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.