Open Enrollment Support: Making Choices for Tomorrow
- Educate about health and ancillary health plan benefits and changes
- Compare health plan options and differences
- Find answers to questions not addressed in open enrollment materials
- Help with navigating on-line enrollment systems
- Locate network doctors, hospitals and ancillary services in new plan
- Help with transitional care issues such as prior-authorization, medical record transfer, changing formulary, and maintaining appropriate supply of maintenance drugs
- Assist with enrollment and eligibility issues, such as obtaining ID cards
- Find health coverage for out-of-area family members
Health Benefits Education and Troubleshooting: Maximizing Healthcare Dollars
- Educate about healthcare benefits, coverage, terms and concepts
- Explain cost advantages of using network providers
- Help get plan approval for non-network providers when services not available through network providers
- Promote wellness programs, EAP’s, health risk appraisal programs and other health management programs offered by health plan or employer
- Obtain referrals and authorizations for required services
- Coordinate benefits with spouse’s plan or between health and ancillary health vendors
- Troubleshoot pharmacy issues including tiered Rx benefits and mail order
- Support with appeals and grievances
Doctors & Hospitals: Finding and Getting Care
- Find doctors, hospitals and ancillary services using health plan’s on-line tools
- Confirm provider network status and scope of practice
- Provide quality and outcomes data to help decision-making
- Estimate cost of care before treatment
- Help arrange appointments and transportation when needed
- Troubleshoot prior authorization issues
- Assist with formulary or point-of-sale eligibility problems at the pharmacy
- Engage with health plan and hospital to ensure optimal care coordination, home care and discharge planning
Clinical Advocacy: Building a Pro-Active Healthcare Consumer
- Arrange second opinions
- Review disease-related educational materials with a registered nurse
- Help participants understand treatments, tests and procedures recommended by their doctors
- Learn about clinical trials, medication/prescription subsidy programs and community-based support groups
- Locate physicians, hospitals, quality data, centers of excellence and home healthcare
- Prepare for doctor visits and surgeries with checklist of questions to ask
- Engage participants in under-utilized health plan resources: disease management, wellness and clinical decision support tools
- Help address quality of care concerns and provide appeals and grievance advice
Claims Assistance: Troubleshooting Medical Bills
- Educate about claims process and understanding explanations of benefits
- Advocate for employee to correct claims errors (deductibles, copays, application of network discounts, UCR’s and COB)
- Negotiate out-of-network provider fees or non-covered charges
- Retroactive audit of bills and statements
- Coordinate with health plans, medical groups, doctor’s offices, hospitals and ancillary providers to resolve billing disputes and inappropriate balance billing
- Work with provider offices to resolve claims submission and coding errors
- Help with claims denials and appeals
- Troubleshoot issues with collections agencies
Retiree Support: Medicare and More
- Educate about Medicare and how it interacts with employer-sponsored health plans
- Assist with eligibility and enrollment process
- Give guidance to common healthcare considerations facing retirees and pre-retirees
- Help arrange appointments and transportation when needed
- Troubleshoot coordination of benefits with Medicare
- Help understand formulary, tiered Rx benefits and mail order
- Provide information on community services for social and financial support
- Locate nursing homes and long term care options
Healthcare Resources: Expert Help when Your People Need It Most
- CareCounsel Tip Sheets on a broad range of healthcare topics
- Disease and condition-related information and support groups
- National and local advocacy groups
- Prescription subsidy programs
- Low-cost transportation options
- Individual health plan options
- Publicly-funded insurance options
- Reputable and unbiased Internet health resources
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