Travel and Foreign Claims

All-Employee Brown-BagMonday, May 23, 2005

Building 2-100B Conference Room

Presented by the Health Care Facilitator Program

Today’s Meeting

• Session I: General presentation until 12:30 (short-term travel)—Handouts available after meeting

• Session 2: Extended session for CERN-based employees (living/working outside U.S.), immediately following. Participants:—Gary Lee, HR Center Manager—Carolyn Charles, HR Generalist—Lisa Ersparmer, Sr. Travel Specialist—Richard Takahashi, Benefits Manager

Short-Term Travel

• Conditions of coverage outside service area• Medical care that is covered• Medical care that is not covered• Emergency Services (ES) • Urgently Needed Services (UNS)

• Notification and authorization requirement• The claim reimbursement process

• Claim packet• Mailing address

• Helpful tips

Do you know …

• Which of the following health plans (Blue Cross PPO and Plus, Kaiser, HealthNet, and Pacificare) offer worldwide service coverage?

A. Blue Cross PPO and Plus only

B. Blue Cross PPO only

C. Blue Cross PPO and Kaiser only

D. All of the above

Answer: D. All of the above.

• BC PPO –

Any provider worldwide for all covered services

• BC Plus, Kaiser, HealthNet, and PacifiCare –

Any provider worldwide for emergency and urgent care services only

What are Emergency Services?

• Medically necessary ambulance or ambulance transport services provided through the 911 emergency response team.

• Medical screening, examination, and evaluation by a physician to determine if an emergency medical condition or psychiatric emergency condition exists.

• If condition exists, ES include the care, treatment and/or surgery by a physician necessary to stabilize or eliminate the emergency medical or psychiatric condition within the capabilities of the facility.

What is an Emergency Condition?

• Manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably result in any of the following:

1. Place health in serious jeopardy

2. Serious impairment to bodily functions

3. Serious dysfunction of any bodily organ or part

4. Active labor• Inadequate time to effect a safe transfer to another

hospital prior to delivery, or • Transfer poses a threat to the health and safety of

member or unborn child

What are Urgently Needed Services?

• Medically necessary health care services required to prevent deterioration of member’s health, resulting from an unforeseen illness or injury for which treatment could not be delayed until the member returns to the plan’s service area.

What is NOT Covered?

• Routine follow-up care to emergency or urgently needed services, such as treatments, procedures, x-rays, lab work, doctor visits, rehab services, skilled nursing care or home health care

• Maintenance therapy and Durable Medical Equipment including, but not limited to, routine dialysis, routine oxygen, routine lab testing, or a wheelchair to assist you while traveling outside your plan’s service area

• Medical care for a known or chronic condition without acute symptoms as defined under ES or UNS

Notification and Authorization

• Regardless of where you are in the world, you or someone else on your behalf, must notify your PCP or plan within 24 hours, or as soon as reasonably possible, following receipt of ES or UNS

• Any medically necessary follow-up services either prior to or following discharge from the hospital must be authorized

• Your PCP or plan reserves the right, in certain circumstances, to transfer you to a participating hospital in lieu of authorizing post-stabilization services at the treating hospital

Claim Reimbursement Process

• Obtain receipts and copies of all relevant medical documentation— Itemized statement

• Name, address, telephone # of provider• Date of services (DOS)• Medical code/description• Amount paid in foreign currency

• Complete foreign claim form• Submit claim

• Use plan’s California mailing address• Within 6 months from DOS

• Receipt of reimbursement• 4-6 weeks from date of receipt• Mailed to mailing address by BC

• Contacts• Plan member services• LBL HCF office

Helpful Tips

• Always present health plan ID card to provider• Make copies of all health plan ID cards• Keep a list of all medication• Fill/re-fill prescription before travel• Let PCP know of planned vacation, trips• Keep a list of PCP’s and health plan’s telephone

#s (during business and non-business hours)• Keep a list of emergency contacts in U.S.• Research info about health care accommodations

and/or restrictions of the places to visit

Reminder

• All:—Please pick up handouts before you leave

• CERN-based employees:—Please stay for an extended session

addressing benefits coverage and relocation issues

and THANK YOU

for attending today’s presentation!