Forms
The following details and defines the forms necessary to assist your employees with
their Saint Mary’s Health Plans coverage. Please visit www.saintmaryshealthplans.com
> Employers > Forms to download forms or contact your SMHP account manager.
Member Enrollment/Change and Termination Form
The form must be completed in its entirety by the employee. This includes
the employee’s social security number, name, address, phone number, date of
birth, dependent(s) information (if family members are being enrolled), date
of employment, effective date and signature. A PCP must be selected and
listed on the form. Carefully check all information for accuracy, legibility,
and thoroughness. Also, please ensure that the request meets all eligibility
requirements.
The Enrollment/Change and Termination form is used to:
• Enroll a new member;
• Make changes such as adding, deleting or changing information regarding
oneself or one’s dependent(s);
• Terminate coverage for a member and/or dependent(s); and
• Waive coverage.
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Authorization for Disclosure of
Protected Health Information (ADPHI)
As a health insurance company, Saint Mary’s Health Plans has access to medical
information concerning our members that is deemed to be “Protected Health
Information” (PHI) by the Health Insurance Portability and Accountability Act of
1996 (HIPAA). The member information is confidential and can only be shared
with the member, the member’s provider or a designated person(s) shown on an
Authorization for Disclosure of Protected Health Information form (ADPHI). There
is a separate form for Protected Mental Health Information. ADPHI forms can be
found online at www.saintmaryshealthplans.com > Health Plans Members > Forms.
Once completed, members can fax the ADPHI form to Member Services at
775.770.3820 and it will be attached to the member’s file for future reference.
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