Question 1

I am a GBA member, why can’t I see my 2017 claims on the member portal?"

Accepted Answer

Coming soon! Be on the lookout for a new link that will take you to your 2017 claims. Meanwhile, if you have any questions about those claims, please call the Member Service number on the back of your ID card.

Question 2

Why is my claim denied?

Accepted Answer

Your benefits are applied using the terms and conditions of your employer’s health plan. Your explanation of benefits can be a helpful tool in determining why a claim is denied. Your Member Service team will be happy to help you understand how your claim was processed.

Question 3

Why is my provider refusing to see me when they say that my eligibility cannot be confirmed?

Accepted Answer

Most healthcare providers require all documentation and approvals to be in place at the time services are rendered. They have access to software and a Provider Service team to acquire your eligibility information.

Question 4

Why is my prescription being rejected at the pharmacy?

Accepted Answer

Some medications are subject to recent changes in legislation. Your pharmacist can call the Pharmacy Benefit Manager number on your card to learn why your prescription rejected and options.

Question 5

Why does it take so long to get reimbursed for my foreign medical claim?

Accepted Answer

You will receive Contract benefits for medical emergency or urgent care and treatment received outside the United States. Contract provisions will apply. Any care received must be a Covered Service. Please pay the Provider of service at the time you receive treatment and obtain appropriate documentation of services received including bills, receipts, letters and medical narrative. This information should be submitted with your claim, translated to English and American currency. All services will be subject to appropriateness of care. We will reimburse you directly. Payment will be based on Covered Services and based on the Maximum Allowable Amount. Assignments of benefits to foreign Providers or facilities cannot be honored.

Question 6

Why does it take so long to get a stop payment and reissue for my payment?

Accepted Answer

We are able to initiate a check tracer 30 days after the date of the check. It is important to update your address with your Human Resources office anytime you have a change of address.

Question 7

Can you please help me find an IN provider for my specific needs?

Accepted Answer

Sure. All we will need to know is which network the group/member is in and we can do a web search for a particular provider based on the location. We can even narrow the search to be per facility or medical specialty. If we are unable to locate it on the web, we have access to Network Representatives we can correspond with to see if they are able to locate an INN.

Question 8

My claim has been paid but my provider is still billing me, why?"

Accepted Answer

It is possible that your provider’s invoice has ‘crossed in the mail’ with our explanation of benefits. You can call Member Services to check on the status of your claim before remitting payment to your provider.

Question 9

How many routine services can I have each year?

Accepted Answer

Several factors apply to the benefits for routine care. Please refer to your Summary of Benefits to determine your policy benefit limits. You may also call Member Services for assistance.

Question 10

It’s getting close to the end of the year and I don’t have any more doctor’s appointments. What are some other items that I can use my FSA card for?

Accepted Answer

Bandages, braces, first aid kits, medical monitoring equipment and testing supplies (blood pressure monitors, syringes glucose kit, etc), contact lens solution, and batteries for hearing aids are a few suggestions.

Question 11

What items are eligible expenses for my FSA?

Accepted Answer

Please visit our Forms page.

Question 12

What is substantiation letter?

Accepted Answer

When we receive a charge that typically does not look like a co-pay, deductible amount, or looks like a questionable service provider, we send out a letter stating we need more information. Does not mean the service has not been paid, just that we need an itemized bill, EOB, or letter of medical necessity explaining the charge.

Question 13

Who pays my claims?

Accepted Answer

Your employer is self-funded for your health benefits. Your claims are “processed” by Paragon Benefits but your health benefits are “paid” by your employer.

Question 14

What is ERISA?

Accepted Answer

Employee Retirement Income Security Act – Passed in 1974, ERISA allows employer an alternate means of funding their medical and other employee benefit plans. Self-funded plans are governed by ERISA and not by the state. ERISA and self-funding allow a plan to be custom designed specifically for the workers of that employer, so the plan itself tends to be more personalized than those under state regulation.

Question 15

What is a PPO?

Accepted Answer

Preferred Provider Organization – A group of “participating providers” including without limitation, physicians, facilities, allied health care providers and ancillary health care facilities who have entered into an agreement to provide covered services on a “fee” basis.

Question 16

What is Reinsurance?

Accepted Answer

Reinsurance is coverage purchased which limits the plan’s liability against large claims and establishes a maximum claims cost for the plan. Stop Loss/Reinsurance contracts differ from a fully insured policy by the incurred period. Reimbursement is only covered if the claim is PAID during the contract year which covered claims incurred during a set period of time.

Question 17

What is Specific Stop Loss?

Accepted Answer

Specific Stop Loss limits the employer’s liability on any individual covered under the plan for the plan year. This coverage picks up after a member has had claims in excess of the “specific” deductible on a contract year basis. A rule of thumb: If you are unsure as to the amount of specific deductible needed, 10% of the annual claims are a good starting point.

Question 18

What is Aggregate Stop Loss?

Accepted Answer

Aggregate Stop Loss limits the annual claims liability on all participants for the plan for amounts under the specific stop loss limit. Generally, the aggregate stop loss attachment point is set at 125% of expected paid claims.

Question 19

What is a PBM?

Accepted Answer

Pharmacy Benefit Manager –The Pharmacy Benefit Manager is the carrier that you the client have chosen to administer your pharmacy/prescription drug benefits.

Question 20

What is Run-in?

Accepted Answer

These are claims that have dates of service prior to the beginning of the client’s plan year.

Question 21

What is COB?

Accepted Answer

Coordination of Benefits – Sets out rules for the order of payment when the patient has two or more plans, including Medicare, which is paying.

Question 22

What is UCR?

Accepted Answer

Usual, Customary and Reasonable – This is a charge which is not higher than the usual charge made by the provider of the care or supply and does not exceed the usual charge made by most providers of like service in the same area.

Question 23

What is HIPAA?

Accepted Answer

Health Insurance Portability and Accountability Act – Protects health insurance coverage for employees and their families when they lose or change jobs. HIPAA also has standards requiring that when personal data is being transmitted in any way, it is “scrubbed” to prevent fraud.

Question 24

What is COBRA?

Accepted Answer

Consolidated Omnibus Budget Reconciliation Act – A federal law requiring that most employers sponsoring a group health plan offer Employees and their families covered under their health plan the opportunity for a temporary extension of health coverage in certain instances where coverage under the Plan would otherwise end.

Question 25

What is a 12/12 contract?

Accepted Answer

Incurred in 12 months and paid in 12 months – does not cover any run-in or run-out.

Question 26

What is a 12/15 contract?

Accepted Answer

Incurred in 12 months and paid in 15 months – covers claims incurred in the plan year and paid up to 3 months after the end of the plan year

Question 27

What is a 15/12 contract?

Accepted Answer

Incurred in 15 months and paid in 12 months – covers claims incurred in the plan year and the 3 months preceding and paid in the 12 month plan year.

Question 28

What is an 18/12 contract?

Accepted Answer

Incurred in 18 months and paid in 12 months – covers claims incurred in the plan year and the 6 months preceding and paid in the 12 month plan year.

Question 29

What is a 24/12 contract?

Accepted Answer

Incurred in 24 months and paid in 12 months – covers claims incurred in the plan year and the 12 months preceding and paid in the 12 month plan year.

Question 30

What is a PAID contract?

Accepted Answer

Covers all claims paid, no matter the date of service, and paid in the 12 month plan year.

Question 31

What is self-funding?

Accepted Answer

Self-funding is an alternative yet effective approach that employers can use to gain greater flexibility and control over their health plan costs. Through self-funding, employers have the ability to take advantage of several benefits not necessarily available under a traditional fully insured program. Lower operating costs, increased cash flow, flexibility in plan design and enhanced claim management are many of the positive aspects of being self funded. In addition, employers often benefit from reduced premium taxes because most states tax only the stop loss premiums and not the self-funded claim fund.

Question 32

What is the difference between “Fully Insured” and “Self-Funded”?

Accepted Answer

A fully-insured plan is one where the employer pays a premium to an insurance company. The insurance premium is actuarially projected to cover anticipated claim costs and the insurance company’s overhead, commission, reserves, risk charges and taxes. All premiums paid by the employer to the insurance company after expenses are paid become the insurance company’s profits. A self-funded plan is one in which the employer assumes some or all of the risk for providing health care benefits to employees. Claims are processed by a Third Party Administrator (TPA).

Question 33

What is an Aggregating Specific Deductible?

Accepted Answer

A deductible that the employer is responsible for all claims over the stated Specific deductible up to a certain amount (the Aggregating Specific deductible). In return, the self-funded employer receives a certain amount of premium relief for sharing in the claims risk of the Aggregating Specific.

Question 34

What is Aggregate Accommodation?

Accepted Answer

An optional component of the Aggregate Excess Loss Insurance. The Aggregate Accommodation provides money to the Employer's health plan account during any month in which accumulated self-funded paid Losses (claims) exceed a pre-determined amount (usually by $2,000). Should accumulated claims in future months fall below the year-to-date accumulated claims liability maximum, the employer will repay the advance up to the accumulated maximum claims liability.

Question 35

What is Aggregate Excess Terminal Liability?

Accepted Answer

If at the end of a Certificate Period the insured terminates its self-funded plan, the Aggregate Deductible and the Loss Claim Basis for the Aggregate Excess Loss Insurance will be modified similarly as follows:The Loss Claim Basis means, for the Certificate Period, only the actual amount of benefits incurred by a Person during the Certificate Period and paid during the Certificate Period or within 90 days immediately thereafter.The revised Aggregate Deductible will be the sum of: (a) three times the twelfth month Accommodation Point, plus (b) whatever the Aggregate Deductible would have been for the Certificate Period if the insured had not terminated its self-insured Plan.*

Question 36

What is Specific Advance?

Accepted Answer

Spec (Specific) Advance is an endorsement by the reinsurance carrier to help the employer pay large dollar claims. After a member has met their specific deductible, the reinsurance carrier will reimburse for claims over the specific deductible prior to the employer funding the claims.

Question 37

What services are offered in your COBRA fee?

Accepted Answer

Generate COBRA notification letters and enrollment forms, calculating the period due, required by law. Give each family member the right to say “yes” or “no” to each benefit plan, as is required by law.
Track secondary events for QBs (Qualified Beneficiaries) with spouse and or dependents.
Track the enrollment period and first payment period for each QB, and print a termination letter if enrollment forms or payments are not received within the proper time frame.
Provide premium payment coupons for all QBs.
Calculate the 2% administrative fee (allowed by law).
Prorate premiums for the first and/or last COBRA month, where applicable.
Print letters to all plan participants telling them the new rates and provide them with new premium coupons when you have premium rate changes.
Provide a spectrum of reports allowing quick and easy explanations of COBRA administrative activity.
Generate a periodic eligibility confirmation letter quarterly.
Generate a letter telling QBs when their COBRA term is nearing an end, then generate another letter after the expiration of the 18, 29, or 36 month COBRA period confirming that they are no longer covered.
Generate a letter when a QB turns 65, reminding them of Medicare eligibility.
Generate a letter confirming address change (if applicable).
Generate a letter if a check is returned as N.S.F. (non-sufficient funds).
Generate late payment notices.
Generate labels for envelopes for COBRA letters if applicable.

Question 38

Where can I obtain benefit information?

Accepted Answer

A copy of your Summary Plan Description is available on the Paragon Benefits website.

Question 39

How do I obtain an ID Card?

Accepted Answer

Call Paragon Benefits at (800) 277-9218 and request an additional card be mailed.

Question 40

Who should my provider contact if I am being admitted to the hospital?

Accepted Answer

Your provider should call the number on the back of your ID Card.

Question 41

Where are claims mailed?

Accepted Answer

Claims are mailed to the address on your ID Card.

Question 42

Why does your website disable my account?

Accepted Answer

After three failed login attempts the account is locked out until Customer Services is called to have it re-enabled.

Question 43

I’ve retired and my COBRA letter says I don’t have coverage, but I submitted my paperwork for my retirement coverage and it was accepted. I don’t understand?"

Accepted Answer

If you look towards the bottom of the first page of your COBRA enrollment form it states that “if you have elected the retirement plan with Fulton County please disregard this notice”. If you have confirmation from Fulton County that your benefits have been activated as a retiree, you can disregard our COBRA notice. You can contact your benefits administrator at Fulton County for further confirmation, if you would like.

Question 44

The premium on this COBRA enrollment form is a lot higher than what I paid when I was employed with ____. Is this the premium for the whole year?

Accepted Answer

No, the premiums listed on the COBRA enrollment form are monthly premiums. As an active employee, the company you worked for funded most of your insurance premium and what came out of your paycheck was just your employee contribution. Because you are no longer actively employed, it is your responsibility to fund the full premium for the same coverage you had as an active employee.

Question 45

How long can I keep my COBRA?

Accepted Answer

You are eligible for 18 months of COBRA if your termination was voluntary, involuntary, if you were laid off, if your FMLA expires, if you were the employee and you retire, or your hours are reduced so you are no longer considered a full time employee. Dependents are eligible for up to 36 months in the event of a divorce, legal separation, if the member enrolls in Medicare and employee drops coverage, if a child dependent reaches maximum age, or in the event that the employee dies.

Question 46

We have an employee who terminated during open enrollment. Why didn’t they receive a COBRA notice?

Accepted Answer

Open enrollment is the time for members to make changes to their plans without qualifying events. Due to this member terminating their coverage without a qualifying event, they are not eligible for COBRA coverage.

Question 47

I have lost my insurance card. How long will it take to get another one?

Accepted Answer

I can request one today and we send cards out weekly. (Depending on the day of the week the member calls to request their card, we are able to get them mailed out within 5-7 days. Also depending on the client, some cards will be mailed straight to the member’s home, and some go to the HR.)

Question 48

I am on COBRA and I have just had a baby. Am I able to add my baby to my plan?

Accepted Answer

Yes, the birth of a child is a qualifying event to make a change to your plan. We can add the baby, but your premium will go up.

Question 49

I just received a letter talking about COBRA but I don’t know why you sent this to me. I just got hired with my company. Did you terminate me?

Accepted Answer

No. The letter you’ve received is just a 4-page notice explaining your rights to COBRA continuation coverage in the event that you experience a voluntary or involuntary termination or any other event that’s listed in the packet. The first sentence reads “You are receiving this notice because you have recently been covered under the above employer group health plan.” At the time that you experience a COBRA Qualifying event and we are notified by your employer, you will receive further information so that you may enroll in continuation coverage.

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