COVERAGE / PROOF OF COVERAGE
DOCTOR / PPO NETWORK
HOSPITAL / EMERGENCY ROOM
PRESCRIPTION DRUG
CLAIMS
What coverages does an Employee have under the Plan?
There are a variety of coverages under different Plans. Inasmuch as PlatinumPLUS offers a number of Plans, some customized, an employee should read and become familiar with the Certificate of Insurance and the other descriptive and informational documents. If, for some reason the employee does not have their Certificate of Insurance, then the easiest method to obtain the information is to either contact the employer; or, if this is not possible, then contact the AARBIS Service Center toll free number (866) 604-6445, Monday through Friday (except on Federal holidays) between the hours of 9:00 A.M. and 5:00 P.M. Pacific Standard Time. The Employee can also email AARBIS at customerservice@aarbis.com.
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Where does the Employee get specific information regarding coverage benefits (visits, benefit schedules, et cetera)?
The Employee should first look in their Certificate of Insurance and Employee Guide. The Employee can also call the AIG Claims Customer Service Department at the telephone number printed on the Employee’s Medical Identification Card: (877) 503-9095. A representative will be available between the hours of 5:00 A.M. and 5:00 P.M., Monday through Friday, Pacific Standard Time.
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What if an Employee has lost or misplaced the Certificate of Insurance?
The simplest thing would be to contact the Employer and ask for a copy. The Employee can also contact the AARBIS Service Center at (866) 604-6445 or email AARBIS at customerservice@aarbis.com. The Service Center is active 5 days per week, exclusive of holidays, between 9:00 A.M. and 5:00 P.M. Pacific Standard Time.
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What if, for whatever reason, the Employee does not have an Employee ID Card?
If the Employee has lost or misplaced the Employee Identification Card, then the Employee should either telephone the AARBIS Service Center or email customerservice@aarbis.com to request a replacement card.
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How does an Employee locate a network doctor or facility in the Employee’s area?
To locate a doctor or facility, the Employee can search on line at the PPO Network or telephone the PPO Network at the toll free number provided (click on the Customer Service button). The web address and the telephone number are also to be found in the Employee Guide. If all else fails, then the Employee can contact the AARBIS Service
Center by telephone or by email at customerservice@aarbis.com.
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Can an Employee see a doctor or go to a facility of his or her own choosing?
Yes and no. Authorization is required in order to see a licensed physician and to receive treatment. PPO network discounts are only available if a PPO network doctor or hospital is chosen.
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What must an Employee do to see an in-network PPO doctor?
If the Employee has a current Employee Identification Card, then simply call the doctor and make an appointment.
The Employee should review the Employee Guide for instructions on where and how to file a claim to obtain payment of the covered benefit.
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What must an Employee do to see a non-network doctor?
The Employee should simply call the doctor and make an appointment.
The Employee should review the Employee Guide for instructions on where and how to file a claim to obtain payment of the covered benefit.
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What should the Employee bring along to the doctor's office?
Your PlatinumPLUS ID card and a claim form. The Employee should become familiar with the “Filing of a Claim” Section in the Employee Guide.
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How much are the PPO network discounts?
PPO network discounts vary from each individual doctor, medical group, facility and hospital. You may obtain the discounts by contacting the AIG Claims Office or the Provider. Please note that Providers have many contractual relationships and may not be able to quote you discounts amounts.
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What is assigning benefits?
Insured can choose to assign or not assign benefits.
Assigning benefits means the employee is authorizing the insurance company to pay the insurance benefits directly to the medical provider.
When benefits are not assigned to the provider benefits are paid directly to the Employee.
Employees can choose to assign or not assign benefits by checking the appropriate box on a Claim Form.
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What should an Employee pay if the benefits are NOT assigned?
An Employee will pay the (full) charges according to the individual Provider’s billing and payment policy. Request an itemized bill from the Provider and submit a claim following the claim procedures provided in the Welcoming Kit.
The benefit payment and an Explanation of Benefits (EOB) will be sent promptly after the claim is adjudicated by AIG Claims Service.
If a PPO Provider is utilized, the EOB will show the applicable discounts to adjust the amount owed to the Network Provider.
Billing and payment for service requirements vary from each individual doctor, medical group, facility and hospital. In non-emergency situations please inquire with the provider’s office as to their billing and payment practices, when an appointment is made.
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How much does an Employee pay if the Employee has assigned his/her benefits?
If the Employee assigns benefits, (Employee gives the Provider a signed Claim Form with the assignment of benefits box checked), the Provider will file the claim and typically bill the Employee the net amount due after the claim is adjudicated. The Employee and the Provider receive copies of the Explanation of Benefits showing the amount due, as well as the Network discount if a Network PPO provider was utilized.
Billing and payment requirements vary from each individual doctor, medical group, facility and hospital. In non emergency situations please inquire with the provider’s office as to their billing and payment practices at the time an appointment is made.
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What if the Employee believes they did not receive the proper PPO discount?
The Employee should review their Explanation of Benefits from the AIG Claims Office and then contact the AIG Company Claim Service Office toll free number at (877) 503-9095 or toll free FAX the Claim Office at (877) 514-5206.
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What if the doctor has never heard of AIG/National Union Fire Insurance Company, AARBIS or PlatinumPLUS?
It is highly unlikely that the doctor or facility has never heard of AIG Companies / National Union as AIG is the largest insurer in the nation and does business in every State and the District of Columbia. AARBIS (“American All Risk Benefit Insurance Services”) is headquartered in San Francisco and may not be known widely. PlatinumPLUS is simply the name that AIG Companies / National Union and AARBIS have given to its product.
If a Provider has questions regarding the PlatinumPLUS Plan that the Employee cannot answer, contact information is contained on the Employee ID card and Claim Form so that the AIG Claims Office, the PPO Network or AARBIS can be contacted.
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Can an Employee simply show up at an Emergency Hospital / Room?
If the Employee requires emergency care, then most certainly the Employee should call 911 or immediately seek care. AARBIS recommends that the Employee identify the closest emergency facility and determine which of them are in the PPO network (so that the Employee is eligible for the Network discount). Again, in an emergency, do what is required to obtain immediate treatment. Gaining permission is not required.
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How does the Employee pay for an Emergency Hospital / Room visit?
Billing and payment requirements vary from each individual doctor, medical group, facility and hospital. Many emergency facilities require full payment for services because they cannot verify eligibility or insurance benefits in emergency situations.
The payment and claims adjudication will follow the procedures outlined for assignment and non-assignment of benefits and the utilization of a PPO Emergency Room or use of a non-network facility.
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Can the Employee go directly to the hospital?
Yes, authorizations or referrals to be admitted to a hospital or to receive a treatment are not required by the PlatinumPLUS Plan.
NOTE: The scheduled benefit for in-Hospital stays is paid for both the admission and then on a per day of hospitalization basis. There is a limit to the number of admissions and days available per year under the Plan.
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Do the monetary benefits for Hospital stays apply to ICU stays?
If the “Intensive Care Unit” benefit is included in the schedule of benefits under the Certificate of Insurance, the ICU benefit is paid in addition to the in-Hospital per day benefit. There are limits per year on both the in-hospital and the ICU benefits.
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What exactly must the Employee do to go to a Hospital?
If the Employee has in-Hospital coverage under the Plan, then the Employee should simply contact the facility directly and go through the facility’s normal admittance procedure. If the Employee chooses a facility that is NOT in the selected PPO Network, then the Employee would not be eligible to receive the Network discount
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How does the Employee pay for the Hospital stay?
If the Employee assigns benefits, (Employee gives the Hospital a signed Claim Form with the assignment of benefits box checked), the Hospital will file the claim and typically bill the Employee the net amount due after the claim is adjudicated. The Employee and the Provider receive copies of the Explanation of Benefits showing the amount due; and, if a PPO provider was utilized, the applicable Network discounts.
If the Employee does not assign the Employee’s Plan Benefits, an Employee will pay the (full) charges according to the individual Provider’s billing and payment policy. The employee should request an itemized bill from the Provider and submit a claim to AIG Claims following the claim procedures provided in the Welcoming Kit.
The benefit payment and an Explanation of Benefits (EOB) will be sent promptly after the claim is adjudicated. If a PPO Provider is utilized, the EOB will show the applicable discounts and adjust the amount owed to the Network Provider.
Billing and payment requirements vary from each individual doctor, medical group, facility and hospital. In non-emergency situations, at the time of admittance, the employee must inquire with the facility as to their billing and payment practices.
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Does the employee have an outpatient Prescription Drug Benefit?
To determine if Prescription Drug Benefits are included in an Employee’s Plan, check the Certificate of Insurance under Outpatient Prescriptions Drugs.
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What exactly does the Employee receive with an outpatient Prescription Drug Benefit?
The PlatinumPLUS prescription Drug Benefit combines a scheduled benefit payment with discounts on brand and generic drugs, through a retail prescription drug card program administered by Walgreen’s Health Initiatives.
Discounts and scheduled benefit payments are for any prescription drug, either brand name or generic, if prescribed by a licensed physician for treatment of either a sickness or injury (unless the illness or injury is subject to a workers’ compensation claim). The Employee will receive both a scheduled benefit payment and, if the Retail Drug Card program is covered by the Plan, a discount from Walgreen’s Health Initiative (“WHI”). The Employee pays the remaining balance if any. It is a simple process all adjudicated at the pharmacy.
By going on line to WHI at www.mywhi.com or by calling (800) 451-3101, the Employee can obtain information on the drugs as well as all discounts.
NOTE: The prescription drug benefit coverage does not include (a) Therapeutic devices or appliances; (b) Experimental Drugs; (c) Drugs, medicine or insulin used by or administered while confined to a hospital or other medical facility; (d) Immunization agents, biological sera, blood or plasma; and, (e) Contraceptive material, devices or medications or infertility medications, except where required by law.
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What is the Walgreen’s Health Initiative Drug Card?
Walgreen’s Health Initiative (“WHI”) is a discounted drug card program for the PlatinumPLUS Plan. The program will allow the Employee to purchase drugs at a discount off full retail price, either brand name or the generic equivalent (if available) and apply the scheduled benefit payment towards the cost of the prescription at the retail drug store.
In addition to Walgreen’s Drug Stores, the WHI network includes most every chain store pharmacy (Sav-on, Target, Costco, Wal-Mart, Albertson’s, Safeway, Long’s and so on) and most every independent pharmacy nationwide. A full listing of pharmacies in the Employee’s area can be found on-line at www.mywhi.com or by calling WHI directly at (800) 451.3103.
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How does the Walgreen's Drug Card work?
Go to a Network pharmacy and present the Walgreen's Health Initiative Identification Card along with the written prescription. The pharmacy will verify the employee’s coverage, determine the discount and then apply both the discount and the PlatinumPLUS scheduled benefit amount. The Employee then, on the spot, pays the balance. Just that simple.
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What is the Advantage90 Drug Plan and how does it work?
In addition to the WHI mail order program, the Employee has access to the Advantage90 drug program. Both can offer a 90 day supply of drugs at a greater discount than the regular retail discount program. To access these programs, go online to Walgreen's Health Initiative ("WHI") at www.mywhi.com and establish an account. Then, enter the name of the drug the doctor has prescribed. The WHI System will then quote the drug's retail pharmacy price, the discounted price through the Advantage90 and/or the mail order program, as well as any generic equivalent that may be available.
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How does an Employee file a claim?
A claim form and instructions are included with the PlatinumPLUS Employee Welcoming Kit. Forms are also available from AARBIS by mail and via the Internet at www.AARBIS.com. Claim forms may also be available from the employer’s Employee Benefits or Human Resources department.
Insured can choose to assign or not assign benefits.
Assigning benefits means the employee is authorizing the insurance company to pay the insurance benefits directly to the medical provider.
When benefits are not assigned to the provider benefits are paid to the Employee.
The required payment procedures of medical providers can vary greatly. Some providers may require all or a partial payment at the time of medical services are provided, while others will not.
Filing a Claim and Assigning Benefits
If you elect to assign benefits to the provider: Upon arrival, give your provider a Claim Form that you have signed and checked the assignment authorization box. If you are utilizing a PPO network provider also present them with your ID card showing your PPO network information.
The provider will submit an itemized bill and claim form to the AIG Claims Office. You may still be required to make a payment based on the benefits payable and the difference between the total charges (or discounted charges if a PPO provider) and the scheduled benefit claim payment to provider.
Filing a Claim and Not Assigning Benefits
If you choose not to assign benefits directly to the provider: At the conclusion of your visit the office staff will bill (and collect) from you the full amount of the medical charges. Forward an itemized bill for the services rendered, with a completed claim form, to the following address:
AIG Claims Services
P.O. Box 44139
Las Vegas, NV 89116
Claims and Benefits Customer Service
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