Additional Employer FAQ

Coverage/Benefits
Is there detailed benefit information for employees, if so, how do they get it?
Yes, employees should receive detailed information on their benefits that includes a certificate of coverage or summary plan document and schedule of benefits.  We typically provide packets of materials for employees at the time of enrollment.  These are generally provided through the broker or Piedmont during enrollment meetings. 
 
Is there a pre-existing conditions waiting period? 
For employer groups with less than 100 employees on the plan, (and for some self-insured plans) a pre-existing waiting period does apply.  Employees receive credit towards this 12 month waiting period for any time that they had creditable coverage prior to enrollment, as long as there was not a significant break in coverage (period of 63 consecutive days).  Employers/employees must submit proof of prior coverage to receive credit.  A pre-existing condition is a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period prior to coverage under the plan.

When traveling, can my employees receive coverage out-of-area?
Members are covered for emergency and urgent care anywhere in the world and at any time.  We understand that emergencies and urgent situations happen while you are outside the service area.  In these situations members should seek immediate care.  Because the Piedmont network only covers certain areas, we do ask them to notify us when these situations happen so that we can help them get the proper treatment and the proper claims processing.  So if something happens while one of your employees is on vacation or traveling for work, don’t worry - we are here to help. 

What type of wellness or health promotion programs do you offer to your members?
We have a full scale wellness program, Healthy Directions, that includes a health risk assessment, clinical testing and biometrics, and follow up with employee participants.  We also have the disease, case, and lifestyle management components in place to compliment the program.  For more information, contact your broker or our Marketing Department.

Pharmacy
Are pharmacy benefits offered with each plan?
Typically pharmacy is offered with each plan, although you can have a plan with no pharmacy benefits included.  Pharmacy includes the 30-day prescription coverage as well as the 90-day mail-in prescription coverage.  We also have certain pharmacies that you can walk into to receive the 90-day prescription coverage.
  
Claims
If a claim is denied, what should my employee do next?
The first step would be to contact Customer Service and have the issue researched by one of our representatives.  If the claim was denied in error, they can resolve it.  They can also explain the appeal process for a claim that your employee feels should not have been denied. 

Do my employees have to file their own claims?
Contracted providers will file the claims for your employees. 
  
What happens to a claim if an employee has more than one health insurance plan?
Benefits are coordinated with the other health insurance coverage.  Typically your plan will be primary for your active employees, so your coverage will pay first. Then the claim will be sent to the secondary coverage plan.  If the secondary would have paid more on the claim had it been primary, then the secondary coverage will pay up to that amount, otherwise the secondary coverage will not pay at all.  Detailed information on the Coordination of Benefits is included in the member’s policy book.

END OF EMPLOYER FAQ