Aetna International Overview For The Church of Jesus Christ of Latter-day Saints

Transcription

1 Aetna International Overview For The Church of Jesus Christ of Latter-day Saints Canada Missions Welcome to Aetna International! The Church of Jesus Christ of Latter-day Saints (the Church) has contracted with Aetna International to assist in claims administration, provide access to direct-settlement payment providers, enhance medical treatment provided to missionaries, and provide insurance where it is required by the government in order to assist the Mission President, his wife, and the Area Medical Advisor (AMA) in their roles of caring for young missionaries. In Canada, Aetna has partnered with Cowan Insurance Group, a Canadian-based company with 51,000+ healthcare providers in their network. As members of the Aetna International program, missionaries will receive an ID card directly from Cowan Insurance Group. This benefit for the Mission President and young missionaries provides the following advantages: Provides direct payment by Aetna to many providers of healthcare Review of claims to identify fraud, thus saving the Church money Premium dollars are returned to the Church if actual medical costs don t reach anticipated amounts Complies with the Church s request that foreign missionaries not enroll in a country s national health program Meets healthcare reform mandate for missionaries returning to the U.S. Aetna International looks forward to serving you. Should you need to escalate an issue, please contact us: Mark Burgin, Account Service Representative BurginM1@aetna.com Carol Griggs, Associate Account Manager GriggsC@aetna.com ID Cards The ID cards will be mailed directly to the Missions from Cowan Insurance Group. When the ID cards are received, please hand them out to the missionaries along with the ID card letter. The ID card letter explains the process to request medical care. This process has not changed. When a missionary needs medical attention, they must still get approval from the Mission President or his wife, who will coordinate the medical appointments with participating healthcare providers. ***Please see enclosed ID card letter*** Benefit Principles Missionary Medical has set forth some benefit principles to guide your medical care decisions. ***Please see enclosed Benefit Principles document*** Contact Cowan Insurance Group 24/7/365 Cowan can assist you with: Benefit questions what is covered? Eligibility questions who is covered? Locating doctor/specialist and coordinating payment Lost or stolen ID cards request another card Phone toll-free aetna@cowangroup.ca The Cowan Infocentre can be reached at and is available from the hours of 8AM to 5PM EST, Monday through Friday. If you are calling after hours or on weekends, you will be presented the option to be automatically transferred to Aetna International for immediate assistance. Canada Telehealth Line is 811 (to speak to a nurse to determine whether care should be received in a clinic or a hospital)

2 Cowan Insurance Group Participating Healthcare Providers: Certificate Number: CLDSAETNA After arriving at enter the passcode CLDSAETNA in Certificate Number field. The system will prompt you to accept the terms and conditions. Next, you will have three options to search for a provider. 1. eclaims Enabled Health Providers: These are the paramedical services such as chiropractor, physiotherapy, podiatrist, etc (and vision) that bill electronically from the point of sale 2. Cowan Dental Provider Search Engine: This is the listing of dentists who bill direct at the point of sale (use 1 st 3 digits of postal code for best search result) 3. Cowan Health Care Provider Search Engine: These are the providers on Cowan s first dollar / provincial health replacement network. This includes, doctors, hospitals, labs, specialists, etc. who bill Cowan directly for services rendered. Once you have selected a provider: 1. Enter the postal code, or select a speciality or type of provider 2. Click Submit or Search (note that the eclaims search tool is slightly different in appearance with different button labels. 3. The system will return the desired results. The e-claims system will return the providers on a map as well. Canadian Medical System note: In many areas of the world it is easy to find a family doctor but this is not the case in Canada. Many Canadians are on waiting lists for years before getting a family doctor. For non-canadian residents often their only option will be to go to a walk in clinic. At the walk in clinic, a file will be created and the member can return to the clinic for follow-up visits but will not necessarily see the same doctor. Non-Emergency Care: (flu, cold, headaches, nausea) Select Cowan participating clinic Make appointment NOTE: Clinics create a medical file on each patient which stays with the clinic and is shared by all doctors within the clinic. The medical file can be transferred to another facility if needed. Missionary takes their Cowan ID card to appointment Clinic can verify missionary s eligibility using the address on the card or by calling Cowan at Clinic bills Cowan for the medical services given TIP: use Google to find clinic website and check wait times online. Specialist Consultation: (dermatologist, allergist, gynecologist) A REFERRAL FROM A DOCTOR IS REQUIRED Select Cowan participating specialist Make appointment A referral from a doctor is required to see a specialist Missionary takes their Cowan ID card and the doctor s referral to appointment Specialist can verify missionary s eligibility using the address on the card or by calling Cowan at Specialist bills Cowan for the medical services given Emergency Care: (broken bones, serious injuries, heart issues) Select Cowan participating clinic/hospital Inform the clinic/hospital missionary is covered through Cowan Missionary takes their Cowan ID card Clinic/hospital can verify missionary s eligibility using the address on the card or by calling Cowan at Clinic/hospital bills Cowan for the medical services given Prescription Drugs: 99.5% of all pharmacies in Canada will accept Cowan ID card as payment Select Cowan participating pharmacy Missionary takes their Cowan ID card to pharmacy Pharmacy can verify missionary s eligibility using the address on the card or by calling Cowan at Pharmacy bills Cowan for the prescription drugs 2

3 Dental Emergency Care **IMPORTANT** ONLY dental procedures as a result of an accident will be covered by the Missionary Medical program. Any urgent dental needs such as extractions, root canals, pain relief procedures, abscesses, etc. should NOT be arranged or paid for by Aetna or our partners. For that type of care, the mission president or his wife or the mission nurse or medical advisor should help the missionary access the dental care needed; however, the mission president will then need to determine if the missionary s family will pay those bills or if the Church funds will be used to cover those costs (by using mission account #XXXX ). No participating Cowan provider or the one you want is not on Cowan website? If the provider needed is not on the Cowan website, please call Cowan directly and they will make outreach to the provider and negotiate a one-time direct payment. Cowan is 90% successful in negotiating one-time direct payments. Cowan will attempt to get them to join their network, especially if you will be needing to send missionaries to that provider again. Guarantee of Payment should not routinely be required, however, some elective procedures will ask for some sort of upfront payment. If this is requested, please communicate with Cowan and they will make the necessary arrangements. Reimbursement 1. Mission President Claims When direct-payment arrangements cannot be made through Aetna s provider network and mission presidents must use their personal funds to pay for their own medical needs, reimbursement should by filling out the Claim Form- Mission President. This reimbursement approach applies only to mission presidents and their eligible family members; when mission funds are used to pay for medical treatment for missionaries, reimbursement should be requested from Aetna International using the Claim Form- Reimburse Missionary Medical. Claim forms are located on the Aetna website developed for the Church. Aetna LDS Website A website has been developed for the Church and will house the following: Contact information for Aetna Instructions for how to locate a Cowan participating healthcare provider Overview of how the program works in Canada Claim form and claims spreadsheet Senior Missionary claim form To view the website: Under the section Choose your mission area and country, click on North America / Canada. Submitting the Claim to Aetna 1. Complete the appropriate claim form. 2. Copy all receipts on a single piece of paper (or as many as necessary). Be certain that all receipts are legible. Receipts must be fully itemized bills and/or detailed receipts that include diagnosis (nature of illness) and the procedures or services performed. 3. Write the missionary s member identification number on each document submitted with the Claim form (refer to the Aetna International ID card or missionary listing sent to you monthly). 4. Be sure to indicate the name of the person who received care (the missionary). 5. Include contact information (phone and address) where the Mission office can be reached in case Aetna has any questions about the Claim. Send the Claim form/receipts via FAX to: Toll-free: Direct: Send the Claim form/receipts by mail to: Aetna; P.O. Box El Paso, TX USA Or to: AISERVICE@AETNA.COM Once claim forms and receipts have been sent to Aetna, it takes approximately two to four (2-4) weeks for processing. 2. Claim Form Reimburse Missionary Medical Reimburse the Church if Mission funds were used. 3. Claims Spreadsheet Reimburse Church Reimburse the Church if Mission funds were used. 3

4 Claims Report for Mission President A claims report will be sent to the Mission President and Mission every month, and will show claims for providers Aetna has paid directly, and claims sent to Aetna for reimbursement to the Church. Each missionary who received care will be listed with their dates of service and amount of the claim paid. This claims report can be used by the Finance Secretary to reconcile the claims sent to Aetna to ensure reimbursement has been given to the Church. Aetna International will reimburse for the following: Prescription drugs Medical services given as a result of a sickness or injury Medications can be purchased in bulk and sent to Aetna for reimbursement please use Mission President s name and Aetna # and indicate bulk medication purchase on the claim form Not Reimbursable through Aetna International: Dermatological helps such as makeup, acne medicine, sunscreen, bug spray, lice shampoos and lotions Vitamins, Over-the-counter pain medications such as Advil, Tylenol, etc. Eye exams or eye care, unless as a result of an accident or injury Dental services, unless as a result of an accident Elective procedures any medical, dental or eye care that is not associated with sickness or injury Pre-mission conditions physical or mental condition that was diagnosed or treated, or that had treatment recommended, within two years before the missionary entered the mission field. The Church does not pay for treatment of physical or mental conditions that existed before a mission, or for prescriptions resulting from these conditions. ***The Mission President has the discretion to override this under special circumstances*** Medical Assistance (90-day continuation of coverage) When a missionary is to be given an early medical or emotional release to return home in order to receive treatment associated with an injury or illness that occurs during missionary service outside of the United States, the Mission President contacts the IFR (In Field Representative) at the Church s Missionary Department. The IFR will contact the DMBA Nurse Team to retrieve all needed information from the Missionary Inquiry system. Once approved by the IFR, a Missionary Change Form is sent to Missionary Medical who in turn contacts Aetna to allow the additional 90 days of coverage. Extended medical coverage and medical assistance covers the specific injury or illness that began during the missionary s service. Aetna will receive notification of these missionaries through an established workflow administered by Missionary Medical. Please see the Aetna LDS website for checklists for the Mission President, and other helpful tools and resources. 4

5 Aetna International Secure s Aetna International s containing missionary names, dates of birth and member ID numbers will come to you in a Secure format. In order to open these s you can do one of the following: Follow the instructions within the click on download below the message name save the message, then click View Downloads click on the envelope with a lock the and attachment will open ready for you to view and save to your computer Or Forward your Secure to zdm@vsn.voltage.com and they will send back your unencrypted and ready to view when the comes back to you, click on the link within the click on SUBMIT on the next screen and attachment will open click on download to open the attachment IMPORTANT: Please save the documents sent onto your computer for continued access to the information, as Secure s and their contents will not be available after a period of time. Resources for the Mission President and Wife, Area Medical Advisors and Church Doctors and Mission Nurses Aetna International Overview (this document): Most critical information to know about medical care and how to seek reimbursement from Aetna. ID card Letter: Outlines the Missionary Medical process for the missionary on how and when to seek medical care. Benefit Principles: Benefit principles set forth by Missionary Medical to guide your medical care decisions. Claim form and Claim spreadsheet: Electronic versions provided by Aetna during implementation. The forms are located on the following website for your reference: Missionary Listing in Excel format: Monthly listing sent to the Mission address, with missionary name (as enrolled with Aetna), date of birth, Aetna ID#, and Mission number (in XX-XXX format) - see below. (Please refer to Secure instructions) Toronto Calgary Halifax Edmonton Montreal Vancouver Winnipeg

6 Monthly Listing of Paid Claims by Mission: Monthly listing sent to the Mission and Mission President address, which contains all claims paid by missionary name, dates of service, and amount, plus whether paid to provider or reimbursed through Missionary Medical. (Please refer to Secure instructions) Cowan Insurance Group Participating Healthcare Providers: Certificate Number: CLDSAETNA 1. eclaims Enabled Health Providers: These are the paramedical services such as chiropractor, physiotherapy, podiatrist, etc (and vision) that bill electronically from the point of sale 2. Cowan Dental Provider Search Engine: This is the listing of dentists who bill direct at the point of sale (use 1 st 3 digits of postal code for best search result) 3. Cowan Health Care Provider Search Engine: These are the providers on Cowan s first dollar / provincial health replacement network. This includes, doctors, hospitals, labs, specialists, etc. who bill Cowan directly for services rendered. NOTES