Frequently Asked Questions

What is a Third Party Administrator (TPA)?
Do I need a referral to see a specialist?
What is Utilization Review (precertification)?
What is Case Management?
How do I enroll a new dependent?
Why do you ask for Full-Time Student Status so often?
What is Subrogation?
What is Coordination of Benefits?
What is a Pre-Existing Condition?
What is a Certificate of Creditable Coverage (COCC)?

Q: What is a Third Party Administrator (TPA)?

A: An independent entity (third Party) that administers group benefits including claims processing, customer service and administration for a self-insured group. A TPA does not assume or underwrite risk.

Q: Do I need a referral to see a specialist?

A: No, you have direct access to specialists.

Q: What is Utilization Review (precertification)?

A: This is a formal review of treatment plans to ensure the appropriateness and quality of health care services being proposed. All inpatient admissions require a pre-certification and that certification will be provided by the Utilization Review company indicated on the back of your health plan identification ID card. Benefits may be denied if the pre-certification requirements detailed in your Plan Document are not followed.

Q: What is Case Management?

A: A process whereby covered persons with specific health care needs are identified and a plan that coordinates the number of services needed by the patient is developed. The process includes a standardized, objective assessment of the patient's needs and the development of an individualized service or care plan that is based on the needs assessment and is goal oriented. A nurse case manager from the utilization review company for your group is assigned to each case to build a patient/nurse relationship to assist the patient and family in coordinating the patient's health care needs.

Q: How do I enroll a new dependent?

A: You need to contact your Benefits Office and complete a form to add your new dependent. We will need a copy of a marriage certificate when adding a new spouse. We will need a copy of the Birth Certificate to add a new child. If the employee's name is not on the birth certificate, we will need a copy of a court order stating that the employee has financial responsibility, or custody, of the child.

Q: Why do you ask for Full-Time Student Status so often?

A: Per your Plan of benefits when a covered dependent reaches the age of 19, to continue on the Plan they must be full time student taking at least 12 credits at a accredited institution of higher learning. As students can enroll and disenroll each semester, we will ask for proof of Full Time Student Status each semester a claim is submitted for your covered dependent. If you can be pro-active and have your covered dependent go to the registrars or bursars office to obtain proof of enrollment we will put that in our eligibility system and that will speed up processing of claims we receive for your full time student dependent.

Q: What is Subrogation?

A: A procedure under which a health plan can recover from third parties the full or some proportionate part of benefits paid for a covered member if the action causing the condition that resulted in claims paid by the plan was the fault of another individual or entity.

Q: What is Coordination of Benefits?

A: A provision in your Plan of benefits that applies when a person is covered under more than one group medical or dental plan. The COB provision requires that payments of benefits be coordinated by all available plans to eliminate over insurance or duplication of benefits. When your AGA plan is secondary to your other Plan of benefits, the benefits payable under your AGA Plan will be either regular benefits or reduced benefits, which, when added to the benefits of your primary plan, will equal 100% of the Allowable Expense under your AGA plan.

Q: What is a Pre-Existing Condition?

A: Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person's effective date of coverage. Per Federal Law, if a covered person has more than a 63-day break in coverage prior to their effective date in their current Plan, the Pre-Existing Condition clause will apply only to conditions diagnosed or treated within a specified period immediately preceding the covered person's effective date of coverage. Benefits for those conditions or treatments will not be provided for a specified amount of time. Refer to your Plan Document for the specifics about the Pre-Existing clause of your particular Plan of benefits.

Q: What is a Certificate of Creditable Coverage (COCC)?

A: Under Federal Law, all group and individual health plans are required to provide their members or insured with a Certificate of Creditable Coverage when they disenroll. The COCC will provide your next plan administrator with the dates of your previous coverage. This is used to determine if the Pre-Existing Condition clause of your Plan of benefits applies. If the COCC shows a break in coverage of more than 63-days from the date of termination of your prior plan to your effective date in your new AGA plan, then the pre-existing condition clause will apply.