Here are some common questions received by our client services department. If you don’t find the answer you’re looking for below, please call client services (see questions 1 or 2 below).
Who do I call if I have question regarding my health plan?
Our Client Services team is delighted to assist you. You may contact Client Services at 800.948.9450. Our hours of operation are from 8:00 a.m. to 5:00 p.m. Monday-Friday, Central time.
Is there any other way to contact Client Services?
Yes, you may email our Client Services team at service@americastpa.com.
What is a self-funded plan?
A self-insured health plan (or a “self-funded” plan) is one in which the employer assumes the financial risk for providing health care benefits to its employees. A self-funded employer pays for employee medical costs as they are incurred instead of paying a fixed premium to an insurance company for fully-insured coverage. Self-funded employers use America’s TPA (Third Party Administrator) for claim processing, shopping for stop-loss insurance coverage, provider network access and utilization review services.
What is a letter of medical necessity (LMN) and who generates it?
This is a letter from your provider that explains why a particular treatment is considered necessary.
What does it mean when a health plan states it covers preventive services?
Preventive services are when a person goes to the doctor and they are not sick. The patient is going to the doctor for a preventive check-up, which includes visits for mammograms, prostate screening, pap smear, etc. These services are usually done once a year.
What is the difference between routine and preventive services?
Preventive services are your yearly wellness physicals or tests/screenings you have done on a yearly basis, such as mammograms, eye exams, Pap smear, prostate screening, etc. Routine services are those done on a routine basis such as high blood pressure check, diabetes check, thyroid check, etc.
My provider wants benefit and eligibility information at the time of my visit. What do I do?
Just give your healthcare provider your America’s TPA identification card. Your provider will call our Client Service team who will be delighted to assist them.
Why does Americas TPA need to know if I have other coverage?
Your plan has a provision regarding what is known as coordination of benefits. We need to know about any other coverage you or your family may have to ensure that your claims are processed correctly. We will need to know who holds the other coverage as well as the name and phone number of the other carrier.
How will you determine which health plan is primary?
Primary status is determined through a series of coordination of benefit rules including but not limited to:
Birthday rule Court ordered coverage Size of employer (Medicare) Type of coverage Divorce Length of time on plan.
For additional information, please refer to your plan summary or call our Client Services team at 800.948.9450.
What is a PBM?
A PBM is a prescription benefits manager. A PBM offers you medications at a discounted cost either through your local pharmacy or mail order.
My pharmacist said my prescription has been denied. What do I do?
Do not leave the pharmacy. Have your pharmacist call the PBM vendor’s phone number on the back of your card. If this does not resolve the problem, please call America’s TPA immediately.
Is there a plan summary that tells me what services are covered?
Yes. You may obtain a copy of your plan summary (SPD) by contacting your HR department.
I’m new to America’s TPA. How long will it take to get my ID card?
It takes about 10 business days to get a new card sent out to a member once we've processed their enrollment information. To obtain a copy of your ID card call Customer Service at 800.948.9450.
How do I add a new family member to my plan?
Your Human Resource department will ask you to complete a change form which will then be submitted to America’s TPA.
My adult child is enrolled full time in college. My plan allows coverage for a full-time student? What documentation will America’s TPA need from me?
A letter from the school’s administration department, stating that the student is full-time, or a copy of the student’s enrollment for the current semester. You will need to supply this information on an ongoing basis.
What is a COCC?
A COCC is a certificate of creditable coverage. This proves your participation in a health plan and gives the length of participation. You will need this if you move to another health plan in order to show that you did not have a lapse in coverage.
How can I get a Certificate of Creditable Coverage for my next benefit plan?
By contacting our Client Services department at 800.948.9450.
How do I file a claim for services received?
Generally, your provider will bill America’s TPA for you. If for some reason you do need to submit a claim, you will need an itemized statement from your provider which includes details about the services rendered and the reason for the visit. If you have already paid for the service, you will need to provide proof of payment so that America’s TPA can send any reimbursement directly to you.
Can I look online to see claim status?
You can view your statements or check on claims in process at the HealthEZ web site.
I don’t understand how my claim was processed. Who can I contact?
Call our Client Services department at 800.948.9450.
What is a pre-existing condition?
A pre-existing condition is a medical condition you may have been treated for prior to your coverage with America’s TPA. This would include conditions for which you may be using medications to treat.
How are claims for pre-existing conditions handled?
If you have had a lapse in coverage of no more than 63 days, America’s TPA will need a copy of your certificate of creditable coverage (COCC). If a COCC is not received, America’s TPA will contact you by mail for additional information regarding treatment dates and providers. America’s TPA will also contact your providers to determine if you have been treated for any conditions that could be considered preexisting.
What if I have expenses for an accident or illness which may be payable by workers compensation, due to a car accident or by another third party?
America’s TPA investigates all claims that may be injury-related, however, we would like you to call us and tell us if there is another party involved. America’s TPA will still process your claim pending a settlement.
How do I get copies of explanations of benefits?
You may contact HealthEZ Payment Services at 888.409.2273.
What is a (PPO) and how does it affect my benefits?
PPO stands for “Preferred Provider Organization.” A PPO contracts with providers of medical care for a discounted rate on their services. Providers under such contracts are referred to as preferred providers or participating providers. Usually, the benefits with a participating provider are significantly better than with a non-participating provider. |
