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

Program OverviewRead more »

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