GVHR » Topics » XI. Administrative Policies

This excerpt taken from the GVHR 10-Q filed Nov 10, 2008.

XI.           Administrative Policies


A.            Enrollment Methodology


The Group’s human resource staff will enroll each new client group’s employees via the Group’s Benefit Election Form or other acceptable method (IVR or web application). On a [*] basis, the Group will present to BCBSF an automated enrollment file.  Enrollments will be accepted as submitted from the Group. BCBSF/HOI’s assigned Personal Service Representative (PSR) will review discrepancy reports produced from the automated enrollment file and work reports directly with the Group’s assigned staff member to resolve all enrollment(s) on a timely basis.


B.            Identification Cards

Identification cards will be issued by BCBSF/HOI to each member enrolled within [*][working days of receipt of the completed enrollment information.


C.            Terminations

Terminations are removed on the date of termination.  BCBSF/HOI will generate Certificates of Creditable Coverage (COC) and submit directly to each member at the address on file for all terminated contracts.


D.            HOI Primary Care Physician Assignment


If an HOI member does not choose a Primary Care Physician (PCP), BCBSF/HOI will assign a PCP based on the member’s home address.  A letter will be generated advising the member that a PCP was assigned and offering them the option to change if they so desire.  The member may call the customer service number on their identification card to initiate the change.  When a member changes their PCP, the effective date of the change is determined by the time of the month the change is requested.  If a member requests a change between the 1st and 15th of the month, the member is eligible to utilize the new PCP the 1st of the following month.  Changes requested after the 15th of the month, will be effective the 1st of the second month following the month the member made the request (Example:  PCP change requested January 20th.  PCP would be effective March 1st.)


E.             Eligibility

BCBSF/HOI and the Group have agreed to accept enrollment as determined by the Group in accordance with the Plan. An eligible employee and/or dependent must enroll within the initial eligibility period as determined in accordance with the Plan or wait until the next Annual Enrollment Period unless a qualified family or employment event occurs under which a member has an additional period to enroll under a Special Enrollment Period if set forth in the Plan.


1.             The Group’s Benefit Election Form


Each employee applying for coverage must complete a Benefit Election Form or be enrolled through the Gevity web application.


2.             Status Change Form








Any membership change, i.e., marriage, divorce, addition of newborns, etc., will require completion of a Status Change form (paper or through the Gevity web application).  The Group will retain adequate documentation of status change requests for a reasonable period of time in the event BCBSF/HOI requires copies to respond to an enrollment inquiry. All qualifying events have a notification timeframe mandated by the Plan.  To the extent allowed by State law, newborns will be covered back to the date of birth.


If changes are not submitted within the specified time frames, the member must wait until the next annual enrollment to make changes except under HIPAA requirements for special enrollment.


F.           COBRA


The Group has chosen to administer COBRA on an internal basis.  COBRA enrollment will be provided to BCBSF/HOI on a weekly basis directly to the assigned PSR of the Membership/Billing Area.  Unless otherwise stated, the Group will be responsible for all COBRA administration including notification requirements.  All previously stated enrollment guidelines will apply.


G.          Overage Dependent Status Verification


BCBSF/HOI is responsible for verifying overage dependent children’s eligibility status on at least an annual basis.  Any overage dependent who is no longer eligible will be reported to the Group so coverage can be terminated.


H.          Disabled Dependent Verification


BCBSF/HOI is responsible for verifying the disability status of overage dependent children on at least an annual basis.  Any overage dependent child who is no longer disabled will be reported to the Group so coverage can be terminated.


I.            Creditable Coverage


The Group will report to BCBSF/HOI the amount of creditable time to be applied to satisfy the pre-existing condition exclusion limitation for those members providing that information at time of eligibility.  If this information is not supplied, BCBSF/HOI will deny the impacted claim.  The denial advises the member that if they had previous coverage a credit may be applicable and to please contact customer service.  Once information is received and reviewed, the claim will be reprocessed and pre-existing condition limitation updated in their system.  The Group will not track creditable time in their system.


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