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Click
here to open the Inquiry Form
Service to our customers is of the utmost importance at The Cornerstone
Group. Claim and benefit questions can be directed to Linda Judge Givens or Cathy Forsyth
at 304-232-2106 or 1-800-766-0268, between the hours of 9:00 am
and 5:00 pm. We have received requests to obtain assistance outside
our regular business hours. To better serve you, we now have an
"on line" inquiry system. You must have Adobe Acrobat
Reader installed to view the Inquiry Form. If you don't have it
installed click
here to download Acrobat Reader 5.0. Click
on link above and please complete the information and Linda
will respond as quickly as possible.
Click
here to open the Release Form
To download
the Release Form, right click on the link above and select Save
Target As. You must have Adobe Acrobat Reader installed on your
computer to be able to open this document. If you don't have it
installed click
here to download Acrobat Reader 5.0. Follow instructions on
form on where to fax or mail this document.
Below are some common questions we are asked.
General
Questions
I
am a new health insurance subscriber, who has chosen maternity benefits
on my coverage. I became pregnant before my effective date. Will
my pregnancy be covered under my new plan?
Recently,
I suffered severe chest pain and difficulty breathing. I immediately
went to the Emergency Room for treatment. Now my claims are being
denied because my insurance carrier says it was not an emergency.
What can I do?
While
out of town on vacation, my child became ill. She suffered vomiting
and diarrhea with a fever. Since we were unable to seek treatment
from our family physician, we went to the nearest emergency room.
She was diagnosed as having influenza. My insurance carrier has
rejected the claims because it wasn't an emergency. What should
I do?
I
am covered by a Health Maintenance Organization (HMO) contract.
What should I do if I need to seek medical treatment while I am
out of town or my child is away at college?
My
health insurance coverage does not cover vision benefits. Is there
anything I can do to get some help in this area?
Blue Cross/Blue
Shield
Carelink
Health Plan
The Health
Plan
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I
am a new health insurance subscriber, who has chosen maternity benefits
on my coverage. I became pregnant before my effective date. Will
my pregnancy be covered under my new plan?
According to the Health Insurance Portability and Accountability
Act of 1996 (HIPAA), health insurance carriers cannot apply a pre-existing
condition exclusion on employer group plans for maternity benefits,
regardless of whether the woman had previous coverage. For this
reason, you will have coverage according to the level of benefits
for maternity care in your employer group contract, even if you
are pregnant before the effective date of the policy. This law applies
to employer group contracts only. If you are covered under an individual
contract, your insurance carrier may exclude the pregnancy as a
pre-existing condition.
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Recently, I suffered severe chest pain and difficulty breathing.
I immediately went to the Emergency Room for treatment. Now my claims
are being denied because my insurance carrier says it was not an
emergency. What can I do?
Medical claims are filed using the final diagnosis of your condition.
If you went to the emergency room because of chest pain and it was
determined to be gastritis (indigestion), it will be billed as gastritis.
Under normal circumstances, indigestion is not an emergency that
would require treatment in the emergency room setting. The threat
of a heart attack, however, could possibly be life threatening.
Claims are filed using codes and numbers only. Your medical records
are not presented with the claim. If you receive a denial from the
insurance carrier, contact Linda Judge Givens or Cathy Forsyth at The Cornerstone Group
for assistance. She will send you a special medical information
release form to submit to the hospital to obtain your medical records/emergency
room report. She will also ask you a few pertinent questions about
the circumstances that made you feel it was necessary to seek immediate
treatment. When she receives the information and documentation,
she will file an appeal for you. In most cases, it can be resolved
without any further action being required of you.
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While
out of town on vacation, my child became ill. She suffered vomiting
and diarrhea with a fever. Since we were unable to seek treatment
from our family physician, we went to the nearest emergency room.
She was diagnosed as having influenza. My insurance carrier has
rejected the claims because it wasn't an emergency. What should
I do?
Most
claims today are submitted electronically to your insurance carrier.
Codes and numbers are used to list the diagnosis and procedures.
The computer automatically processes the claim using those codes,
with little human intervention. Since the flu can safely be treated
in a physician's office, the system determines that it is not an
emergency requiring the Emergency Room setting. For this reason,
the claim is denied. As you know, this treatment was not sought
under normal circumstances. Being in an area where physicians are
unknown to you, the Emergency Room was the only place you could
take your child. Upon receiving a denial from the insurance carrier,
you should contact Linda Judge Givens or Cathy Forsyth of The Cornerstone Group for assistance.
She will send you a special medical information release form to
send to the hospital to obtain the Emergency Room report/medical
records. She will write the appeal to the insurance carrier for
you. In most cases, you will need to do nothing further.
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I am covered by a Health Maintenance Organization (HMO) contract.
What should I do if I need to seek medical treatment while I am
out of town or my child is away at college?
Your HMO contract requires that all medical care be coordinated
by your Primary Care Physician (PCP). Unless the situation is life
threatening, you should call your PCP before seeking any medical
treatment. With the approval of the PCP, you will have coverage
for treatment out of the network. Please remember, if it is a true
life-threatening emergency, seek medical treatment first. Then,
you or a family member must contact your PCP as soon as possible
after the emergency.
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My health insurance coverage does not cover vision benefits.
Is there anything I can do to get some help in this area?
As an added benefit to their health insurance coverage, some carriers
offer a vision discount program. Although this is not actually vision
coverage, by showing your medical insurance ID card at selected
providers, you are given upfront discounts on exams and vision product
purchases.
Mountain State Blue Cross/Blue Shield offers a program administered
by Davis Vision, Inc. To locate a provider in this network, call
1-877-923-2847 and enter code 7859. You may also access their website
at www.davisvision.com.
Click on "Find a Doctor". Go to the blue section and enter
the "Control Code 7859". This will give you a list of
the providers in your area that offer the Davis Discounts.
The Health Plan of the Upper Ohio Valley offers a discount program
that is managed by Cole Vision Corp. To locate a Cole network provider
you may call 1-800-424-1155 and enter your zip code. You may also
access their website at www.colemanagedvision.com.
Click on "Find a Provider". Enter the plan number 46216
and postal (zip) code. This will give you a list of providers in
the Cole network.
Blue Cross/Blue
Shield
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I am covered by a Blue Cross/Blue Shield Preferred Provider Organization
(PPO) contract. How can I find a provider who is in the PPO network?
Blue Cross/Blue Shield offers a PPO network that is nationwide.
It is very simple to access the provider directory via the Internet.
Go to the website at www.bcbs.com/healthtravel/finder.html.
Enter the alpha prefix from your identification number (Example: "ZPN").
You need only to enter the city and state where you are trying to find a doctor or hospital.
Then choose the Search Radius Mileage and follow the other prompts.
Any provider that appears on the list is the in the PPO network.
You may also call The Cornerstone Group for assistance (1-800-766-0268).
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I am covered by Blue Cross/Blue Shield in one state but live
in another. I know my doctor is in the PPO network where I live
or have received treatment. How should the claims be filed so that
I obtain the in-network level of benefits?
Instruct your doctor or hospital to submit all claims to their local
Blue Cross/Blue Shield Plan. To avoid delay, the entire member ID
number, including the three-digit letter prefix, must appear on
all claims.
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I am a new subscriber to Blue Cross/Blue Shield. My claims have
been rejected because pre-existing conditions are not covered under
my contract. Is there anything that I can do to get them covered?
Most Blue Cross/Blue Shield contracts have a 365 day waiting period
for pre-existing conditions. However, this clause may be waived
if you have had continuous medical coverage with another carrier
for at least one year without a break in coverage of more than 63
days. To have this clause waived, you must submit written documentation
from the prior carrier or carriers showing the initial effective
date and cancellation date of that coverage. You should call the
prior carrier and ask for a "Certificate of Creditable Coverage".
When you receive that documentation, call Linda Judge Givens or Cathy Forsyth at The Cornerstone
Group for instructions on submission to Blue Cross/Blue Shield.
Carelink
Health Plan
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My doctor has prescribed a new medication for me. My pharmacist
says my plan pays differently if the prescription is for a formulary
drug or a non-formulary one. What is a formulary drug and how can
I find out if my medication is on the list?
A managed drug formulary is a list of approved drugs. Before a drug
is approved for the formulary, it is studied for safety and effectiveness.
In some cases, there are major differences in the costs and documented
benefits to patients. With all of these factors in consideration,
the Pharmacy and Therapeutics Committee compiles a list of approved
medications. Carelink looks at both the effectiveness of the drug
for quality care and cost-effectiveness to keep your premiums as
affordable as possible. The formulary list is reviewed and updated
several times per year, adding some medications and dropping others.
To see if your medication in on the formulary, you may access the
website by clicking on www.carelink.cvty.com.
Then click on "Members", then "Prescription Formulary",
and follow the prompts.
The Health
Plan
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Do all family members have to select the same Primary Care Physician?
HMO plans are based on having a Primary Care Physician (PCP) to coordinate
your medical care. You may choose a different PCP for each family
member.
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Once I choose a PCP, do I have to stay with them forever?
The choice of a PCP is not final. Your health care needs and comfort
with your physician are the most important aspects of any health
plan. A member may change PCP's once per calendar month by calling
The Health Plan at
740-695-3585 or 800-624-6961.
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