Producer guide - IHC Health Solutions

Recommendations

Info

Type of ChangeIncrease DeductibleAdd Wellness or OutpatientAccident RiderAdd Enhanced PrescriptionDrug Card RiderRemove a Benefit RiderPPO Network ChangeReinstatementRequest for Removal of an ExclusionaryRider or RatingContinuation for DependentPlan change – (e.g. Traditionalto PPO, no deductible or benefitrider changes)RequirementsWritten Request from thePrimary InsuredWritten Request from thePrimary InsuredWritten Request from thePrimary Insured with New CompletedMedical Section of the ApplicationWritten Request from the PrimaryInsuredUnderwriting ApprovalRequiredNoWritten Request from the PrimaryNoInsuredWritten Request from the PrimaryInsured with a New CompletedMedical Section of the Application; Yesall premiums due as of thereinstatement dateWritten Request from the PrimaryInsured, all Medical RecordsYesRegarding the Condition at theInsured’s ExpenseWritten Request from the ContinuingDependent if age 19 or Over. Also,written request from the currentprimary member removing the Nodependent from coverage; a new CAMembership application is needed forthe dependentWritten Request from the PrimaryInsuredWritten Request from the PrimaryInsuredNoYesYesNoIAC ActionLetter confirming the change, newcertificate face page and ID card(if affected by the change)Letter confirming the change andnew certificate face page sent tothe insuredIf approved, letter confirming thechange and new certificate facepage; if declined, letter is sentnotifying insured of decisionLetter confirming the change andnew certificate face page sent tothe insuredLetter confirming the change andnew ID card sent to the insuredIf approved, letter confirmingreinstatement is sent to insured; ifdeclined, letter is sent notifyingclient of decision sentIf approved, letter confirming thechange is sent to the insured; ifdeclined, letter is sent notifyinginsured of decision is sentLetter confirming the continuation,new certificate face page andID card sent to dependent and thecurrent primary insuredLetter confirming the change, newcertificate face page and ID cardsent to the insuredTermination of CoverageNote: Depending on the original eligible/billing date, terminations are madeeffective on the 1 st or 15 th of the monthfollowing receipt of the request or the lastfully paid month. Premium refunds willnot be paid to insureds on monthly bankdraft billing mode.NoLetter to confirm the terminationand Certificate of CreditableCoverage sent to insuredAdding or removing benefits or dependents, making plan changes, etc. are all effective on the 1st or 15th of the month (depending onbilling mode) following approval and/or receipt of the request. You are copied on all correspondence.17
Medical Claim ReviewClaims received at IAC that are inconsistent with information provided on the application or may be subject to apre-existing condition limitation are sent to medical review. When a claim is reviewed, the analyst will look at the originalapplication, telephone interview, evaluation of prior coverage, and determination of HIPAA eligibility. Investigations willdetermine if the condition on the claim is a pre-existing condition or if there was a material misrepresentation in theapplication. The producer and insured will be sent correspondence providing the status of the medical review process.Rescission or Reformation of CoverageFalse or misleading information on the application may be the basis for rescission or reformation of coverage. Rescissionvoids the coverage back to the effective date. Reformation allows a rating to be applied or an exclusionary rider to beadded to the policy back to the effective date. Be sure that the applicant completes the application accurately, including allanswers to medical questions and height and weight information.RewritesA re-written application on an inforce case that currently utilizes monthly bank draft of monthly credit card bill will onlyneed to submit a copy of a voided check or credit card for the enrollment fee. IAC will not draft or charge the rest of thepremium until the case is issued so that the insured is not paying two premiums simultaneously.Reinstatement of CoverageReinstatement is available in all states for up to 60 days from the lapse date. An application and all premium due is requiredto re-evaluate the health status of proposed insureds. Additional underwriting requirements may be requested at thetime of reinstatement. Reinstatement will only be approved if the original underwriting decision is still valid. If a rider orrating would now be required to approve the case, the reinstatement will be denied. If approved, the reinstated coveragewould not have a lapse and there would be no change of effective dates.Reinstatement is not allowed for insureds that have submitted a written request to cancel coverage.ContinuationContinuation of coverage is available to dependents that lose eligibility. A request for the dependent to continue on his/herown certificate must be received within 31 days of the status-changing event. If approved, the dependent will have thesame benefits as the certificate from which s/he converted.Turning Age 65 – Medicare EligibilityA notice will be sent 90 days in advance of an existing insured turning age 65 and therefore, eligible for Medicare coverage.This notice will inform the client of the ability to continue coverage under our plan but that benefits will be payablesecondary to Medicare. Coverage will NOT automatically terminate upon the insured’s 65 th birthday.18
Page 2 and 3: Table of ContentsImportant Addresse
Page 4 and 5: Communicating for America, Inc.The
Page 6 and 7: In addition to the list of occupati
Page 8 and 9: Juvenile Build Table, Ages 14 and U
Page 10 and 11: Pre-ScreeningIf a client has a cond
Page 12 and 13: Underwriting DecisionsAfter review
Page 14 and 15: Empowered Underwriting Matrix, cont
Page 16 and 17: Underwriting Decisions, continued3.

Producer guide - IHC Health Solutions

Create successful ePaper yourself

Delete template?

Save as template?