How can I request access to the portal?
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| Please click here and make the appropriate selections. If you require assistance, please contact customer service at 1-800-279-4000.
Member requests will be processed within 1 business day . Provider and employer requests will be processed within 48 business hours. |
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What do I do if I have forgotten my user ID or password?
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| Your user ID is the email indicated during the sign-up process. Please contact customer service at 1-800-279-4000 for assistance. |
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What if I need help with the portal?
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| Submit a message to Customer Service with the Send a Message link on this website. A response will be received within the next 4 business hours. Customer Service can be reached at 800-279-4000 between the hours of 7:30 and 5:00 |
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How can I contact Customer Service?
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| Submit a message to Customer Service with the Send a Message link on this website. A response will be received within the next 4 business hours. Customer Service can be reached at 800-279-4000 between the hours of 7:30 and 5:00 |
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How long will it take to process my claim?
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| The time to process a claim depends on these factors:
1.) Generally claims are received within 30 days from the date of service. Some cases can take up to 60 days before your doctor or hospital submits a claim.
2.) Claims are processed within 30 days of receiving them.
3.) If you have gone to a non-network doctor or hospital, two additional factors may affect how long it takes to process your claim:
4.) Whether the doctor or hospital requires partial or full payment at the time of service.
5.) Whether the doctor or hospital bills us directly or requires you to submit a medical claim form. |
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What if I can't find my claim?
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| If the claim doesn't appear in the list after searching, here are a few things to try:
1.) If your doctor submits your claims, and it has been less than 15 days since the date of service, check again in a few days.
2.) If it has been at least 15 days since the date of service, contact your doctor's office to make sure they sent in the claim
3.) If you sent in the claim yourself, and you sent the claim at least 15 days ago, double check your copy to make sure all the information is correct (such as your Member ID, Group number, patient name, date of birth). If information is incorrect, please send in the claim again.
4.) If a claim is older than two years, please contact customer service at 1-800-279-4000. |
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Can I print an explanation of benefits/payment?
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| Not at this time. Please call Customer Service at 800.279.4000 if you need a copy. |
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How much am I responsible to pay?
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| 'Estimated Total Patient Responsibility' is the amount the provider may bill you. This is found within the claim under the claim detail section. |
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What does the Net column in the Claim Detail screen mean?
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| This is the amount we have paid the provider for the service. |
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Why does the request adjustment link at the bottom of my claim detail screen give me an error message?
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| If you feel that we have incorrectly processed your claim, please send us a secure message. |
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What does claim status: 'Processed' mean?
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| A final determination of payment has been made. |
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Why does the end date on my eligibility screen show 1/1/3000?
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| This does not mean your plan has termed, this is the date the system uses because there needs to be a date listed in this field. |
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What is Allowed Amount?
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| We limit reimbursement to the maximum allowable fee for cost-effective covered services, subject to applicable deductible, coinsurance, and copayment amounts. If a charge exceeds our maximum allowable fee, we may reimburse less than the billed charge. You are responsible for any amount charged in excess of our maximum allowable fees, as well as applicable deductible, coinsurance, and copayment amounts.
When you use a Network provider, we will pay the amount we have contracted to pay for each covered service, subject to applicable deductible, coinsurance, and copayment amounts. Other than deductible, coinsurance, and copayment, Network providers will not bill you for amounts that exceed our payment for covered charges.
Non-network physicians are not limited in what they can bill you. Their bill can sometimes be more than what the plan allows (which is the Allowed Amount). You may be responsible for paying the entire difference, and the amount may not apply to your out-of-pocket maximum or deductible. |
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What is the difference between a copayment, deductible, coinsurance and MOOP?
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| Deductible
The deductible is the amount that you must pay in a Benefit Period for covered services before we will reimburse you for any covered costs you incur during the remainder of that Benefit Period. The deductible must be satisfied in each Benefit Period. Deductible amounts you must pay out-of-pocket are generally less for Network providers than for non-network providers.
Individual and Family Deductible
We apply an individual deductible to the maximum allowable fee for covered services incurred by each individual during a Benefit Period. Once an individual satisfies his or her deductible, no further deductible applies to that individual for the remainder of that Benefit Period.
However, there is also a maximum family deductible. Deductible amounts paid for individuals are combined to satisfy the family deductible. Once each individual's deductible or the family deductible is met, whichever happens first, no further deductible applies to any family member for the remainder of that Benefit Period. The individual and the family deductible amounts, for both Network and non-network services, are specified on your Benefit Summary.
Copayments
A copayment is a fixed amount you must pay out-of-pocket each time you receive certain services. For example, Physician office visits, urgent care visits, emergency room visits, and the prescription drug benefit of this policy may be subject to copayments. Copayments do not apply to all services, and the amount may vary for different services. Copayment amounts you must pay out-of-pocket are generally less for Network providers than for non-network providers, and may be different for primary care providers than specialty care providers. Your Benefit Summary specifies copayments you must pay, for both Network and non-network services, and the services to which they apply.
Coinsurance
Reimbursement for covered services may be subject to a coinsurance payment. This means we pay only a specified percentage of the maximum allowable fee for covered services, and you are responsible for paying the remainder. Coinsurance amounts you must pay out-of-pocket are generally less for Network providers than for non-network providers. Your Benefit Summary specifies the coinsurance percentages you must pay, for both Network and non-network services, and the services to which they apply. |
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What is out-of-pocket maximum?
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| The maximum out-of-pocket limit is the most that you must pay for deductible, coinsurance, and copayment amounts during any Benefit Period. Maximum out-of-pocket limits are higher for non-network providers than for Network providers.
Note: The amounts we apply to your non-network maximum out-of-pocket limit are not transferable, and do not apply to your Network maximum out-of-pocket limit. You must meet each maximum out-of-pocket limit separately, if you seek services from both Network and non-network providers. |
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Can I submit a claim adjustment in the portal?
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| A provider can submit a claim adjustment in the portal when reviewing a claim by selecting the link to submit an adjustment request. The form will allow you to attach all supporting documentation associated with the request. |
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How does the Grievance process work?
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| What a Grievance Is
A grievance is any written dissatisfaction with our services, our claims practices, or our administration of your health plan. For example:
1.) You believe you have not received the reimbursement the policy promises.
2.) You believe you have been denied coverage promised by the policy.
3.) You are dissatisfied with covered services you received from one of our providers.
4.) You believe your coverage has been unfairly terminated.
Right to Submit a Grievance
If our ombudsperson is unable to resolve your complaint to your satisfaction, you may pursue your complaint through our grievance procedure.
How to Activate the Grievance Process
We have two grievance procedures: a standard grievance procedure and an expedited grievance procedure that includes a process for urgent care claims. Both are summarized below. If you would like more information about either grievance procedure, you may request a copy of our detailed description, which includes all legal requirements.
Procedure for a Standard Grievance
To file a formal grievance, you or your authorized representative must submit it to us in writing at this address:
Ombudsperson
WEA Insurance Corporation
P.O. Box 7338
Madison, WI 53707-7338
Your written grievance may be submitted in any form but should include the following information:
1.) The employee's name and subscriber number.
2.) Why you are dissatisfied.
3.) Any information you think is relevant, such as dates and events in chronological order and names of any providers involved.
4.) Copies of any documents that relate to your grievance.
5.) What you believe to be a fair resolution of your grievance.
We will acknowledge receipt of your grievance within 5 business days after we receive it. Your grievance will be considered by our Grievance Committee within 30 calendar days of its receipt. If we are unable to make a decision about your grievance within the 30-day time limit, we may extend the limit an additional 30 calendar days by informing you in writing of the reason for the extension and the date by which the decision will be made. |
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Do I need a referral to see a network physician specialist?
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| The Trust does not require a referral to see a network physician specialist; however you may want to check with your individual clinic they may require one in order to schedule an appointment with a specific physician. |
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Do I need to notify you prior to going to the hospital?
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| To receive maximum reimbursement, you must notify us of any overnight hospitalization. If your hospitalization is or can be planned in advance, you must notify us before you are admitted at least 5 days in advance, whenever possible. If you are hospitalized due to an emergency, you must notify us within 72 hours of being admitted or as soon as it is medically feasible for you to do so, whichever is later. If you don't notify us as required, your reimbursement will be reduced by the amount of the penalty shown on your Benefit Summary. |
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Can I request prior authorization in the portal?
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| A user representing a provider can request an authorization in the portal. Once the user is signed in, please select the Request an Authorization link, which will take you to the existing online form. Authorization reviews can take up to 15 days from the time the request is submitted. For urgent requests (services within 72 hours), please contact Customer Service. If you require assistance, please contact Customer Service at 1-800-279-4000. |
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Why can't I find my authorization?
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| If you are unable to find your authorization, it may be because the authorization has not yet been submitted for approval. If you are looking for a closed or completed authorization that is older than two years, please contact Customer Service at 1-800-279-4000. |
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How do I change my name or address?
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| To change your name or address, your may send us your request through our secure portal. |
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How do I add or remove a dependent or edit information about them?
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| Complete the Enroll a Dependent form on this website. |
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Can I discuss someone else's health care?
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| You must have permission from the member or the member's representative in order for us to provide their health information to you.
Our policies strictly adhere to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). |
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Can I see claims for other family members?
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| The person who signed up for the health plan (the subscriber) can usually view claims for a dependent. Still, they can only see health information that is not protected by various privacy laws.
Members 14 years of age and older require a unique sign-in to view medical information. |
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I can't find all of my eligibility information.
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| For any missing information or information older than two years, please contact customer service at 1-800-279-4000. |
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I can't find my Summary of Benefits and Coverage or my Benefit Summary.
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| For any missing information or information older than two years, please contact customer service at 1-800-279-4000. |
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How soon would I see my new enrollment or enrollment change?
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| New enrollments and enrollment changes are typically processed within 5 business days. |
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I can't find my individual bill for premium.
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| Individual premium bills are not currently available through the portal. Please contact Customer Service at 1-800-279-4000. |
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