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I have Medicare and group health coverage. Who pays first?
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I have Medicare and retiree coverage Who pays first?
● I am disabled and covered
by a group health plan of a family member who is
● I have End-Stage Renal Disease (permanent kidney
failure and group health
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I have COBRA and Medicare. Who pays first?
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I have more than one group health plan. Who pays first?
● Why did I receive a subrogation form and why do I need to complete and
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Why can't I change my address over the phone?
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What do I do when I discover incorrect personal information on my
ID card?
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How do I get coverage for a new dependent(s)?
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What do I need to do in case of divorce?
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What do I need to do when my dependent reaches the age of 19?
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What do I need to do when my dependent is about to graduate from
college?
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What is the fax recall system? ●
How can my healthcare provider become a participating provider of
our
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How can I get information about a claim payment?
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What is Creditable Coverage?
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What is an EOB or Explanation of Benefits?
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Does my plan require a Pre Cert?
●
How do I/how does my provider find out if a provider is a
participant in 
FAQs Frequently Asked Questions
working. Who Pays first?
coverage (including a retirement plan). Who pays first?
sign it?
Company's Preferred Provider Network if they do not
currently participate
as a preferred provider?
my preferred provider network (PPO)?
I have Medicare and group health coverage. Who
pays first?
current
employment or the current employment of a spouse of any age,
Medicare is secondary payer if the employer has 20 or more employees, and covers
any of the same services as Medicare. This means that the group
health
plan is the
primary payer.
If your employer has fewer than 20 employees, Medicare is the primary
payer for all
participants
enrolled
in the group health plan.
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I have Medicare and retiree coverage. Who pays first?
Medicare will pay first for your health insurance claims, and your retiree coverage
I am disabled and covered by a group health plan of a family
member who is
working. Who pays first?
If the employer has less than 100 employees, Medicare is the primary payer
and
your group health plan is the secondary payer. If the employer has 100 or
more
employees, the group health plan is primary and Medicare is secondary.
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I have End-Stage Renal Disease (permanent kidney
failure
and group
health coverage (including a retirement plan).
Who pays first?
The first 30 months of eligibility or entitlement to Medicare, the group
health plan is
the primary payer and Medicare is the secondary payer. After 30
months, Medicare
is the primary payer without regard to the number of employees the employer has
and the group health plan is the secondary payer.
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I have COBRA and Medicare. Who pays first?
If you or your spouse are age 65 or over and have COBRA continuation
coverage,
Medicare is the primary payer. If you or a family member has Medicare based on
disability and COBRA continuation coverage, Medicare is the primary payer.
However, if you or a family member have Medicare and End-Stage Renal Disease,
COBRA continuation coverage if the primary payer for a 30 month period and
Medicare is the secondary payer.
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I have more than one group health plan. Who pays first? 1. The group health plan of the parent whose birthday falls earlier in a year
pays When a child’s parents are divorced or legally separated, these rules apply:
A group health plan that does not have a coordination provision will pay
first. Plans
with such a provision will be considered after those without one.
A group health plan which covers a person as an employee, member or
subscriber
pays first before a group health plan which covers the person as a dependent.
A group health plan which covers a person as an employee pays first before a
group
health plan that covers that person as a laid-off or retired employee. A group
health plan which covers a person as a dependent of an employee pays first before
a group
health plan which covers a person as a dependent of a laid off or retired
employee. If
the other group health plan does not have this rule, and if, as a result,
the plans do not agree on the order of benefits, this rule does not apply.
The group health plan which covers a person as an employee who is neither
laid off
nor retired or a dependent of an employee who is neither laid off nor retired pays
first before those of a plan which covers the person as a COBRA beneficiary.
When a child is covered as a dependent and the parents are not separated or
divorced, these rules apply:
first before the group health plan of the parent whose birthday falls
later in that
year;
2. If both parents have the same birthday, the group health plan that has
covered
the child for the longer time pays first before the group health plan
of the other
parent.
1. This rule applies when the parent with custody of the child has not
remarried.
The group health plan of the parent with custody will pay first
before the group
health plan of the parent without custody.
2. This rule applies when the parent with custody of the child has remarried.
The
group health plan of the parent with custody pays first. The group health
plan
of the stepparent that covers the child as a dependent will be considered
secondary. The group health plan of the parent without custody will
be
considered
last.
3. This rule will be in place of items 1) and 2) above when it applies. A
court
decree may state which parent is financially responsible for medical and dental
benefits
of the child. In this case, the group health plan of that parent will be
considered before other plans that cover the child as a dependent.
4. If the specific terms of the court decree state that the parents shall
share joint
custody, without stating that one of the parents is responsible for the health
care expenses of the child, the plans of benefit determination rules outlined
above; when a child is covered as a dependent and the parents are not
separated or divorced.
If there is still a conflict after these rules have been applied, the benefit
plan which
has covered the employee or dependent for the longer time will pay first. When
there is a conflict in coordination of benefit rules, the plan will never pay more than
50% of allowable charges when paying secondary.
If a plan participant is under a disability extension
from a previous group health
plan, that group health plan will pay first and this group health plan will pay second.
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complete and sign it?
Alternative Insurance Resources sends each Plan Participant a
subrogation form
when a claim has been received on the employee or dependent of
the employee
that indicates that there has been a possible accident. Some
accidents are caused
by another party. If this is the case, there may be liability by this third party
and this third party may fully or partially pay
any claims in connection with this
accident. Your group insurance plan contains a subrogation clause that states
that in the case of third party liability the
plan may recover any benefits paid
under the Plan. Please complete and sign the
subrogation form and the
accompanying accident form and return to us to expedite
your claim. If the claim
is not an accident, please state so. For more
information refer to the "Provision
for Subrogation and Right of
Reimbursement" in your Plan. A copy of the Plan
is available on this website.
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Why can’t I change my address over the phone?
Due to privacy concerns any change of address must be made in writing. You
need to send the change of address to your employer and request that they
advise us of the change. You can also send the change of address directly to
us by mail, by fax or by email as long as the email will show your name in the
email address.
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What do I do when I discover incorrect personal information
on my ID card?
Due to privacy concerns any correction on your ID card must be requested in
writing. This includes spelling of any name, social security number or ID
number,
or birth date of any covered family member. These corrections can be
made
through your employer, or directly to us by mail, by fax or by email as
long as
the email will show your name in the email address.
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How do I get coverage for a new dependent(s)?
If you already have dependent coverage on your policy, your new dependents
will be covered from the day they qualify as dependents (birth, adoption or
marriage). You need to notify your employer of the birth of a child, placement
of a child in your household for adoption, or marriage. Prompt notification of
your
employer will help avoid any delay in coverage and will expedite the
ordering of
new medical ID cards with the names and birthdays. Documentation of
the
adoption or marriage may be requested. If you marry a person who has
dependents that will reside with you, you will be asked for a copy of any court
order designating who is responsible for medical insurance coverage for the
stepchildren.
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What do I need to do in case of divorce?
You must notify your employer of your divorce within 60 days after the
date of
your divorce. Your former spouse will be eligible to enroll in COBRA
continuance
of medical insurance from the date of the divorce. You will also
need to supply
a copy of the first page showing the parties involved, the last
page of the decree
with the date and the judge’s signature and a copy of any
pages that state
which party is responsible for medical insurance coverage for
any dependent
children.
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What do I do when my dependent reaches the age of 19?
You must notify your employer within 30 days of the dependent’s 19th
birthday
if the dependent will not be attending a university, college or trade
school. At
that time your dependent may be eligible for COBRA continuation of
medical
insurance.
If your dependent will be attending a university, college or trade
school you
must
notify your employer within 30 days of the 19th
birthday and provide verification
from the registrar’s office that your
dependent is enrolled (or pre-enrolled) as a
full time student for the first semester/quarter following the 19th birthday.
Please refer to your benefits booklet for notification of subsequent attendance
at the university, college or trade school.
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What do I do when my dependent is about to graduate from
college?
When your dependent begins the last semester/quarter in college and you have
a graduation date, you need to notify your employer of that date. Notification
of graduation from college must be received within 30 days of graduation. You
can also send the same information to us by mail, fax or email, or you may
request that your employer notify us. After graduation your dependent may
then be eligible for COBRA continuation of medical insurance.
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What is the fax recall system?
The fax recall system is an automated system which will fax to the caller
information on eligibility, plan coverages, and claim status for a specific
eligible
eligible employee
information on eligibility, plan coverages, and claim status for
a specific eligible employee and family members.
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How
do I access the system?
You may access the system directly by dialing 205-871-3270. As a provider,
you will need your tax ID number and/or your fax number and the covered
employee’s social security number. Choose option #1 for providers and
follow the prompts:
#1 - Eligibility, benefits (medical), & claim
status.
#2 - Dental benefits
#3 - Vision benefits
#4 - Claim status only
OR you may dial 800-451-4318 and choose option #5 for the fax recall system
and then follow the above instructions.
You must use the covered employee’s social security number not the patient’s
SSN to access the system. If you have any questions about the fax system,
please call 800-451-4318 and press "0" for the operator.
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What
is a Preferred Provider Network?
A Preferred Provider Network, also
commonly referred to as a PPO or PPO network
is a group of hospitals, doctors, medical equipment companies, physical therapy
companies and so on that agree to accept a discounted price for healthcare
services provided to a Plan Participants of an Employer’s Group Health Plan. A
Plan will generally offer more generous benefits if a Plan Participant will utilize
the services of a healthcare provider participating in the PPO network. If your
Plan utilizes the services of a PPO network, you can find that information on
your ID card or your Plan’s Home Page that can be accessed from our Home Page.
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How can my healthcare provider become a participating provider
of our
Company’s Preferred Provider Network if they do not
currently participate
as a preferred provider?
First, of course, your healthcare provider must be willing to participate in
your
Company’s Preferred Provider Network. If your provider agrees to
participate,
they should contact the telephone number for the preferred provider
network
listed on your ID card. Your providers willingness to participate does not
guarantee that your Company’s PPO network will enroll them as a preferred
provider, but the chances are good that the PPO network will extend an offer
for your provider to participate subject to certain discounting agreements and
credentialing.
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How
can I get information about a claim payment?
Once your claim is processed, our office will send to your last known mailing
address an EOB (Explanation Of Benefits). Please allow
approximately 3 weeks
for your claim to be processed and an EOB mailed to you.
You may contact our
office after this 3 week period if you have not received any
correspondence
from our office about the status of your claim. This information
is also available
through your Plan’s Home Page. Once you access your Plan’s
Home Page from
our Home Page screen, follow the instructions for eligibility
status and claims
status on that screen.
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What
is Creditable Coverage?
Creditable Coverage is prior coverage under either group or individual
insurance,
COBRA, Medicaid, Medicare or a public health plan. The prior coverage
only
qualifies as creditable if
it is continuous under the Health Insurance
Accountability
Act of 1996 (HIPAA) definition. That is, there must not be a
break in coverage
of 63 days.
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What is HIPAA?
HIPAA is the "Health Insurance Portability and Accountability Act of 1996."
It is
legislation designed to improve a person’s ability to change jobs within
certain
limitations without losing eligibility for health coverage for a
condition that existed
prior to being hired by a new employer and enrolling in
their plan.
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What is an EOB or Explanation of Benefits?
A written statement from our office "explaining" how your "benefits" are
processed.
These statements are mailed to members twice monthly if a member has
had
claims processed during that time period.
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Does my plan require a Pre Cert?
Your Plan may require precertification for a variety of healthcare services.
PRECERTIFICATION INFORMATION IS PROVIDED UNDER THE SCHEDULE OF
BENEFITS. This
information may also be obtained off of our website under your
Plan’s Home Page.
Enter the four character group number off of your ID card
and this will take you to your Plan’s Home Page. From there, you can access
this information in the on-line copy of your Plan Booklet.
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participant
in my preferred provider network (PPO)?
In order to identify if your provider is a member of your PPO network, you
(or your provider) may contact the PPO network at the number listed on the
back of your ID card. If the telephone number of the PPO network is not listed
on your card or if you prefer, you may go to our Home Page and enter the group
four character group number from your ID card to enter your Plan’s Home Page.
Then click the appropriate button to get this information from your PPO’s website.
You may call Alternative Insurance Resources for the telephone number of your
PPO network or contact your insurance representative at your Employer.
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What is COBRA?
COBRA is the Consolidated Omnibus Budget Reconciliation Act
of 1985. This law
provides for the continuation of group health coverage that
otherwise would be
terminated.
COBRA contains provisions giving certain eligible employees, former
employees,
retirees, spouses and dependent children the right to temporary
continuation
of health coverage at group rates. This coverage, however, is only
available in
specific instances. Group health coverage for COBRA participants is
usually more
expensive than health coverage for active employees, since usually
the employer
formerly paid a part of the premium. It is ordinarily less
expensive, though, than
individual health coverage.
The law generally covers group health plans maintained by employers with 20
or more employees in the prior year. It applies to plans in the private sector
and
those sponsored by state and local governments. The law does not, however,
apply to plans sponsored by the Federal government and certain church- related
organizations.
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How long does COBRA last? Spouse and Employee entitled of Medicare 36 months
Beneficiary Qualifying Event Length of Coverage:
Employee and Termination of Employment 18 months
Dependents
Employee and Reduction of Hours 18 months
Dependents
Dependent Child
Spouse and Divorce or Legal Separation 36 months
Dependent Child
Spouse and Death of Employee 36 months
Dependent Child
Dependent Child Loss of "Dependent Child" Status 36 months
In certain circumstances, coverage may be extended due to Social Security
Disability determination, please contact our eligibility department for more
information.
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To order a new card, please contact our eligibility department at 871-3229 in
Birmingham or 800-451-4318 outside of Birmingham, and one of our
representatives will be happy to place a card order for you. New cards can
also be ordered by your employer, or by making a direct request to us by mail,
by fax or by email as long as the email will show your name in the email address.
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What is a deductible?
A deductible is the amount of covered expenses for which you are responsible before
What is coinsurance and copay?