Mod 5 Chpt 3

Acts of third Parties and Subrogation
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Terms in this set (40)
Acts of third Parties and Subrogation
These provisions allow a plan 2 b reimbursed for medical expenses they have covered that should have been covered by another party
Acts of third Parties (ATP) & Subrogation
These are provisions that are included in many benfit plans to allow for recovery of money paid on claims incurred as a result of a third partys act or acts for which that party in financially responsible.
Subrogation
T/plan allows 4 recovery of money paid on claims as a result of a 3rd party act. under subrogation t/insurance has an obligation 2 pay a benefit under t/contract and has a subrogated right for a portion of t/recovery that t/claimant may obtain from a 3rd party.
Preexisting Conditions
is a condition that t/claimant was treated for within a specified time period before t/claimant became covered under t/plan.
HIPAA & Health Insurance Portability Law: (signed in)
In 1996 a new law was signed by President William Clinton, regarding insurance called Health Insurance Portability & Accounting Act (HIPAA)
HIPAA & Health Insurance Portability Law: (important change)
This law made important changes that include preexisting limitatios, prior coverage certification, and privacy issues.
1 of 5) HIPPA restrictions for which a group health plan may exclude coverage for a preexiting condition.
A health plan (h/plan) may not impose a preexisting condition limit unless t/plan provides prior notice to the member of the existence & terms of t/preexisting condition exclusion.
2 of 5) HIPPA restrictions for which a group health plan may exclude coverage for a preexiting condition.
A h/plan may not impose a preexisting exclusion unless t/member received tx or advice from a St./Lic. medical practitioner for t/condition within t/6 month period preceding t/date of enrollment under t/group h/plan.
3 of 5) HIPPA restrictions for which a group health plan may exclude coverage for a preexiting condition.
T/group h/plan must credit an individuals prior health coverage toward satisfaction of t/preexisting condition limit unless that coverage was solely for excepted benefits, commonly called riders or waivers.
4 of 5) HIPPA restrictions for which a group health plan may exclude coverage for a preexiting condition.
The max period allowed for a preexisting condition exclusion is generally 12 moths (18 months in the case of an individual who does not enroll when first eligible).
5 of 5) HIPPA restrictions for which a group health plan may exclude coverage for a preexiting condition.The group h/plan may not impose any preexisting condition exclusion 4 pregnacy or 4 a newborn or newly adopted child enrolled within 30 dys.Preexisting RequirementsHIPAA limits t/preexisting period (aka: t/look back time) in determining a conditon is preexisting to 6 months. A preexisting provision generally: Medical advice, diagnosis, care, or tx that is either recommended or received for a condition.Prior NotificationUnless the insurer gives t/insured prior info regarding preexisting limitations they may not impose them. Most insurance carriers include preexisting clauses in their contracts.Credit for Prior CoverageHIPAA states that an employee may b given credit 4 t/period of time, covered by, former employment, provided t/coverage is considered credible. Therefore if an employee only had medical coverage in t/old plan w/former employer t/employer will receive credit for medical care, but not for dental, vision and other services.Credible Coverage: Like & Similardoes not take into consideration t/benefits of the old and new plan, but only that the former plan was medical & the new plan is medical coverage. A new insurance carrier may choose to enact the preexisting limitations on certain items that were not included in the old plan.Credible Coverage: 1Under t/new law, preexisting exclusions are limited to a 6 month look back period & credit must be given for prior coverage.Credible Coverage: 2If covered by ins., & transfers ins. coverage to a new company prior to 63 dys of ceasing coverage at the old company, the new ins. carrier may not apply preexisting limits to tx.Credible Coverage: 3If a break of 63 dys or more between termination of the old coverage & t/date of the new coverage, preexisting exclusions are limited to 6months.Maximum Periods: (continuous coverage requirements)Those who do not satisfy the contined cover require; preexisting exclusions r limited to conditions for tx received within 6 months prior to coverage.Maximum Periods: (allowed exclusion)Are only to remain in effect for 12 months, after 12 months t/carrier must cover the condition whether it was preexisting or not.Maximum Periods: (late enrollment)If not enroll when, first became eligible then preexisting exclusions are allowed to continue for 18 months.Maximum Periods: (measured date)HIPAA states that if a preexisting condition exists, the 12 month period for imposing the exclusion is measured from the employees enrollment date.Pregnacies, Newborns, and Adopted Children Under 18 Excluded:Preexisting limits are not allowed for pregnacy , newborns, or adopted children under 18, If a woman transfers coverage while pregnant, the new ins. carrier must cover the costs associated with the pregancy.PreexistingHIPAA mandates that the look back period is a 6 months, preexisting conditions can b excluded for only 12 months, & a credit from previous eligible group h/plan must b applied to t/12 month period.Prompt pay Laws: (time period)require h/plans to pay health ins. claims within a specified time period, or face fines, added interest payments, and other penalties.Prompt pay Laws: (clean claim)apply only to "clean claims" (meaning claims without defect and with full info provided) if a state requires clean claims to b paid within a certain time the stare is listed under t/ appropiate time limit.External or Independent Grievance SystemsAllows claimants to take disputes w/their h/plan to a doctor or review board unaffiliated with their h/plan. Claimants can file a complaint against their health insurer w/their states department of ins.Handling Procedures (Note:)improperly handled claims for preexisting conditions are a frequent source of complaints and lawsuits(Handling Procedures) An examiner has an obligation to : 1*Investigate thoroughly, at t/earliest appropiate time, preferably on t/1rst claim if expenses result from an injury incurred after t/effec. date of t/plan or r not chronic.(Handling Procedures) An examiner has an obligation to : 2*Notify t/member & provider of t/delay in writting.(Handling Procedures) An examiner has an obligation to : 3*Bring t/investigation to a conclusion as rapidly as possible with a t/decision 2 pay or a fully documented denial.Treatment Free Provisions: Qualify 4 Pymt.2 qualify 4 payment on t/basis of having satisfied t/tx-free provision & t/total limitation (no payment of preexisting conditions 4 12months), it must b determined that the pt did not receive any tx 4 t/preexisting condition form a doctor, hospital, clinic, or other practioner.Treatment Free Provisions: DeterminingIt must b determined that the pt did not receive any tx 4 t/preexisting condition form a doctor, hospital, clinic, or other practioner. is *Advice w/o-tx is tx.How 2 determine a condition is preexisting: 1*Identify all potential preexisting conditions by noting t/diagnosis & t/length of time between t/effec date of t/plan and t/1rst tx documented on t/claim form or in t/claim file.How 2 determine a condition is preexisting: 2*initiate t/investigation as soon as appropiate by writting to t/attending physician and all other consulting or referring phsicians whose names can b determined.MandatesR laws enacted by states that require ins. carriers to cover certain services or dependents or services provided by certain providers.Mandates forms: 1* The ins. carrier is required to provide t/coverage as part of all plans offered by the carrier;Mandates forms: 2* The ins. carrier within the state must offer the benefit. It is not required to b part of a standard policy.Mental Health Parity Act: (act passed)In 1996 t/federal government passed the Mental Parity Act.Mental Health Parity Act: (equal coverage)States; group ins. plans 4 employers w/more than 50 employees must provide parity (equal amount of coverage) between t/benefits for mental health tx & 4 medical/surgical tx.