IMPORTANT PLAN DOCUMENT PROVISIONS
The following are several important Plan provisions
closely reviewed by SLG Benefits’ claim staff when analyzing a claim
reimbursement request. We ask our TPA’s to assist us in our prompt
review by carefully reviewing these Plan provisions and submitting
explanations and supporting documentation with each reimbursement
request if applicable.
Eligibility Review
Perhaps the single most important part of our claim
review is to determine if an employee or a dependent was covered under
the Plan at the time they incurred their expenses. We will rely on the
Plan Sponsor’s Plan Document for the definitions of Eligible
Employees, Eligible Dependents, waiting periods for new hires and
termination provisions.
The Excess Loss Insurance Policy reinsures the Policyholder's Plan
Document and provides for reimbursement based on the exact wording
contained therein. Therefore, it is extremely important that all
parties fully understand the Plan benefits and that SLG Benefits be
provided with information that clearly and precisely indicates how a
person has been determined to be eligible under the Plan. For this
reason, our Specific Claim Filing Forms request detailed information
regarding how a claimant has been and continues to be covered under
the Plan. In order for SLG Benefits to properly review a claim
reimbursement request, our questions must be answered in their
entirety. If this is not possible, we request that the TPA provide as
much information as they have available along with an explanation as
to why certain items cannot be obtained and/or submitted. Failure to
do so may delay the review process.
When determining if an individual is covered under the Plan, please
consider the following
important items:
Employees:
What is his/her current employment status?
Is the employee actively working the minimum
required number of hours to be covered under the Plan? (The standard
is generally 30 hours, but each Plan varies)
Is the employee retired? If so, are retirees
covered under the Plan and when did the
employee retire? Are retirees covered under the Excess Loss
Insurance Policy?
Is the employee disabled? If so, when was his/her
last day actively at work and how has
coverage been continued? (i.e. sick time, vacation, FMLA, Leave of
Absence or COBRA)
Is the employee currently on a temporary Leave of
Absence? If yes, please outline the Plan's provisions regarding the
length of time such an individual would be allowed to remain on the
Plan. Should he/she have been offered COBRA? If yes, what was the
date?
Has the employee been temporarily or permanently
laid off? If yes, what is the Plan's time-frame for allowing such an
individual coverage under the Plan?
Dependents:
Does the dependent meet the Plan's definition of
a covered Dependent?
If a child, what is the Plan Document's age limitation?
If over the Plan’s age limit, (many Plans use age 19) does the child
have to be a full-time student? If so, please provide full-time
student verification from the school.
Has the dependent elected COBRA? If so, please submit copies of the
COBRA
Election form with verification that all COBRA premiums have been
paid to date.
Sample
Higher Education and Plan
Eligibility/Work Status Forms can
be found in the
Forms Section
of this Guide.
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