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Frequently Asked Questions |
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| Q: | What are the customer service telephone numbers for the Cleveland Clinic EHP, Cleveland Health Network, Antares, Marymount Behavioral Health Services, CVS Caremark, SummaCare Health Plan EPO, and Kaiser Permanente HMO? |
| A: |
Cleveland Clinic Corporate Employee Health Plan Administrative Office: 216-448-0800 or toll-free 1-866-811-4352 Cleveland Health Network: 216-986-1050 or toll-free 1-888-246-6648 Antares Management Solutions: 1-800-451-7929 Marymount Behavioral Health Services: 216-986-1190 or toll-free 1-877-677-2247 CVS Caremark (Pharmacy Benefit Manager): 1-866-804-5876 SummaCare Health Plan: 330-996-8515 or toll-free 1-800-996-8701 Kaiser Permanente: 216-621-7100 or toll-free 1-800-686-7100 |
| Q: | When do I need to provide proof of eligibility? |
| A: | Upon enrollment of your dependents in any of Cleveland Clinic's benefit plans, proof of eligibility is required. If you enroll during the Open Enrollment period, our consultant, Willis, Inc., will contact you to provide the necessary documentation. Failure to produce the documentation will result in the termination of your dependent(s) coverage back to the effective date of coverage. If you have a life event change, i.e., marriage, birth of child, etc., documentation is required before the dependent will be added. |
| Q: | Is payroll deduction available for co-payments? |
| A: | All Cleveland Clinic and Regional Hospital EHP members (not Summa or Kaiser) are able to pay office visit co-payments through payroll deduction at the time the service is received at Cleveland Clinic Main Campus or the Regional Medical Practices only. At check-in, you must present your employee ID badge. The Patient Service Representative (PSR) will have you sign the co-pay receipt. If you would like your dependent's co-payment to be processed through payroll deduction, the employee must be present to provide their ID badge and sign the co-pay receipt. Otherwise, payment will need to be made via cash, check or credit card. |
| Q: | Is there a difference between a co-payment and co-insurance? |
| A: | Yes. Co-payment is a specific dollar amount paid at the time the medical services are rendered. Co-insurance is the percentage required to be paid when covered benefits are less than 100%. This amount is usually billed to the patient and accrues toward the annual out-of-pocket maximum and/or annual deductible. |
| Q: | Is there a co-payment for Primary Care Provider (PCP) and/or Specialty visits? |
| A: | If you seek services from a Tier 1 PCP, you are covered at 100% with NO co-payment. Physician specialties considered primary care include Family Practice, Internal Medicine, Gynecology, Obstetrics, and Pediatrics. All other physician specialties are reimbursed at 100% after a flat $35 co-payment per visit. You do not require a referral to see a specialist. |
| Q: | Why was I charged a $35 co-pay to see my Primary Care Physician (PCP)? |
| A: | Some PCP's provide specific specialty services and only see patients for that service, i.e., women's health, breast health. |
| Q: | Is there a co-payment for tests ordered by a specialist? |
| A: | No. The member is only responsible for the co-payment for the specialty office visit. |
| Q: | What does the term "allowed amount" mean? |
| A: | Negotiated charges for allowed healthcare services as described in the Cleveland Clinic EHP Summary Plan Description (SPD). |
| Q: | Do I need to register each time a family member or myself receives services? |
| A: | Yes. At the time of every healthcare appointment, you should present your medical I.D. card(s) to the registrar. The registrar will confirm that all information is updated in the system as it relates to that particular visit. |
| Q: | How do I add a new dependent (spouse, newborn, etc.) to my health plan? |
| A: | You must call your Human Resources representative within 31 days of a life event change to add your dependent to your health plan coverage. If you do not notify your Human Resource representative, the child will not be covered for any charges incurred. Please refer to Section One of your Summary Plan Description for Coverage Options and Life Event Changes. |
| Q: | Who should I contact to change my address? |
| A: | Notify your supervisor/manager when you have a change of address. Your supervisor/manager must complete the Employee Data Change Form located on the Human Resources Web site. |
| Q: | If I am covered by more than one health plan, can I decide which health plan pays primary? |
| A: | No. Coordination of Benefits (COB) is the procedure used to pay healthcare expenses when you or an eligible dependent is covered by more than one health plan. If you/your dependents are covered by more than one health plan, the Cleveland Clinic EHP Third-Party Administrator (TPA) follows rules established by Ohio law to decide which health plan pays first (primary plan) and how much the other healthcare plan (secondary plan) must pay. The combined payments of all healthcare plans will not exceed the actual amount of your bills. For more information about COB click here for Section 2 of the Summary Plan Description. |
| Q: | I did not receive my Cleveland Clinic Employee Health Plan (EHP) Summary Plan Description (SPD). |
| A: | Contact the Cleveland Clinic EHP Customer Service Unit (CSU) to have a SPD mailed to you. |
| Q: | If I select the Cleveland Clinic EHP, do I need a referral from my PCP to see a specialist? |
| A: | No. Although it is recommended you have a designated PCP, you do not need a referral to see a specialist. |
| Q: | Do I have to choose a tier at the time of enrollment? |
| A: | No. The Cleveland Clinic EHP offers a two tier Network of Providers. As a Cleveland Clinic EHP member, you can use either provider tier at anytime throughout the benefit year and may see providers in both tiers if you choose. The tier you select, however, determines the amount of coverage you will receive. To receive maximum coverage, you must use Tier 1 Providers. |
| Q: | Where can I find a list of participating providers? |
| A: | It is the employee’s responsibility to verify and obtain the most current Tier participation each time services are obtained. The most current Tier 1 and Tier 2 Provider information can be found on the Internet at the CHN Web site: www.chnetwork.com and clicking on “EHP.” The Cleveland Clinic EHP does not print a hardcopy Provider Directory. If you do not have access to a Web site you can either call Antares Management Solutions at 1-800-451-7929 or the Cleveland Clinic EHP Customer Service Unit (CSU) at 216-448-0800 or toll-free at 1-866-811-4352 and request a listing of doctors in your geographic area by physician specialty. |
| Q: | Where can I find the locations of the Family Health and Surgery Centers? |
| A: | You can log on to www.clevelandclinic.org then click on the "Locations" tab. |
| Q: | What charges are applied to my out-of-pocket maximum? |
| A: | In Tier 1, all co-payments accrue to your annual out-of-pocket (OOP) maximum. Your Prescription Drug benefit has its own OOP maximum so co-payments for that service do NOT accrue to your Cleveland Clinic EHP OOP maximum. In Tier 2, Ancillary services will reimburse at the Tier 1 benefit level after the deductible and any applicable co-payments are met. Ancillary co-payments and co-insurance do not accrue to the annual deductible or OOP maximum. |
| Q: | What is my benefit for Urgent Care and Emergency Care? |
| A: | Emergency and Urgent Care are covered at 100% regardless of the provider as long as the visit meets emergency or urgent care criteria. Criteria and definitions can be found in Section Six of your SPD. A $50 co-payment is applicable for any Emergency Department visit that does NOT result in an admission. Observation stays in the hospital are NOT considered admissions. |
| Q: | Does the Cleveland Clinic EHP cover routine eye examinations? |
| A: | Yes. One routine (annual) vision examination is covered in a 12 month period in the Cleveland Clinic Tier 1 Network. Examinations are not covered under the Cleveland Clinic Vision Plan. The Vision Plan covers hardware only. Services for contact lenses and lens fittings are not a covered benefit unless the contact lenses are required because of an ophthalmologic condition that cannot be corrected by glasses. |
| Q: | What if I do not agree with the Appeal decision of the Third-Party Administrator (TPA)? |
| A: | If the situation is not resolved to the employee’s satisfaction through the TPA appeal process, the employee should contact the EHP Customer Service Unit (CSU) at 216-448-0800 or toll-free at 1-866-811-4352. Before calling, the employee must have all the information and paperwork sent to and received from the TPA as well as the name and phone number of the contact person at the TPA. The EHP CSU will instruct the employee on the next steps to take to resolve the issue and can provide you with the appropriate Appeal Form. |
| Q: | What is the eligibility criteria for infertility coverage? |
| A: | Member must be a participant in the EHP for a minimum of two consecutive years. Detailed information regarding coverage can be found on page 28 of your Summary Plan Description. |
| Q: | What is the eligibility criteria for bariatric surgery? |
| A: | Member must be a participant in the EHP for a minimum of two consecutive years. Predetermination is required through the EHP Medical Management Department. The member must call Medical Management when the workup begins to initiate the predetermination process. Click here to see page 27 of the Summary Plan Description for more detailed information on required criteria. |
| Q: | What procedures require member responsibility for predetermination? |
| A: |
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| Q: | Is predetermination required for occupational, physical, or speech therapy? |
| A: | There are no predetermination or medical necessity requirements. Occupational, Physical, and Speech therapy is covered at 100% of the allowed amount after a $10 co-payment per visit. There is a limit of twenty-six (26) visits per therapy per benefit year. |
| Q: | Cleveland Clinic EHP is my secondary insurance. Will Cleveland Clinic EHP pay my primary insurance co-payments? |
| A: | No. A co-payment is the employee/member responsibility and will be collected at the time of service. |
| Q: | How do I obtain authorization for outpatient behavioral health/substance abuse services? |
| A: | In order to complete prior authorization, the patient must contact Marymount Behavioral Health Services (MBHS) on or before their appointment date at 216-986-1190 or toll-free at 1-877-677-2247 and receive authorization from MBHS to initiate treatment. If the initial authorization is not completed, the patient has financial responsibility for the charges associated with the visit. Referrals directly from one practitioner to another, whether in the Cleveland Clinic Network or not, do NOT qualify as a prior authorization. Referrals given to the Cleveland Clinic EHP member by their Primary Care Provider (PCP), Pediatrician, or CONCERN® counselor do NOT qualify as prior authorization. After treatment has been authorized and the patient has begun the visits, it is the behavioral health provider’s responsibility to forward treatment plans to MBHS at the required intervals so that coverage for the visits will continue. |
| Q: | Do I have a co-payment at time of visit for behavioral health/substance abuse services? |
| A: | Yes. In Tier 1 – 100% coverage after a $35 co-payment. In Tier 2 – 100% coverage after a $50 co-payment. With the exception of emergency situations, there is NO benefit coverage for Behavioral Health Service if an employee seeks services outside of the Tier 1 or Tier 2 Provider Networks. |
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