Skip to main content

Health Benefits FAQ

On October 17, 2018, the PEA leadership and district leadership met at LaNeve’s to discuss the issues and concerns of the Union membership regarding the self-insured Medical and Prescription Drug Plan.

Members voiced their concerns, and I decided to place them into categories. Over 150 members participated, and 40 members spoke about their experiences with the self-insured Medical and Prescription Drug Plan.

Liberty Consulting Firm has provided the following information:

The categories are as follows: (Click on title for information)

  • Patient receives treatment from the out-of-network provider
  • The provider presents a bill either to the patient following the treatment or sends the bill to the
  • Claims Administrator (TPA). This is the “billed amount.”
  • TPA makes payment based on the out-of-network fee schedule. This is the “allowed amount.”
  • TPA sends patient an Explanation of Benefits (EOB) detailing their cost sharing. Cost sharing is
  • Out-of-network provider accepts the allowed amount as payment in full or sends the patient a
  • balance bill. Balance bills include the difference between the allowed amount and billed
  • amount.

Out-of-network doctors do not have a contract with Cigna. Accordingly, there is no pre-set arrangement (fee schedule) for how much to pay out-of-network doctors. Out-of-network claims are reimbursed using a reasonable and customary fee schedule. When you exercise the benefit for the out-of-network option, you will be responsible for deductibles, coinsurance based on the reasonable and customary fee schedule, and any amount exceeding the reasonable and customary allowances for all services. Most out-of-network care is reimbursed at a percentage of the reasonable and customary allowance after an annual deductible is met.

The SEHBP is the only self-funded insurance carrier that does not provide new carriers with information regarding your previous copay, coinsurance, and deductible cost sharing. At the beginning of the plan year, the Paterson Health Plan provided information on how to obtain your cost sharing information from the SEHBP and send it to WebTPA. If you did not complete that process, WebTPA had to process your claims as though there was no member cost sharing achieved.

Out-of-network providers do not have a contract with the PPO Network, in this case, Cigna OAP. They are not bound by any contractual obligations, and such, can run their business however they choose. They may ask you to pay for their services before they are rendered, in part, or in whole. They may bill the Health Plan, or have you submit the bill on their behalf along with evidence of your upfront payment. This requires the TPA to get the needed information for the Health Plan to be able to reimburse you for payments made up-front and outside of your member responsibility.

Reimbursement request forms are located on the WebTPA WebPortal. Complete the form and submit along with evidence of your up-front payment (receipt or statement from provider showing your payment) and a copy of the invoice or claim from your provider including provider’s full name and address, date of service, member name, diagnosis code, procedure code and charges. For clean claims, typical reimbursement will be received within 30 days.

If you receive a balance bill from an out-of-network doctor, refer to the corresponding EOB you received from WebTPA, your claims administrator. At the bottom of the EOB, follow the directions by contacting NCN, at 866-835-4022 They will take your information including your name, ID number and specific claim information and reach out the provider on your behalf to negotiate a settlement.

New ID cards were mailed the week beginning 10/22/2018. The new ID cards contain your copay information on the back. It is important to note that your old ID will still work as well.

On the back of your ID card, under “Customer Service” the card reads “To verify Benefits, Eligibility, Obtain Claim Information or Pre-Certification or Referral call WebTPA: 866.259.5442 (option 4) or visit www.webtpa.com. Your doctor should NOT call Cigna or check through their own medical system to verify your benefits. Cigna provides access to their network, but does not provide your doctors with benefits, eligibility information or pay your claims.

  • Check in with the front desk and present them with your insurance card.
  • If they need to verify your benefits, this information is contained on the back of the card
  • If they request a copay, that information is now on the back of your card
  • Your doctor’s office should call WebTPA for additional information and should NOT call Cigna

Precertification is the process by which a third party determines whether or not a service is medically necessary. The services that are subject to precertification are outlined in the Plan Document and are equal to the requirements under the previous plan supported by the SEHBP.

Your prescribing physician must obtain a precertification before you are able to receive certain services. Your physician can obtain a precertification by following the instructions on the back of your medical ID card. If you schedule a service before you have your precertification, you run the risk of missing your appointment if the precertification process has not been completed.

Cigna Medical Management takes the lead to review the documentation supplied by your provider in order to make the determination of an approval. At times, additional information or clarification from your provider may be needed in order for Cigna to be able to offer an approval. When this is the case, a denial may be issued along with instructions for the provider to submit the missing or additional information needed. All approvals and denials will generate a letter to the provider and member including instructions about filing an appeal.

If a denial is received, you as the patient should reach out to the provider and have a discussion on next steps. Typically, the provider would act on your behalf to rectify the situation by submitting to Cigna the additional documentation requested for them to reconsider for precertification approval or initiate an alternate treatment plan.

There are many reasons why you may receive a bill. If you have received a surprise bill, please contact your on-site advocate at 855-402-5478.

In general, claims are paid within 30-45 days.

During the first two months of the plan year, there were ongoing negotiations between the business office and PEA. One of the major talking points was how to reimburse out-of-network doctors and how to provide members with resources to protect themselves from balance billing. During these ongoing negotiations, out-of-network claim payments were held until a final decision was made. All of these claims were processed and paid by 11/9/2018. If you have a question on the status of a specific claim, you can log in to the member WebPortal at www.webtpa.com or contact your on-site advocate assist by calling 855-402-5478

You can check to determine if your doctors are in the network by going to www.cigna.com or having your on-site advocate assist by calling 855-402-5478.

Submit the NJWELL paperwork you would have submitted to the SEHBP  to your on-site advocate, inperson at 90 Delaware, or via email at amartinez@crumdaleadvocates.com.

You are eligible to receive a flu shot at a participating in network pharmacy or your doctor’s office. If you receive a flu shot at your doctor’s office, it runs through the medical program, if you receive a flu shot at a participating in network pharmacy it runs through the prescription drug program.

Once a claim is finalized and the payment is released an EOP (providers statement) and EOB (member’s statement) are mailed. Member EOB’s will also appear on the member’s WebPortal by logging into www.webtpa.com. When there is no member responsibility (meaning the claim is covered by the Health Plan at 100%) no EOB is mailed. However, all EOB’s regardless if there is a member responsibility or not will still appear on the WebPortal. This is equal to the same practice followed by the previous Health Plan administered by Horizon BCBS and Aetna.

You do NOT need a referral for a specialist from your primary care provider if you are enrolled in any of the PPO or HDHP plans. You need a referral if you are enrolled in an HMO plan, the cards state “no referral required” but under any HMO, your primary care provider is the “gatekeeper” of all your services and you will need his expertise to see a specialist. If you do not have a referral under an HMO plan, your claims will be denied.

The Paterson Health Plan complies with DU31, P.L. 2003, c. 375, that permits young adults to continue coverage or become covered under a parent’s group health plan as an over-age dependent until the young adult’s 31st birthday. For more information about this law, please visit: https://www.state.nj.us/dobi/division_consumers/du31.html

Contact Human Resources. They will review with you the requirements for qualifying for this program and assist you with completing the enrollment form. HR will submit your enrollment for processing. Once enrolled, the member will receive in the mail the DU31 packet of information including the monthly premiums owed depending on the plan option they are eligible for. The monthly premium must be paid by the last day of the month in order for your coverage not to be interrupted. Once the first premium payment is received, the member’s new ID card will be issued.

If you have an issue or concern regarding your prescription drug insurance, call Express Scripts at 855-667-8682.

You have access to the largest Express Scripts formulary currently available. Over the counter drugs are not covered by Express Scripts, so those will be denied. Some drugs have “fill limits” on them, for example a 17 pill fill limit. Amounts exceeding that limit will be denied. Contacting Express Scripts at 855-667-8682 is the quickest way to get the issue resolved. If you require additional assistance, please contact your on-site advocate at 855-402-5478 and your care will be coordinated.

If your doctor was in-network with the SEHBP but out-of-network with Cigna OAP, you may do one of the following:

  • Continue to see that doctor, but as an out-of-network doctor, subject to out-of-network benefits
  • Seek care from an in-network provider

Coverage for DME is based on the plan in which you are enrolled and are equal to the DME benefits under the SEHBP plans. However, all plans require pre-certification for DME claims over $2,500.

If you had been pursuing the $250 incentive through the NJWELL program, you will be grandfathered in. Please submit the NJWELL Horizon BCBS or Aetna forms to your on-site advocate in person at 90 Delaware Avenue, or call your on-site advocate assist by calling 855-402-5478

As it was set up with Horizon BCBS and Aetna, WebTPA follows the same process. All EOB's are mailed to the member when there is a member responsibility associated with the claim. Additionally, all EOB's with and without member responsibility are also available on the WebTPA web portal.

Physical Therapy is a covered service subject to medical necessity. The only limit on physical therapy visits is the number prescribed by your doctor and the number deemed medically necessary. As is standard practice, the Physical Therapists provide the health plan with detailed treatment plans.

“Medically Necessary”, “Medical Necessity” and similar language refers a service or supply that the Plan determines meets each of these requirements:

  • It is ordered by a doctor for the diagnosis or the treatment of an illness or injury;
  • The prevailing opinion within the appropriate specialty of the United States medical profession is that it is safe and effective for its intended use, and that its omission would adversely affect the person's medical condition;
  • That it is the most appropriate level of service or supply considering the potential benefits and harm to the patient; and
  • It is known to be effective in improving health outcomes (for new interventions, effectiveness is determined by scientific evidence; then, if necessary, by professional standards; then, if necessary, by expert opinion).

With respect to treatment of substance use disorder, the determination of Medical Need and appropriate Level of Care shall use an evidence-based and peer reviewed clinical tool as designated in regulation by the Commissioner of Human Services.

Precertification/Preauthorization is defined as the process by which the eligibility and medical appropriateness of services or supplies is determined before services are rendered.

  • Once a claim is received by WebTPA after being sent from the provider, the plan requires processing within 45 days.
  • Claims in inventory awaiting processing are able to be viewed on the WebPTA web portal.
  • If a member has a question of when the claim will be processed or feels the claim has been in inventory past the 45 day, they can contact WebTPA to inquire by using the Customer Service number on the back of the ID card.
  • Providers must file claims with the TPA within one year and 90 days of the end of the calendar year in which services were rendered.

Claims are paid pursuant to the Plan Document. This document is required to be equal-to-or-better-than the SEHBP Plan Document (Guidebook). If you believe that a claim has been denied and should not have, please contact your on-site advocate at 855-402-5478. If it is supposed to be covered pursuant to the Plan Document, it will be covered. If it is not supposed to be covered pursuant to the Plan Document, it will not be covered.

Dependents 18 years or older must give permission to their parents in order for the parent to have access to their protected health information (PHI). Click here to download the request form.

  • Write or call Cigna to have your denial reviewed
  • If you request an appeal in writing, include the following:

          o A copy of your denial letter 
           
o Any other information you want Cigna to consider. You may have information Cigna did not have when the decision was made.
          o Mail your request to Cigna at: Cigna Health Management, P.O. Box 188062, Chattanooga, TN 37422-8062

  • Call Cigna at: 866-494-4872
  •  If you appeal, a doctor will review your request. This doctor doesn’t work for or report to the doctor who made this decision.
  • The reviewer will make a decision no later than 30 days from when Cigna receives your request.
  • Cigna will mail you a letter with the decision within 30 days of your request.

In certain cases, Cigna can make a decision more quickly – within 72 hours. This is called an expedited appeal. Your appeal may be expedited, if you haven’t had the health care service yet and you’re in one or more of these situations:

  • You’re appealing a denial to extend your hospital stay
  • Your health care professional believes a delay:

          o Might harm your life, health or ability to regain your full health
          o Would cause you severe pain that can’t be managed without the care or treatment you are requesting

Expedited appeals can be received by calling, writing, or faxing Cigna.

  • Call Cigna at: 866-494-4872
  • Mail your request to Cigna at: Cigna Health Management, P.O. Box 188062, Chattanooga, TN 37422-8062
  • Fax your request to: 877-804-1679
  • Make sure to write EXPEDITED on any written requests.

Virtual Credit Check (VCC) Payments are a convenient paperless payment method that allows providers to accept claims payments just like they would any other credit card payment. It is also mandated that electronic payments be made available per many state regulations. Should any provider be unable or unwilling to accept the VCC payment for any reason, they can simply contact the number provided on the EOP and a paper check will be generated and mailed.

  • Faster than a check. Pays in real-time, which is typically 10 days faster than checks.
  • Allows for payment and remittance advice to be delivered together.
  • Eliminates fraud. One-time secure payments reduce fraud, prevent sharing of account numbers, cannot be overcharged, and is trackable.
  • Complies with state regulations.
Other Resources

In addition to the answers provided above, Liberty Benefit Advisors is creating several YouTube videos that will address specific questions in greater detail.

 

The Paterson Public School District is also working on creating an online benefits webpage via the Paterson Public Schools mobile app which will include all relevant benefits information. The webpage will be routinely updated with new information, FAQs, enrollment forms, and general benefits information.

 

As of November 9, 2018, all out of network claims will be processed and payment will have been sent by the Paterson Public School District for claims that have exceeded the 45 day window.  A vast majority of those were processed on October 30 and provider payments were sent soon thereafter.

 

I will continue to intervene when necessary to ensure that these issues do not continue. I will remain in contact with President John McEntee regarding member’s concerns and follow through with Liberty Benefit Advisors.