EPIA Helpful Hints: Waiting for Group Insurance Approval





After a new application is submitted to a carrier, the carrier will review the application before approving it. The processing time will usually take 5-7 days.


It's important to keep in mind that November and December are peak times for carriers, so applications can take a little bit more than usual.


But what can you do and what are the best practices, as an employer, while the enrollment process of your employees is being processed?


EPIA is here to help you. We gathered this information to assist you during this period.


Emergency Care


In case of an emergency situation, you should call 911 or go to the nearest hospital and pay cash or use a credit card for any incurred fees. Once your group is approved by the carrier, you can request reimbursement (less your plan’s emergency room co-payment). Also, we would like to remind you to keep a record of your payment for submission to the carrier. Some plans waive the emergency room co-payment if the patient is admitted to the hospital directly from the emergency room.


Important: The diagnosis by the emergency room physician must meet the carrier’s definition of a true emergency in order to receive any reimbursement. If you need to be taken by car or ambulance to a non-network hospital because it’s within closer proximity than an in-network hospital, the new carrier must be notified within 24-48 hours. Please call your company’s insurance contact person or your broker, if you need assistance with this notification process.



Continuity of Care/Completion of Covered Services


If you or your enrolling spouse/domestic partner is pregnant and receiving care from a non-network doctor, you are undergoing treatment for an acute condition, a serious chronic condition or terminal illness by a non-network doctor or your newborn child is receiving care from a non-network doctor between birth and age 36 months, you may come under the provisions of the California law requiring carriers to provide continuity of care (completion of covered services) with the nonnetwork doctor in specific circumstances. It is important that you notify your company’s designated insurance contact person or your broker as soon as possible to get assistance with submitting the continuity of care form to the carrier if their situation meets this law’s criteria and the carrier’s program guidelines.



Canceling Previous Insurance Coverage Before New Application Approval


When your employee enrolls in your company's health insurance plan, it's recommended that they do not cancel any existing coverage until they have their official approval from the insurance carrier.


  • Delays can happen for a variety of reasons (missing information, etc.), so waiting until approval has come through is the best way to avoid any accidental lapses in coverage.

  • Once the employee receives confirmation that their application has completed processing, they should reach out to their previous insurance carrier to cancel their old coverage retroactively.


Note about the retroactive cancelation


Carriers may or may not allow employees to cancel their coverage retroactively if they have used that coverage that month. It is recommended that employees do not use their previous coverage if possible while their application is being processed.


In the event that the employee needs to use their previous coverage, the carrier may deny the retroactive cancellation, or otherwise may process it and bill the employee for claims that were paid for that month. The employee should discuss their options with their insurance carrier.



Effective Dates, Approval Dates, and Catch-Up Deductions


Start dates for deductions depend on the effective date for coverage. Deductions can't begin until after the effective date for a new individual or group insurance application.

  • If an application is completed and approved before the effective date, deductions will begin on the effective date.

  • If an application is completed after the effective date, deductions will begin before the application is approved to avoid catch-up deductions.

Payroll deductions will begin on the first check date on or after the effective date of the benefit.



Seeing a Doctor After Insurance Effective Date


Employees can still see a doctor or fill a prescription while waiting for a carrier to approve their insurance applications.


Remember:


  • Only eligible expenses can be reimbursed. Employees must review the Summary of Benefits and Coverage for the pending plan to understand which medical expenses are covered. You can contact us for more details on what types of expenses are covered under the plan before seeking care.

  • Expenses incurred before the employee's effective date are not reimbursable. Only expenses incurred on or after the employee's effective date will be processed by the carrier.

  • If the carrier does not approve the application, employees are responsible for the costs of care or prescriptions received while waiting for approval.



Office Visits


Employees can seek reimbursement for the cost of an office visit to a doctor or another care provider or request an invoice for services.


  • Reimbursement: Pay for the visit out of pocket, then submit a reimbursement claim to the new carrier once the application is approved.

  • Request an Invoice: Some (but not all) providers will accept invoices from care providers once the insurance application is approved. Employees can request invoices from their care provider and submit the invoice after approval. Talk to the new carrier to determine whether this method is accepted.

Prescriptions

You should refill maintenance prescriptions prior to the effective date for your new coverage. For example, you should refill a maintenance high blood pressure medication no later than 12/31 for new coverage that will be effective 1/1. If you need to fill a prescription on or after the effective date for your new coverage, but you do not have your new ID number yet, you can pay for the prescription at the pharmacy and then request reimbursement from the carrier once you receive your new ID number.



  • Reimbursement: You must submit the pharmacy receipt that includes the name of the drug & dosage rather than only the cash register receipt. If you paid for the prescription by credit or debit card, and return to the pharmacy with your ID number within 7-10 business days, some pharmacies will credit any overpayment back to your account. This is the fastest way for you to get your money back. When a medication is expensive, some pharmacies will work with you by allowing you to buy a smaller amount (Ex: a 10-day supply).


Once the plan is approved and your employees have received their new membership cards:


  • They should carry their membership card at all times. It is important for them to show their new ID card to their doctor during the first visit after their new insurance plan becomes effective.

  • You should always make sure they use an in-network doctor or an in-network hospital in order to maximize their coverage and prevent significant gaps in coverage and/or higher out-of-pocket expenses.

  • You should review all of the benefit descriptions you received during enrollment and your Explanation of Benefits booklets (which the carrier mails to your home address) so you are familiar with your co-payments and covered procedures.

  • Ensure you are aware of which procedures will require prior authorization in your plan documents. Remember that procedures authorized with your previous carrier may require pre-authorization with your new carrier. Each carrier has their own criteria, so an authorization by one carrier does not guarantee authorization by another carrier in all circumstances.


We are here to help you. If you need any assistance regarding your benefits, please contact us. Call 626.912.1988, send an email to info@epiagroup.com, or submit a ticket with your inquiries or questions at https://help.ppo-hmo.com/portal/en/newticket.


EPIA Inc. - Experience is the Ultimate Protection™


Source: EPIA back office support team

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EPIA inc. is a private Insurance Agency with no ties with legal entities. While we strive to provide useful general information applicable to the majority of our clients, we do not - and cannot - provide legal advice specific to your company and your situation. If you have specific legal questions or concerns, we encourage you to discuss them with your legal advisor.



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