Claims FAQ for Group Plans
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WHAT DOES THE WORD "CLAIM" MEAN?
A claim is a request for payment in accordance with an insurance policy. For our purposes, this would require an original itemized bill, along with a completed claim form.
WHERE CAN I GET A CLAIM FORM?
HOW DO I SUBMIT A CLAIM?
Complete the Claim Form and mail it to IEES with the original detailed bill from the doctor, hospital or any other medical provider. The bill from the provider should include the provider's name and address, the insured's name, patient's name, a diagnosis, the date of service, and a detailed listing of the charges incurred. Note that your claim form must include your name exactly as it is in your sponsor's or educational institution's records.
Keep in mind when submitting your documentation that only original bills will be accepted; however, the claim form may be photocopied.
HOW OFTEN DO I NEED TO SUBMIT A CLAIM FORM?
One claim form will be required for each new and separate illness or injury. Additional claim forms do not need to be submitted if you are under continuing care with your physician for the same condition.
WHY DO I NEED A CLAIM FORM?
The Claim Form gives us the information we need to process your claim. The following are just a few examples of why a claim form is required:
- Loss due to an Injury: The claim form enables the examiner to determine where, when and how the injury was incurred. Signing the portion of the claim form that authorizes the release of information allows claims examiners to obtain police reports, medical records, test results, or other documents needed to evaluate the claim.
- Auto Accident: By describing the accident and its exact location (i.e., "Intersection of Main Street and Elm Street"), police reports can easily be obtained.
- Multiple Claims: Your benefits are based on a "per illness/per injury" basis. If you are being treated for more than one condition at the same time, the claim form allows you to designate which charges belong to which condition so that you may be properly reimbursed. In some cases, medical records, police reports, test results, etc. can be requested immediately.
- Large Claims: A completed claim form includes an authorization for release of information. This allows the insurance company to request critical information from the medical providers when necessary without further delay.
- Missing Information: All claims submitted without the required information will result in a delay in processing.
CAN I GO TO ANY PHYSICIAN OR HOSPITAL I WANT?
Yes. Your policy is an indemnity plan which allows you to go to the physician or hospital of your choice. However, due to various limitations and exclusions under the policy, please have the service provider call IEES at our toll free number within the United States 866-433-7462 or overseas call collect, 607-272-2707 prior to services being rendered. If you are within the United States and would like a referral to a doctor or healthcare facility, please refer to your BCS Medical Insurance ID card. You should see the Hygeia/First Health logo, and you may use their online provider search. Remember that it is your decision whether or not to contact Hygeia/First Health and your benefits are not affected by your decision.
WILL I HAVE TO PAY WHEN I GO TO THE DOCTOR?
Present your Identification Card when you go to a hospital or physician. Medical Providers within the United States, with few exceptions, will bill IEES directly. Physicians in the United States who belong to the Hygeia/First Health network should bill IEES directly for covered services. If you visit a private physician's office or clinic that requires payment at the time services are rendered, you will have to pay the bill yourself and submit the claim to IEES for consideration. If the provider has any questions regarding your insurance coverage, please instruct them to call IEES during business hours at our toll free number, 866-433-7462 (within the United States), or 607-272-2707 (overseas call collect), to verify insurance benefits.
HOW CAN I KEEP THE EXPENSES OF MY MEDICAL BILLS TO A MINIMUM?
By seeking medical care at your college or university Student Health Center, if one is available. If not, visit a doctor's office for non-emergency services rather than a hospital's Emergency Room. An Emergency Room will generally charge much higher prices than a doctor's office. However, if your condition is urgent or life-threatening, you should go directly to an Emergency Room.
SHOULD I GO TO THE EMERGENCY ROOM?
A hospital Emergency Room is designed to cope with urgent and life-threatening medical conditions. For example, an Emergency Room might be the best place to seek treatment for sudden chest pain, serious wounds with bleeding that you can't seem to stop or that are deep enough to need stitches, eye injuries, broken bones, loss of consciousness, drug overdose, severe abdominal pain, or other conditions that you think may cause death or serious and lasting harm if not treated immediately.
Emergency Rooms will treat the sickest patients first, and if your condition is not immediately life-threatening, you may have to wait for treatment. In some metropolitan hospitals, the wait can be several hours for non-urgent conditions.
Colds or flu, coughs, rashes, minor fevers, earaches, headaches, scrapes or minor burns, sore muscles or backache generally are not life-threatening and do not warrant Emergency Room visits. An appointment, scheduled within 24 hours with a local physician or a walk-in clinic, can often treat these important, but not life-threatening, conditions.
Some plans have a "co-payment" requirement for Emergency Room visits. With a co-payment requirement, you will be required to pay an additional $100 (in addition to your deductible) for Emergency Room charges. In most plans, this co-payment is waived if you are admitted to the Hospital as an Inpatient.
WHAT IS A DEDUCTIBLE?
A deductible is the portion of a bill that is not covered by the insurance company and that is therefore the responsibility of the insured. It is the dollar amount of eligible medical expenses which must be paid as an out-of-pocket expense by each covered person on a per illness/per injury basis before certain benefits are payable under the policy.
HOW DO I BUY PRESCRIPTIONS?
The IEES plan requires that you pay for the prescription at time of purchase from the pharmacy. Please submit the original detailed receipt which includes your name, physician's name, date, medication name, strength, quantity and price to IEES for consideration of payment. No cash register tapes will be accepted. You may want to discuss using generic drugs with your physician as an option as they are often significantly less expensive.
WHY DO YOU NEED MEDICAL RECORDS?
Medical records may be requested for a number of reasons. Following are just a few:
- To determine whether or not a claim is a pre-existing condition.
- To determine the history of a sickness or injury: how, when and where it began and how far it has progressed; whether or not it has been cured; the likely future course of treatment; and what complications, if any, may have arisen as a result of the condition.
- When a physician lists multiple diagnoses, the records help us to determine how many of the diagnoses listed were actually treated and which ones were mere observations noted by the physician. With some insurance policies, this may affect the reimbursement.
- In the case of injuries, medical records give a clearer picture of what happened, so that we can more accurately determine what benefits you are entitled to.
WHAT DO YOU MEAN BY PRE-EXISTING AND HOW IS IT DETERMINED
A medical problem is considered "pre-existing" when a covered person has received medical treatment for a condition prior to being insured under the policy. To determine whether a condition is "pre-existing",the claims examiner must review important data, such as medical records, test results, X-rays, etc. Most policies will not cover you for a condition that was in existence prior to your effective date of coverage.
HOW LONG WILL IT TAKE FOR ME TO BE REIMBURSED?
If you have completed the claim form fully and there are no problems or questions that require additional information or follow-up with your doctor or medical service provider, payment should be processed within 3 to 5 business days. If there are questions, or if we require additional information, your payment will be delayed until those issues are resolved. However, if payment of your claim will be delayed, you will be notified.