Use Emerge to view or confirm receipt of CCF/PMH or MR after it is received. These are usually associated with claims coded "08".  You can also use the Claims module of Emerge, search for all claims, and then search for claims with a “Mod” of X (MR) or a “Mod” of R (PMH). See claim number 2014072400282.00 for member ID 1059257.

When the insured request to have the CCF/PMH letter resent to them, there is a way for us to print them ourselves and send them. Please see below for instructions.

You would first have to find out which examiner sent the initial CCF/PMH form, for example Lisa Kegley. The examiner name will be in Emerge. Please click on the details button and read the notes.

1. You would need to go into the G drive, when the carrier is Transamerica OR H drive when the carrier is Hartford

2. Chose JMS Correspondence

3. If the policy is Hartford. Locate the oldest date we sent CCF/PMH. Open that folder and locate your patient's name. Create a new email, and attach all of your patient's documents and email it to them. 

All emails must be placed in Imagenow. Leave detailed notes. 

**NOTE: if the insured has a common last name such as Jones, or Smith. Type in the first and last name and locate your insured. 

If the insured has a unique last name you most likely won't need the first. 

4. You would need to choose the insured person name, claim form will be listed next to the name. it would look something like this

LK Sarah Stewart claim form

5. Once you click on the information, it will bring up the PMH letter that was sent initially. Please be sure to print all of the letter we sent. There may be multiple, please look for all of them. 

Retail policy claims with a date of service during the first 6 months of coverage are subject to the pre-existing conditions waiting period.

The claims auditors research the condition to see if it is new or pre-existing. The first step is for the member to fill out a claim form giving us the name(s) of his/her doctor(s) and permission to obtain/review medical records from the doctor(s). While we perform this research, the claim will be processed with EOB remark code 8 “This claim is currently on file pending receipt of information requested from the member or provider". 

When you see that a claim has been processed with EOB remark code 8, please open up the detail screen and look at the EOB comments (blue summary button), the examiner notes, and the correspondence (purple button). These notes/comments/letters will explain where we are in the process.

PMH – Stands for Previous Medical History. We gather physician names and contact information (as well as authorization to obtain medical records) from the member, via a long claim form.

CCF – Stands for Completed Claim Form. We send this long claim form to the member for completion.

MR – Stands for Medical Records. One of the things the member will provide to us when completing the long claim form is the name(s) of any physician(s) who treated the member for the condition in question. We will often need to contact the physician(s) for medical records on the patient. See below for details regarding physician reimbursement for providing medical records.

PEC – Stands for Pre-Existing Conditions. After reviewing the medical records, someone in Claims will list the PECs in the Emerge claim notes.

If we do not receive the PMH or MR, we follow up with a second request in 15 days. If a response is still not received 15 days after the second request, we close the case.

A claim that has been closed may later be reprocessed and covered, if we find out that the condition was new and not pre-existing.

In other cases, claims will be reprocessed and denied if we confirm that the condition was pre-existing. These claims will be denied with EOB remark codes 21 or 22.

For an example of a claim going through pre-ex investigation, see ID number 1059137, Douglas DOS 1/6/14.

This section is a synopsis of the information found in the certificate language and within this Pre-Ex Document. To see the full details, please read the certificate and this entire Pre-Ex Document.

On our Retail plans, claims for pre-existing conditions are not covered during the first six months of the policy. A pre-existing condition is defined as any injury or sickness whether diagnosed or undiagnosed, for which a covered person received medical care or treatment within the 6-month period leading up to the effective date of his or her supplement insurance.

When the date of service on a claim is within the first 6 months of coverage, the claims examiner must determine whether or not the condition is pre-existing. This determination is made by reviewing the insured’s medical records. First, we will need the member to complete and sign the authorization section of a claim form. The Claims Department will send claim forms to the member for this purpose. After the signed form is returned, the Claims Department writes to the physician(s) to request the records. After the medical records are received, the Claims Department is able to identify the pre-existing conditions. Please see this section for more details on how the Pre-Ex Limit may affect the processing of claims.

The pre-existing conditions limitation only applies to the Retail (non-employer) members. Corporate/employer plans do not have a pre-existing conditions limitation.

In some cases, the pre-existing conditions limitation can be waived or shortened. Please see the following sections for details on when and how this may be done.

Waiver of Pre-existing Condition Exclusion

1. When a USBA application (or any other application) is processed and waiver of pre-ex is requested, the examiner on Fran’s team will validate the request 

If the validation indicates the applicant is eligible for waiver of pre-ex, then,

1. Rose/claims is notified and Emerge is updated with the waiver indicated (the policy needs to be enrolled with a payment made, such that there is an x-ref number)

What is the notification?  How is Claims notified?  Is it in workflow?  Rose prefers not to use workflow, would prefer email.  Sam to investigate and report back

 A letter is sent to the applicant (the letter is manually produced by the examiner) acknowledging approval of the waiver of pre-ex

Enroll with P05 status, manually added by Enrollment so that it doesn’t go into the pending agent workflow, until we receive validation; 

Need to send letter, and create letter regarding pending of app due to validation of waiver of pre-ex. 

2. If the validation indicates the applicant is NOT eligible for waiver of pre-ex, then,

1. A letter sent to the applicant indicating the decline

3. HTRI records in Inspro do not have the field, or the field is not accessible by the examiners, to indicate waiver of pre-ex.  I put in an IT ticket (#16825) requesting that the field be added or displayed in the HTRI version of the Inspro records.  Too soon to tell if the modification can be made.

Whether this is in Inspro does not impact claims; if pre-ex is waived it is recorded in the notes field in Inspro; if waiver of pre-ex is added post-enrollment by claims, then it is not recorded at all in Inspro

Ron -- Send list of USBA insureds who were supposed to have waiver of pre-ex to Rose so she can check status in Emerge

4. There is a general notes/comments field in Inspro where the waiver could be noted, BUT this field is not available when the enrollment examiner is entering the record.  It would have to be entered after the record is established in Inspro.  This could be a work-around opportunity if the letter is cc’d via email internally to someone who could update the record after enrollment has entered it.  Clearly not ideal though.

If app received with validation, then Andreia enters, it gets A01 status and xref, and app is batched.  After it is processed by Inspro, then Andreia would go back in and add the note and send email to Rose/claims, Rose/claims would add note in Emerge; Andreia then triggers letter to be sent to insured to advise that waiver of pre-ex is approved, letter is imaged but not attached to Inspro record

If app received without validation, then Andreia enters, it gets P05 status, manually added by Enrollment so that it doesn’t go into the pending agent workflow, until we receive validation; Andreia triggers letter regarding pending of app due to validation of waiver of pre-ex (need to create this letter).

If app received and is judged NOT to be eligible for waiver of pre-ex, then policy is issued and letter declining waiver of pre-ex is triggered by Andreia.

CHAMPVA PRE-EX WAIVER 

For Insureds in all available States:

AGP-592805 Certificate

The effective date of these updated cert is 05/01/2020

Waiver of Pre-existing Conditions Limitation:  The period of time required to satisfy the Pre-Existing Conditions Limitation will be waived for Your spouse  and Your Dependents if:

1)  You enroll for coverage within 63 days of Your retirement date from Active Duty; or 

2)  You enroll for coverage under The Policy within 63 days of enrolling in CHAMPVA.

This rider becomes effective on the latest to occur of:

1. May 1, 2020; 
2. Your Coverage Effective Date; or
3. the first day of the month on or next following the date We accept Your required premium.