Other Information

Coordination of Benefits

If you are covered under more than one insurance plan, health benefits will be coordinated for reimbursement. At no time should the combined reimbursement of all plans and your member cost share exceed 100% of charges. When this plan pays secondary, you will be responsible for your member cost share.

Primary and secondary benefits can depend on factors such as whether you are the head of contract or a dependent in those plans and whether the plan is an employee or retiree plan:

As a retiree, your health insurance coverage through your former employer is generally considered primary for you unless you have Medicare.
Your health plan may be primary for a period of time if you have Medicare due to end-stage renal disease.
If you are the head of contract in more than one retiree plan, the oldest plan is considered your primary coverage.
If your spouse has coverage through his or her employer, that coverage will generally be primary for your spouse and secondary for you.
Primary coverage on children is determined by which parent’s birthday comes earliest in the calendar year. The insurance of the parent whose birthday falls last will be considered the secondary plan. This coordination of benefits can be superseded if a court orders a divorced parent to provide primary health insurance coverage.

The plans require an annual verification of other coverage. This information must be returned to your health insurance carrier in order to process claims. Claims will not be processed until this information is received.

Coordination of dental benefits should be reviewed in each program’s certificate of coverage. Vision benefits do not coordinate with other plans.

Subrogation

The medical plan and The Tennessee Plan have the right to subrogate claims. This means that the medical plan and The Tennessee Plan can recover the following:

Any payments made as a result of injury or illness caused by the action or fault of another person
A lawsuit settlement that results in payments from a third party or insurer of a third party
Any payments made due to a workplace injury or illness

These payments would include payments made by workers’ compensation insurance, automobile insurance or homeowners insurance whether you or another party secured the coverage.

You must assist in this process and should not settle any claim without written consent from the Benefits Administration subrogation section. If you do not respond to requests for information or do not agree to pay the plan back for any money received for medical expenses the plan has already paid for, you may be subject to collections activity.

Fraud, Waste and Abuse

Making a false statement on an enrollment or claim form is a serious matter. Only those persons defined by the group insurance program as eligible may be covered. Eligibility requirements for retirees and dependents are covered in detail in this guide.

If your covered dependent becomes ineligible, you must inform Benefits Administration and submit an application within one full calendar month of the loss of eligibility. Once a dependent becomes ineligible for coverage, they cannot be covered even if you are under court order to continue to provide coverage.

If there is any kind of error in your coverage or an error affecting the amount of your premium, you must notify Benefits Administration. Any refunds of premiums are limited to three months from the date a notice is received by Benefits Administration. Claims paid in error for any reason will be recovered from you.

Financial losses due to fraud, waste or abuse have a direct effect on you as a plan member. When claims are paid or benefits are provided to a person who is not eligible for coverage, this reflects in the premiums you pay for the cost of your health care. It is estimated that between 3-14 percent of all paid claims each year are the result of provider or member fraud. You can help prevent fraud and abuse by working with your plan administrator to fight those individuals who engage in fraudulent activities. Please contact Benefits Administration to report fraud, waste or abuse of the plan. All calls are strictly confidential.

How You Can Help

Pay close attention to the explanation of benefits forms sent to you when a claim is filed under your contract and always call the carrier to question any charge that you do not understand
Report anyone who permits a relative or friend to “borrow” his or her insurance identification card
Report anyone who makes false statements on their insurance enrollment applications
Report anyone who makes false claims or alters amounts charged on claim forms

To File an Appeal

If you have a problem with coverage or payment of medical, behavioral health and substance use, or pharmacy services, there are internal and external procedures to help you. These procedures do not apply to any complaint or grievance alleging possible professional liability, commonly known as malpractice, or for any complaint or grievance concerning benefits provided by any other plan.

You should direct any specific questions regarding initial levels of appeal (the internal appeal process) to the insurance carrier member service numbers provided on your insurance cards.Benefits Administration is not involved in the appeal process. The appeals process follows federal rules and regulations and assigns appeal responsibilities to the carriers and independent review organizations.

Benefit Appeals

Before starting an appeal related to benefits (e.g., a prior-authorization denial or an unpaid claim), you or your authorized representative should first contact the insurance carrier to discuss the issue. You or your authorized representative may ask for an appeal if the issue is not resolved as you would like.

Different insurance carriers manage approvals and payments related to your medical, behavioral health, substance use and pharmacy benefits. To avoid delays in the processing of your appeal, make sure that you submit your request on time and direct it to the correct insurance carrier. For example, you or your authorized representative will have 180 days to start an internal appeal with the medical insurance carrier following notice of an adverse determination with regard to your medical benefits.

Appealing to the Insurance Company

To start an appeal (sometimes called a grievance), you or your authorized representative should call the toll-free member service number on your insurance card. You or your authorized representative may file an appeal/member grievance by completing the correct form or as otherwise instructed.

The insurance company will process internal levels of appeal — Level I and Level II appeals. Decision letters will be mailed to you at each level. These letters will tell you if you have further appeal options (including independent external review) and if so, how to pursue those options and how long you have to do so.