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Benefit and Claim FAQs:
Q:
Does APWU Health Plan have online access to claims and
other health records?
A:
Yes. Our online eHealthRecord is available to High Option members with Internet access
and an e-mail address.
Click here for eHealthRecord
for members.
Q:
What information can I view with eHealthRecord?
A:
Members can view the following:
- Your claims
- Explanation of Benefits (EOB)
- A new Health Statement with year-to-date information about claims, including:
-In and out-of-network deductible balances for medical and mental health and
substance abuse benefits
-Catastrophic limits
-Wellness Benefit balance
-Claims detail
-Details of prescription drug transactions
When you initially log in, your Member Identification Number
from your ID card and your e-mail address are required; then you will
receive a user ID and create a password.
Other Capabilities: Family members can be added and deleted, member contact can be modified
(HIPAA Representatives), PPO network is displayed under Member Detail, you can view your member id
and order a duplicate, choose to suppress printing EOBs and see when a check has cleared for claims
payment, and when a claim will be paid if it is in-process.
Click here for eHealthRecord
for members.
Q:
How can I find the status of a claim that I have
submitted to the APWU Health Plan?
A:
There are several ways for you to determine the status of a claim that you have
submitted to the Plan. First, you can access eHealthRecord, our
online access to membership details and claims history.
You may also E-Mail a status inquiry form to the Plan requesting claims status.
Click "status inquiry form"
for e-mail status inquiry. You may also call the Health Plan at 1-800/222-APWU
(222-2798), between the hours of 7:00 am and 8:00 pm, Eastern Time, Monday-Friday, and
key certain requested data onto your telephone keypad. When you do this, the automated telephone response system will give you the status of your claim. Finally, you may call the above number between the hours of 8:30 am and 8:00 pm, EST, Monday-Friday, and speak to a Customer Service Representative regarding your claim status.
Q:
I have read about "precertification" of services. What services do I need to have precertified?
A:
The Health Plan's contract requires precertification for inpatient hospital stays. Home nursing care and services of either a physical, speech or occupational therapist, and durable medical equipment require prior approval (High Option). See the Plan's Federal Brochure (RI 71-004) to determine if a service you are about to receive needs precertification or preauthorization.
Unless a hospital stay takes place outside of the United States or Puerto Rico, or unless you have other insurance, including Medicare Part A as your primary health insurer, all inpatient hospital stays must be precertified. If a hospital stay is not precertified, a $500 penalty will be assessed when the claim is paid. Planned admission into the hospital must be precertified at least 48 hours prior to the
admission to avoid the precertification penalty. If you have an emergency
admission or an unscheduled maternity admission, you must certify the stay
within 48 hours of the admission, even if you have already been discharged.
For a maternity admission, the newborn's stay does not have to be precertified
unless the child stays in the hospital after the mother has been discharged.
At the time of the mother's discharge, the newborn's stay becomes a separate
admission. We have furnished precertification telephone numbers and
information under "Customer
Service--Contact Numbers" here at the Plan's web site. See the table of
Preferred Providers, under the Customer
Service option for information on who to call for certification of an inpatient hospital stay.
If home nursing, physical, speech or occupational therapy services are not preauthorized, the Health Plan may deny services, even if they are considered medically necessary and appropriate. These benefits are covered when prescribed by a doctor, and the doctor submits a treatment plan for these services.
To preauthorize nursing or therapy services, call the precertification
vendor for your area - click here.
MedSolutions, Inc. is responsible for precertification
of CAT/CT/MRI/NC/PET Scans. Prior approval of these procedures is required. Failure to
obtain required precertification can result in a $100 penalty and/or denial of the claim
pending review. The new toll-free number for MedSolutions is 1-888-693-3298, found on the
High Option ID Card. Have your provider call prior to these procedures.
Q:
A:
The catastrophic out-of-pocket maximum or limitation, does not indicate any one illness or condition. The catastrophic limitation is the maximum amount of coinsurance that a member has to pay out of their own pocket before the Health Plan pays covered charges at 100% for the balance of the calendar year. Most conditions that the Health Plan pays on your behalf for the High Option, at a percentage amount, will have your portion of the fee (the coinsurance) apply toward a maximum out of pocket amount. Once that maximum amount (the catastrophic limit) has been met by a member, the Plan pays covered charges, for the remainder of the calendar year, at 100% of the Plan allowance, or the PPO negotiated rate if you use a Preferred Provider.
Click here for information on Catastrophic Protection for Members.
Q:
A:
No. The only amounts that are accrued toward the catastrophic limitation are coinsurance or co-payments for covered services. The one exception to this is copayment or coinsurance charges for prescription drugs, which are not accrued toward the catastrophic maximum.
Click here for information on the Catastrophic Amount and how charges are applied for Members.
Q:
A:
There are several ways to determine if your provider--doctor, hospital
or other-- participates with the APWU Health Plan. For the High Option,
if you have a Preferred Provider Organization (PPO) directory, consult
the directory. If you do not have a directory, either ask the provider's
office if they participate with one of the Plan's PPOs, or call the
Health Plan at 1-800/222-2798 between 8:30 am and 8 pm, EST, Monday
through Friday and request a PPO directory from a Customer Service
Representative. Or check out the High Option Online Preferred Provider Directory on our website.
Another way to find out if your provider belongs, or to find a provider who does belong, is to call the PPO itself. The following numbers are used to contact the organizations during normal business hours:
- Alabama, Alaska, Arkansas, Arizona, California, Colorado, Connecticut, District of Columbia, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Idaho, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, New York, Nevada, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Virgin Islands, Washington, West Virginia, Wisconsin and Wyoming
- CIGNA
- 1-800/582-1314
Minnesota - PreferredOne
1-800/451-9597
U.S. Virgin Islands - V.I. Equicare
Preferred Provider Network: 1-340/774-5779
All states Mental Health and Substance Abuse - ValueOptions
1-888/700-7965
Q:
How do I get a referral to see a specialist--either a PPO specialist or non-PPO specialist?
A:
You do not need a referral to see a specialist when you are a member of the APWU Health Plan. You are free to choose your covered providers without seeking our permission.
Q:
What is the Health Plan's High Option prescription drug coverage?
A:
The Health Plan offers two comprehensive prescription drug programs to its members.
There is no deductible to satisfy for either program. With the Plan's Mail Order drug
benefit, for generic prescriptions, members pay a $15 copayment and a coinsurance of 25%
for brand name drugs.
The Plan also has a contract with 59,000 pharmacies nationwide, to allow our members to
purchase prescriptions at a discount. Our members may purchase covered prescriptions at
any Medco Health Prescription Solutions network pharmacies. When a Medco Health
Prescription Solutions network pharmacy is chosen, our members will pay a $8 copayment for
generic drugs for immediate care prescriptions. For brand name drugs, members pay a 25%
coinsurance.
With both the Mail Order and the retail drug programs, there is no paperwork for the member to file--the pharmacy does it on your behalf. For more information about either program, or to locate a pharmacy near you, call Medco Health at 1-800/841-2734, between 8 am and 8 pm, EST, Monday through Friday, or 8 am to noon, Saturday.
Click here for information on Prescription Drug Coverage for Members.
Q:
A:
When you select the APWU Health Plan as your insurer, you are always covered, no matter where you are. Your coverage always goes with you, whether you are in another state or another country!
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Enrollment FAQs:
- Q:
- Who is eligible to join the APWU Health Plan?
- A:
- The American Postal Workers Union Health Plan is open to all eligible postal and federal employees and retirees. Additionally, it is open to employees of the District of Columbia who were employed by the District prior to October 1, 1987. As a rule of thumb, if an employee, retiree, surviving spouse or child is eligible to enroll in the Federal Employees Health Benefits Program, that person is eligible to join the APWU Health Plan.
- Q:
- I have an enrollment issue with the Health Plan. How do I handle it? Can I take care of it through the Internet?
- A:
- You may make an address change over the
Internet. Click here to change your
address. Other enrollment changes, such as an add or drop of a covered family
member, an addition of or change in Medicare or other insurance coverage are made by
sending a letter explaining the situation to the APWU Health Plan at
799 Cromwell Park Drive, Suites K-Z, Glen Burnie, MD 21061, Attention: Enrollment Department. At this time we do not accept enrollment change requests through the Internet because, for your protection and ours, we want to have the request for change in writing, for verification purposes.
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Online Security FAQs:
- Q:
- What are APWUHP's Legal and Privacy Policies?
- A:
The APWU Health Plan is committed to safeguarding your privacy online. In general, you can visit our site without revealing any personal information about yourself. At times, we may ask you for personal information if it is necessary to assist you in selecting appropriate services offered by the APWU Health Plan. All information is provided voluntarily and explicitly by visitors of the site.
The Health Plan's online access to membership details and claims history for members, eHealthRecord, is secure and protected and meets all Federal requirements for privacy and security. Access is only available when you enter your Member Identification Number from your ID card and your e-mail address is required; then you will receive a user ID and create a password.
The e-mail facilities at our site do not provide a means for completely secure and private communications between us. Your e-mail, like most non-encrypted Internet e-mail communications may be accessed and viewed without your knowledge or permission while in transit to us. If you consider the information you are communicating to be confidential and you wish to keep it private, please do not use e-mail. Instead, you may contact us by telephone at 1-800/222-APWU (2798), or if you are a current member, at the number listed on the back of your identification card. Please note that e-mail sent to us will be shared with our customer service representatives or the staff members who are best able to address your questions or concerns. Once we have responded to your communication, it may be discarded or archived, depending on the nature of the inquiry.
The APWU Health Plan web site gathers routine usage information, such as how many people visit the site, the pages visited, and length of time a visitor spends on the site. This information is collected on a random, anonymous basis, which means no personal identifiable information is associated with the data. This data helps us to improve the site content and overall usefulness for visitors.
This site contains hypertext links to other web sites. The APWU Health Plan has no control over the content or the availability of these sites, and assumes no responsibility for the privacy practices of such web sites. These links are provided for convenience and reference purposes only, therefore we are not liable for any information or materials contained in them.
The APWU Health Plan reserves the right to modify this legal disclaimer and privacy policy at any time. If you have questions about the privacy statement or the practices of this web site, you should contact information@apwuhp.com.
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