a complete Understanding Health Benefit Plan - EBA&M

a complete

Understanding your Health Benefit Plan

WELCOME DEAR PLAN MEMBER: Welcome to Employee Benefits Administration & Management Corp. (EBA&M). EBA&M has been selected to provide administrative services to your employer’s Health Benefit Plan. We are dedicated to providing the highest quality service in claims administration and management of employer sponsored benefit plans. Included in this packet you will find your identification cards. The group number is listed on the front of your identification card. These cards are important as they identify your group number and vital EBA&M contact information. You must alert your providers of the change to EBA&M. Please present your EBA&M identification card each time you visit your provider. When submitting claims to EBA&M, please provide the group number and the employee’s identification number on all original itemized bills. EBA&M will accept photocopies when this plan is the secondary payor. You will be contacted in writing if additional or updated information is required to provide full benefits under the plan (e.g., spouse’s insurance, dependent status, etc.) EBA&M may be unable to pay claims until the complete information is received from you or your healthcare provider. Please submit all claims, along with any other requested information, to the address on the back of your identification card. EBA&M is committed to providing you with superior quality service. If you have questions please call the following number: Claims/Customer Service • 800-249-8440 EBA&M’s professional staff is pleased to have the opportunity to serve you. We look forward to assisting you in receiving the benefits to which you are entitled and helping you to become a wise healthcare consumer.

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Claims/Customer Service • 800-249-8440

TAKE YOUR “LINK TO CARE” WITH YOU EVERYWHERE Your health plan ID card is your direct link to healthcare. Remember to carry your ID card and show it to physicians, other providers and pharmacists whenever you need care or prescriptions. Please encourage your healthcare providers and pharmacists to make a copy of the front and back of this ID card, as it contains information necessary for the accurate submission and processing of claims. What information is included on your EBA&M ID Card? 1 Eligibility Information: Employee (The enrolled member’s name); Group Number/Location Number (Your employer’s assigned number with EBA&M); Identification Number (enrolled member’s ID number).

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2 Preferred Provider Network

(EPO or PPO) logos: Identifies the name(s) and logo(s) of EPO or PPOs your employer contracts with to ensure the best discounts for healthcare services.

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5 NOTE: ID Card formats vary, so yours may look different.

3 Pharmacy Information: Rx vendor information. 4 Member Customer Service Contact Information: Claims Questions (EBA&M Online website and Client Service Center phone number); Rx Claims (Rx Customer Service phone number); Inpatient Hospital Stays (Pre-Certification). 5 Provider Customer Service Contact Information: Hospital Pre-Certification (if applicable); Provider Questions (EBA&M Client Service Center); Claims Submittal (mailing address).

Claims/Customer Service: 800-249-8440 www.ebam.com


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BENEFITS INFORMATION ONLINE WE’VE MADE ACCESSING YOUR BENEFITS INFORMATION EASY! How do I access this information? From the Internet, go to www.ebam.com and click on “Plan Participants.” • Click on the EBA&M ONLINE button to get to the User ID and Password screen. Input your User ID and Password. If you don’t have one yet, click on Register. Click the drag-down menu arrow in the User Type menu and choose Employee or Dependent, then input your 5 digit Group Number. Once you do that, Employees will be asked for their Social Security Number or Member ID, while dependents will be asked for their name, date of birth and gender. • You will now be asked for your address, phone number and email address. KEY FEATURES Claims Inquiry: You can check the status of your claims 24 hours a day, 7 days a week. Coverage Inquiry: Although you should always refer to the actual Summary Plan Document for detailed Plan Benefits, you may access a summary of your benefits here. You can also verify your eligibility at any time. Links: The “Links” section offers you web-links to all of the various vendors associated with your plan, i.e. the PPO Network, the Utilization Review company, or the Prescription Drug Plan. Frequently Asked Questions (FAQ): Here you will find a list of answers to the questions that we receive most frequently from our clients. Reimbursement Plan Accounts: You can check the status of your FSA or HRA claims and balances 24 hours a day, 7 days a week.

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STRATEGIES TO HELP YOU CONTROL YOUR HEALTHCARE COSTS EBA&M... providing real solutions for healthcare cost control Employee Benefits Administration & Management Corporation, (EBA&M) takes the responsibility to control healthcare costs for our members seriously. EBA&M utilizes an experienced team of claims examiners, along with sophisticated software programs, to identify specific areas where extra cost savings should occur for our members. Recently, we have enhanced this process to include a special fraud and billing abuse detection review.This analysis allows us to examine our members’ medical claims for accuracy to ensure fair and consistent reimbursement to all providers.

Some estimates project $750 billion annual fraud, waste and abuse or $.30 of every health care dollar spent. Institute of Medicine

EBA&M has worked with the providers to help them understand what can be billed to you. If you are billed more than your liability of deductible, copay, coinsurance or non-covered services, please contact them to clarify the balance owed. If they continue to bill you for more than your liability, contact our Client Services at the toll free number (listed on the back of your health plan ID card). EBA&M will work with the provider to help them further understand our coding and reimbursement policies. Just as you would review a restaurant tab for accuracy, EBA&M reviews claims of services billed ala carte to ensure they are bundled appropriately, based upon generally accepted coding and reimbursement guidelines. These coding rules were created by the American Medical Association in conjunction with multiple specialty societies, CMS (Medicare) and representatives from multiple healthcare insurers. A study of 40,000 hospital bills found that 97% had billing errors... Estimated errors represent $15 billion each year. -Equifax


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STRATEGIES TO HELP YOU CONTROL YOUR HEALTHCARE COSTS HEALTHCARE PROVIDERS Participants who are informed and involved in their individual healthcare decisions will be rewarded by improved overall health status and more money in their pocketbook! EBA&M Corporation, your Health Plan’s benefits administrator, has developed specific strategies for you to become an educated and empowered healthcare consumer. • Shop around for a physician. Not all physicians charge the same fees. Check to make sure your physician is in your company’s discounted (PPO) network. You should also verify that your provider is utilizing a hospital or other healthcare facility (for procedures, lab work, etc.) which is part of this discounted network. Inform your physician about which PPO network your group utilizes so they can make the appropriate arrangements. For a listing of providers and facilities within your group’s PPO network, login to your personal account on: www.ebam.com. •R esearch your medical condition. To avoid unnecessary tests or procedures, research treatments for your medical condition to ensure you aren’t going to pay for procedures you don’t need. You can access much of this information through online resources such as those found within Mayo Clinic (www.mayoclinic.com) or WebMD (www.webmd.com). • Seek alternative treatments. It is important that you always get the medical care you need, but sometimes, the first treatment suggestion isn’t the best. Ask your doctor about alternative treatments. Some illnesses and diseases can be treated by lifestyle changes and other non-medical means.

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FREQUENTLY ASKED QUESTIONS FREQUENTLY ASKED QUESTIONS BY NEW EBA&M-ADMINISTERED HEALTH PLAN MEMBERS EBA&M works hard to meet customer service goals established for all areas of our organization. We believe the first part of service starts with educating our members about their benefit plan. We hope this tool will answer your benefit questions, and help you to navigate your benefit plan with EBA&M. Q: How do I know if a claim has been paid? A: Y ou can access this information on EBAM ONLINE (refer to page three of this booklet). You can also speak with a Client Service Representative at the toll free number listed on your ID card. Q: W hat types of benefits are available through my employer’s benefit plan? A: You can access a copy of your company’s Summary Plan Description (SPD) on your personal EBAM ONLINE account. Or, you can speak with one of the representatives in our Client Service Center by calling our toll free number, listed on the back of your ID card. Q: What is a Preferred Provider Network? A: As part of your employer’s commitment to provide its members with a high quality, cost-effective health benefit plan, they have secured contracts with certain hospitals, physicians and other healthcare providers, known as Participating Providers. Because these Participating Providers have agreed to accept reduced fees for persons covered under your health benefit plan with EBA&M, your company can reimburse a higher percentage of their fees, resulting in less out-of-pocket expense to you. Q: How do I know if my Provider is a participant in one of our group’s Preferred Provider Networks? A: You may access Participating Provider information from the EBA&M website, or by contacting the Customer Service department of each Preferred Provider Network. The website information and customer service phone number, when available, is also included on your EBA&M ID card. Claims/Customer Service • 800-249-8440

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WHAT TYPE OF INFORMATION MIGHT I RECEIVE FROM EBA&M EBA&M - administered health plan members receive information at the time of enrollment, and throughout the year, which highlights programs and services available through your company’s benefit plan. There are also times when EBA&M’s Claims and Eligibility departments require additional information to correctly process your claim. EBA&M will detail what is needed through documentation on your Explanation of Benefits or a personal letter. Some examples of other types of “requests” you might receive from EBA&M: Other Insurance Coverage (OIC): Each year EBA&M asks for this information on employee’s dependents who either currently have no other insurance, documented in our system, OR where EBA&M would pay secondary (i.e. the birthday rule). Accident: An accident letter will be mailed by EBA&M to the plan participant for completion of questions when a claim received includes an accident diagnosis code. If the completed accident letter is returned by the plan participant indicating a motor vehicle accident or other potential for third party liability, the Phia Group subrogation attorneys will further investigate. Preauthorization: This letter responds to a request for preauthorization for treatment.

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CLAIMS PROCESSING EBA&M’s core service is processing your claims. It is our goal to educate you as a participant in your employer sponsored health plan to create a productive relationship. After a claim is incurred, either you or your service provider submits it to EBA&M. It is received one of two ways, hard copy or electronically. Electronic and paper claims that have been scanned are automatically sent through the claims paying system. Hard copy claims are routed to the claims department for manual registry. If all pertinent information is included and correct, the claim may be processed automatically. Claims that are not auto-adjudicated are received by your group’s dedicated claims examiner and manually processed. Throughout the claims paying process, it may be necessary for you or your service provider to provide additional information regarding your claim. A few examples of the types of information that may be requested are: other insurance information (OIC), accident details, dependent status, and evidence of prior health coverage (HIPAA certificate). You will be contacted in writing (either through code description on the EOB or in a separate letter) when additional information is required for proper processing of your claim. To prevent further delay in processing or possible payment denial, please return requested information to EBA&M in a timely manner. An Explanation of Benefits (EOB) containing information on how your claim was processed will be sent to you and your provider. A sample EOB is included in the back of this booklet. To access additional information and down-loadable claim forms, please visit EBA&M’s website at www.ebam.com


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SAMPLE EXPLANATION OF BENEFITS J0B5 [26] 2 of 2

20140305T14 1079 5478

E.B.A.& M. CORPORATION P.O. BOX 5079 Westlake Vlg. CA 91359-5079

Explanation of Benefits

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RETAIN FOR TAX PURPOSES

THIS IS NOT A BILL

Forwarding Service Requested

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Customer Service Group: Group #: Provider: Member ID: Date:

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JOHN SMITH 1234 MAIN STREET ANYTOWN, USA 12345

EBAM 0564 WEST MEMORIAL HO 00E211155 03/05/14

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If you have any questions about this claim, please call (714) 668-8920 or (800) 249-8440 Status & Benefits visit www.ebam.com

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5 Claim #: Patient:

1405000164 JOHN SMITH

Procedure Dates of 7 Description Service 02/07-02/07/2014 LAB OP HOSP Column Totals

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Patient Responsibility:

4 Billed Amount $262.78

Provider Discount $183.95

$262.78

$183.95

$7.88

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Enrollee:JOHN SMITH Patient #:H1665439555 Ineligible Amount $0.00

Reason Code BBP

$0.00

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Covered Deductible Co-pay Coinsurance Amount By Plan Amount Amount $78.83 $0.00 $0.00 $7.88 $78.83

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$0.00

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$0.00

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Balance Amount $78.83

Paid At 90%

Payment Amount $70.95

$7.88 $78.83 Other Credits or Adjustments Total Net Payment

$70.95 $0.00 $70.95

Reason Code/Description BBP

PRUDENT BUYER PROVIDER. REDUCED ACCORDING TO BLUECROSS/PRUDENT BUYER CONTRACT. PATIENT IS NOT LIABLE FOR CHARGE. CONTACT YOUR LOCAL BLUECROSS PROVIDER APPEAL DEPT WITH ANY QUESTIONS.

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Payment Details

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Paid To WEST MEMORIAL HO

Amount $70.95

Appeal Rights

You are entitled to a review of this benefit determination if you have questions or do not agree. Written request for review must be mailed within 180 days following receipt of this explanation. To obtain a review, submit your request to the address listed below to the attention of "Appeals Department". Your request should include your name, member ID and other identifying information shown on this form, as well as a statement of the issue and any data, documents or comments you would like to have considered. Ordinarily, you will receive notification of the final determination within 60 days following receipt of your request. If special circumstances require an extension of time, you will be notified of such extension within 60 days following receipt of your request. SEND ALL WRITTEN APPEALS TO: APPEALS DEPARTMENT c/o E.B.A.&M. Corporation 3505 Cadillac Ave. Suite O-201 Costa Mesa, CA 92626. Please be advised this Plan is an ERISA Plan subject to the provisions of the Federal Claims and Appeals Regulation (July 2002). Your plan may or may not require satisfaction of co-pays, annual deductibles, or coinsurance. For additional information on why a co-pay, deductible or coinsurance was applied to this claim, please refer to the Schedule of Benefits section of your Summary Plan Description.

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SAMPLE EXPLANATION OF BENEFITS 1. Indicates the name of the health plan and where your claim was processed. 2.

THIS IS NOT A BILL is simply a statement of benefits received.

3. Provider is the name of the health care provider who submitted the claim. The provider may be a doctor, specialist, hospital, lab, clinic, or other medical facility. The group name and group number in this section should match what’s printed on your EBA& HealthCare ID card. Date is the date that the check was printed, not the date the care was received. 4. Employee information includes the name of the enrollee and patient’s name. The claim number is a unique number we assign to each claim. The patient number is supplied by the provider of services. 5. Service Date(s) is the actual date(s) the patient received heath care services from the provider. 6. Procedure Description describes the type of service(s) the patient received from the provider. A description of this code is found in box 18. 7. Billed Amount is the total reasonable and customary fee that the providers charge to provide the type of service received. 8. Provider Discount is the contracted fee discounts the provider has agreed to accept. You are not responsible for this amount. 9. Ineligible Amount references any portion of the total charges ineligible for payment under your HealthCare benefits plan. For example, Services not covered by your plan or services exceeding the maximum allowable reimbursement are not covered. Your provider may bill you for these charges. 10. Reason Code is an explanation of a remark code and tells you how your claim payment was adjusted. A description of this code is found in box 18. 11. Covered By Plan is the portion of the submitted charges that is eligible for coverage under your benefit plan. 12. Deductible Amount is the portion of the submitted charges that is not payable because it’s being applied to your annual deductible, your plan covers a percentage of eligible charges. 13. Co-Pay Amount is the amount the patient is responsible for paying at the time of service to the provider for services rendered. 14. Co-Insurance Amount is the amount the patient must pay after the plan has paid its share. For example: Your plan may pay 80% for covered services and require you to pay the remaining 20% as coinsurance. 15. Paid At is the percentage of the balance covered by your particular benefit plan. For example: If your plan requires that you pay 20% coinsurance amount for covered health care services, the eligible portion of your claim will be “paid at” 80%. 16. Payment Amount is the total amount we paid to the provider or insured. This will also include the patient responsibility amount. The patient responsibility amount you may owe the provider if your plan did not pay all the charges. But remember that your EOB is not a bill. Don’t send your payment unless you receive a bill directly from the provider. If you are billed for more than this amount, ask the provider for a detailed explanation. 17. Paid To indicates the total amount the plan paid to the provider or insured. 18. Reason Code/Description includes messages to help explain how a claim was processed. 19. Appeal Rights explains what to do if you disagree with the way your claim was processed and would like to request a formal review.


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EBA&M has been a leading provider of administrative services for employer sponsored health plans for over 35 years. Working with our clients we design, implement and administer benefit programs that address the needs of their employees. Every program is backed by our commitment to deliver superior customer service with cost-savings through technology and products that best manage our client’s health care dollars. We are committed to remaining an industry leader and take pride in being a key component of our country’s dynamic health care system. Costa Mesa - Corporate 3505 Cadillac Ave., O-201 Costa Mesa, CA 92626 800-249-8440 Agoura Hills 30851 Agoura Rd., #105 Agoura Hills, CA 91301 800-249-8440 San Jose 560 S. Winchester Blvd., Suite 500 San Jose, CA 95128 800-249-8440 www.ebam.com

a complete Understanding Health Benefit Plan - EBA&M

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