Population: New or Prospective Non-Represented
Participant Advocacy Service
The Company wants you to get the most out of your health care benefits! The Participant Advocacy Service is here to help ensure that you do!
Through the years, we have gathered a wealth of information and created and maintained the Your Benefits Desktop website to help you make the best decisions regarding your benefits. We’ve encouraged you to become a better health care consumer and to practice preventive care, and we’ve provided links to websites that can assist you (link to Health and Wellness Focus from the Your Benefits Desktop homepage).
Despite it all, issues may arise. To help you resolve any conflicts you may have with your medical, dental, or health care reimbursement account carrier, the Company offers a Participant Advocacy Service.
Sometimes, despite your efforts to resolve an issue directly with your health plan, you may still find that the issue isn’t closed. It is helpful to have an objective party who can research your issue and converse with the health plan on your behalf.
The Advocate Team helps ensure your issue is given the attention it deserves and considered fairly. However, contacting the Advocate Team does not guarantee the resolution you want; the terms of the plan still apply.
What Is Participant Advocacy?
This service puts you in touch with the Advocate Team, which will help you with unresolved health plan access to care or claims issues. The Advocate Team will research your issue and work with your health plan to resolve it on your behalf.
The service is available to employees and retirees enrolled in medical (which includes vision, hearing, prescription drug, and mental health care), dental, and the health care reimbursement account plans.
How Can I Reach the Advocate Team?
Call 1-800-571-0400 and follow the voice recognition prompts to speak with a Benefits Express representative. All calls are confidential.
Before you request assistance from the Advocate Team, you must make at least one informal attempt to resolve the issue directly with your health plan. This attempt should not be in writing. If your issue is still unresolved after you’ve discussed it with the health plan customer service, call a Benefits Express representative. If you contact Benefits Express before talking to your health plan, your issue will not be passed on to the Advocate Team. Instead you will be directed to contact your health plan.
You should be able to tell the representative:
- The type of issue and a description of what is unresolved;
- The name of the health care provider;
- The date of service;
- The amount of a claim in question; and
- The health plan’s response to your initial call.
On rare occasions, it may be necessary to provide detailed diagnosis information.
The Benefits Express representative will pass your issue on to the Advocate Team, which will begin researching. The team will contact you within two business days to follow up. If your issue is deemed urgent, you may be connected to an advocate immediately. In that case, for instance, if you are calling from a provider’s office or from the pharmacy, you do not have to contact your health plan before calling Benefits Express.
What Types of Issues Can Be Resolved?
Following are examples of some common issues the Advocate Team works to resolve:
Medical
- You call your plan to confirm that your doctor is in the network before seeing the doctor. After care, you then receive an Explanation of Benefits, which states that the physician is not part of the plan and the claim is processed as non-network.
- You disagree with the amount your carrier agrees to pay.
- You receive a collections notice for a claim that has not been paid by your health plan, and you are not able to secure a mortgage loan due to the collections notice on your credit report.
- You are being denied precertification for medical care.
Dental
- You are at an in-network dentist's office and are told you need to pay in full because that is the dentist's policy, and you feel that you should only have to pay the coinsurance according to your plan guidelines.
Prescription
- You are at the pharmacy and are having difficulty getting your prescription filled because your doctor has changed the dosage of your prescription, and you only have a one-day supply left and need to get your prescription today.
Who Can Afford to Ignore These Issues?
No one! Getting all of the benefits you are entitled to is important, especially since the cost of health care continues to rise. You need to give your health benefits the attention they deserve.
We encourage you to take advantage of this service.