I understand that Corporate Benefit Services of America, Inc. (CBSA) is the Third Party Administrator (TPA) of my employer’s health benefit plan. If I have general questions, how can I reach them?

Mail	Corporate Benefit Services of America 400 Highway 169 South , Suite 800 Minneapolis, MN 55426-1141 or CBSA P.O. Box 27267 Mpls., MN 55427-0267
Phone	800-925-2272
Flex Department Phone	800-262-3875
Fax	Service Center 952-541-9943
24 Hour Customer Service Information Line, an Interactive Voice Response (IVR) System	800-566-9311
24 Hour Answer Line, for frequently asked questions; an Interactive Voice Response (IVR) System	888-593-6490
Website	www.cbsainc.com

A self-insured group health plan (or a 'self-funded' plan as it is also called) is one in which the employer assumes the financial risk for providing health care benefits to its employees. In practical terms, self-insured employers pay for employee medical costs as they are incurred instead of paying a fixed premium to an insurance carrier for what is known as a fully insured coverage. Typically, a self-insured employer will set up a special trust fund to earmark money (corporate and employee contributions) to pay claims as they are incurred.

Self-insured employers can either administer the payment of claims in-house, or subcontract this service to a third party administrator like CBSA. Third party administrators can also help employers set up their self-insured group health plans and coordinate stop-loss insurance coverage, provider network contracts and utilization review services.

On most plans, an eligible dependent will be a covered person’s married spouse. Some of the plans do allow coverage for a domestic partner. Check your benefit booklet for details.

Generally coverage is also available for each unmarried child who is not yet age 19. Some plans also allow unmarried children to be covered until ages 23 or 25. Verify the age limit in your benefits booklet.
The term “child” is defined as:

a) a natural born child
b) a stepchild
c) an adopted child
d) a child for whom the Covered person is the legal guardian

Most health and dental plans contain a coordination of benefits provision. This means that if one person is covered by two benefit plans, both companies share responsibility for covering the person's health care expenses. This avoids the duplicate payment of benefits and helps hold premium costs down.
CBSA periodically requests updated information regarding other coverage you and your family members have. Examples of other coverage are:

• Medicare, either due to age or disability,
• Group coverage through the employment of another family member,
• Association group coverage through an organization you or a family member belong to,
• Student health insurance covering dependent children, or
• Coverage mandated by a divorce decree, requiring a divorced spouse to carry coverage on certain dependent children

The information can be mailed, faxed or called in to our Service Center. The information should include:

• The name, address, phone number and policy number of the other insurance company or plan;
• In the case of group or employer coverage, the name of the group or employer
• The name and birth date of the person who is listed on the coverage as the primary member or policyholder
• The effective date of the coverage
• The type of coverage, such as medical or dental
• The names of the family members covered under the plan

Information returned to CBSA by mail can be returned to the address indicated in the letter you received, or to:

CBSA
P.O. Box 27267
Mpls., MN 55427-0267

The number for information returned by fax is 952-541-0193. When faxing information to CBSA, it is important that you keep a copy of the fax machine's confirmation record which shows the date, time and phone number you faxed the information from. Our Service Center staff will need this information if you call later to confirm receipt.

On most policies, yes. Check your benefit booklet for the age limit.

Unmarried dependent children are usually not covered under your plan once they reach an age specified by your policy; usually age 19. Coverage may, however, be continued if the dependent is a full-time student at a high school, accredited college, university or trade school. Coverage then ceases at an age specified by your plan, such as age 25.

If your dependent is required to be a full-time student, coverage will be continuous over any scheduled academic breaks such as winter and summer breaks, as long as the dependent was enrolled and attending each academic session before and after the break. We may request dependent eligibility information from you periodically, or when a claim for the dependent is received. You must submit proof of the dependent's full-time student status to us when requested.

Acceptable written proof may include a Bursar's receipt for tuition, a Registrar's letter or other documentation provided by the school which verifies the quarters enrolled in, and the student's full time attendance.

If you received a letter or Explanation of Benefits form from CBSA requesting proof of a dependent's full-time student status, please attach your documentation to the form and return it to CBSA as soon as possible by fax or by mail. We are unable to take this information over the phone. Information returned by mail should be addressed to:

Corporate Benefit Services of America, Inc.
400 Highway 169 South, Suite 800
Minneapolis, MN 55426-1141

If the student status request was made on the Explanation of Benefits form for a claim, the number for information returned by fax is (952) 541-0193. If the student status request was made in the form of a letter from our eligibility department, the number for information returned by fax is (952) 593-2879.

When faxing information to CBSA, it is important that you keep a copy of the fax machine's confirmation record which shows the date, time and phone number you faxed the information from. Our Service Center staff will need this information if you call later to confirm receipt.

You should have received one when you joined the plan, but you can request one from your Human Resources department. You can also view your plan benefits on the CBSA website by going into the Electronic Services section.

Either you or your provider can obtain this information any time of the day or night through the IVR system. Dial 800-566-9311 and choose Option #1. You will need the policyholder’s social security number and the fax number to which the information should be sent. Providers can also obtain this information directly from CBSA’s website once they have signed up for access to patient information. You or your provider can also request this information by calling a Service Center Representative.

Once your enrollment form has been completed and submitted to CBSA, you should receive your ID card in 10 working days. If you need your coverage information prior to receiving your card, dial 800-566-9311 and choose Option #5 to request a faxed ID card.

If an employee has a new dependent as a result of marriage, birth, adoption, or placement for adoption, they may be able to enroll for coverage provided the employee requests enrollment within thirty (30) days after the marriage, birth, adoption or placement of adoption of a new dependent child.

The employee should get the enrollment forms or report of change forms from their employers’ benefit specialist.

You can verify this information in the eligibility section of your plan booklet.

You may have your proposed medical procedure preauthorized by CBSA’s Medical Review Board. Your doctor should fax a letter of medical necessity and a description of the procedure to 952-541-4754. When the review is complete, CBSA will notify your doctor of the decision. If you wish, you can call a Service Center Representative to verify this information.

Precertification is a part of the utilization review process; it is designed to ensure that patients receive quality care that is medically necessary and appropriate to their condition. Your managed care company must be contacted prior to a non-emergency admission. If you are admitted to the hospital on an emergency basis, you have up to 48 hours after admission to make the notification. The appropriate phone number can be found on the back of your ID card.

CBSA does not require claim forms to be submitted. The bill from your health care provider often provides adequate information to process a claim. The appropriate mailing address is indicated on the back of your ID card, which should always be shown to your provider at the time of service. You can verify your claims mailing address by calling the IVR system at 800-566-9311 and choosing Option #3.

You have a right to question and/or appeal the processing of a claim. To receive an explanation, contact a CBSA Service Center Representative, or email your inquiry to service@cbsainc.com

If you are still in doubt after receiving an explanation, send a written appeal to CBSA, Attn: Medical Review Department, P.O. Box 27267, Minneapolis, MN 55427-0267. Following a complete review, you will receive a written opinion/response.

A recent change in the law governing self insured employer groups, requires CBSA to send you a claim determination notice within 30 days of receiving your claim for benefits. This applies to claims received at CBSA on or after July first 2002.

For some self-insured employer groups, this means you may occasionally receive a claim determination notice, (or Explanation of Benefits form as it is called), before the check for benefits is actually released. This happens because the timing and frequency of check cycles for each group will vary depending on the funding options chosen by the group. If the benefit check has been released, the check number will be shown on the Explanation of Benefits.

Benefit checks are usually released no later than four weeks from the date the Explanation of Benefits form was mailed. If after more than four weeks, you receive a "balance due" statement from your provider, call the provider to see if all benefit payments received in the office have been credited to your account. In most cases, we find that the provider has the payment but has yet to credit your account. If payment has still not been received by the provider, please call our Service Center at 1-800-925-2272.

Your medical plan may contain a waiting period for expenses incurred in connection with a pre-existing condition. In general, a pre-existing condition is any illness or injury for which medical advice, diagnosis, care or treatment was recommended or received within a specified time period prior to your coverage enrollment date. Specific details on this time period and the waiting period for coverage can be found in your health plan benefits booklet or certificate of coverage.

If you submit medical claims for a condition which may be pre-existing, additional information may be required from you and your provider of service. You may be asked for a list of physicians that have treated you in the past for the condition, or your provider may see a request from CBSA for your medical records on the Explanation of Benefits form for the claim you submitted. It is your responsibility to make sure this information is submitted to CBSA since your claim will remain in a denied status until the requested information is returned.

The requested information can be returned to CBSA in several ways. If you were asked for a list of physicians that treated you prior to you're your enrollment, you can supply the information at the bottom of the Explanation of Benefits form you received and return it by mail or fax. You can also call our customer service department and provide the information by phone. Your provider can return requested medical records attached to a copy of CBSA's request by fax or mail. When all of the requested information has been received, your claim will be re-opened and a coverage determination made.
Information returned by mail should be addressed to:

CBSA
P.O. Box 27267
Mpls., MN 55427-0267

The number for information returned by fax is 952-541-0193. When faxing information to CBSA, it is important that you keep a copy of the fax machine's confirmation record which shows the date, time and phone number you faxed the information from. Our Service Center staff will need this information if you call later to confirm receipt.

The Health Insurance Portability and Accountability Act of 1996, placed limits on the extent to which your group coverage can exclude or limit coverage for pre-existing conditions.

For example, if you were covered by "creditable" health insurance for 12 straight months, with no lapse in coverage of 63 days or more, prior to your enrollment date with CBSA, the pre-existing conditions exclusion of your coverage will not apply to you.

If you had less than 12 months of prior creditable coverage, the waiting period for coverage of a pre-existing condition will be shortened by the number of days you were covered under the prior qualifying health plan. For example, if you had:

• high blood pressure as a pre-existing condition and
• three months of prior creditable health coverage and
• your new coverage with CBSA excluded benefits for pre-existing conditions for 12 months,

the 12 month waiting period would be reduced to 9 months, due to your three months of prior qualifying health coverage.

Most prior health coverage qualifies for this credit. It includes prior coverage under a group health plan (including a governmental or church plan), health insurance coverage (either group or individual), Medicare, Medicaid, a military-sponsored health care program such as CHAMPUS, a program of the Indian Health Service, a state high-risk pool, the federal Employees Health Benefit Program, a public health plan established or maintained by a state or local government, and a health benefit plan provided for Peace Corps members.

If you had prior creditable coverage but had a claim rejected by CBSA due to a pre-existing conditions limitation or investigation, we may not have a record of your prior coverage. In order to receive credit for the time you were covered, you need to request a COCC, "Certificate of Creditable Coverage" form from your prior benefits carrier. Your prior carrier is required to give you this information if you ask for it. After receiving this form, you should attach a copy of it to the claim determination or letter you received from CBSA, then return it to us by fax or mail.

The fax number information can be sent to is (952) 541-0193. When faxing information, it is important that you keep a copy of the fax machine's confirmation record which shows the date, time and phone number you faxed the information from. Our Service Center staff will need this information if you call later to confirm receipt. The address for mailing this information is;

CBSA
P.O. Box27267
Mpls.,MN 55427-0267

You can verify the status of all claims through the Electronic Services section of CBSA’s website or by calling CBSA’s IVR system at 800-566-9311 and choosing Option #2. You will need to have this information available:

• Employee social security number
• Dates of service for claims in question

You can also contact a Service Center Representative to request an annual claims detail report for tax purposes.

If we receive a claim that could be the result of an accidental injury or that may be the responsibility of a third party, you may receive a letter from CBSA requesting additional details. We ask that you please respond as soon as possible to the inquiry by fax or by mail to avoid a denial of benefits. We are unable to take this information over the phone. This information is important for several reasons.

Your plan may include special benefit provisions for accidental injuries or your health plan may not cover medical expenses resulting from a work injury. In the case of motor vehicle accidents, we may need to coordinate our benefit payments with your automobile or motorcycle No Fault medical coverage.

In addition, your health plan may have a right to recover payment made on your medical bills if they were incurred for an injury or condition caused by another party. This right falls under the subrogation and reimbursement provision of your coverage. If we pay benefits as a result of that injury or illness, we have the right, independently of you, to proceed against the party responsible for your injury or illness, to recover the benefits we have paid. Under certain circumstances, we may also be entitled to be reimbursed for the benefits we have paid from a settlement or a judgment you receive from the party responsible for your illness or injury.

Information returned to CBSA by mail can be returned to the address indicated in the letter you received, or to:

CBSA
P.O. Box 27267
Mpls.,MN 55427-0267

The number for information returned by fax is 952-541-0193. When faxing information to CBSA, it is important that you keep a copy of the fax machine's confirmation record which shows the date, time and phone number you faxed the information from. Our Service Center staff will need this information if you call later to confirm receipt.

You can request an EOB through the Electronic Services section of CBSA’s website or by calling CBSA’s IVR system at 800-566-9311 and choosing Option #2. Have this information available:

• Employee social security number
• Date of service
• Fax number for EOB to be sent

More commonly known as your RX vendor, a PBM contracts with independent pharmacies or a chain of pharmacies to provide prescription medicines at a discounted rate for retail and mail order prescription drug programs. Your PBM name and phone number is located on your ID card.

First, ask your pharmacist to contact the pharmacy help desk at the number listed on the front of your ID card to find out if there is a basic problem. If your pharmacist does not make the call, contact your Pharmacy Benefit Manager.

If your Pharmacy Benefit Manager indicates that the prescription is not covered, you may be required to seek pre-approval. If so, ask your doctor to send a letter of medical necessity to CBSA, Attn: Medical Review Dept., P.O. Box 27267, Minneapolis, MN 55427-0267.

A preferred provider is a member of a network of physicians or hospitals that has agreed to accept discounted fees for their services. Using a preferred provider will generally assure that you receive the best benefits for your health care dollars.

Since changes in network participation can occur, it is important to verify that your health care provider is a current participant prior to receiving medical services. Verification can be obtained by contacting the network directly or by logging onto CBSA’s website and clicking on “links”.

If you need additional assistance or verification, contact a CBSA Service Center Representative at 800-925-2272.

How can I have a provider added to the PPO?

Ask your provider to contact the PPO directly, or have your provider complete the provider nomination form on the PPO website. Once the desired provider has submitted an application for membership, the PPO will screen the provider based on their credentialing criteria to become a network member. The credentialing process differs for each network.

Your Human Resources department can make the changes on line through CBSA’s interactive website. Or, you can call a CBSA Service Center Representative.

You can request an ID card through CBSA’s interactive website. You can also use CBSA’s IVR system. Dial 800-566-9311 and choose Option #5. Have your fax number available.

If CBSA administers your COBRA coverage, you can contact a CBSA Service Center Representative at 800-925-2272.

You can request a COCC by calling CBSA’s IVR system at 800-566-9311 and choosing Option #6. Have your fax number available.