Health Plan Transactions

The following information is provided by Group Benefits Strategies (GBS), SMHG’s Central Benefits Administrator

ENROLLMENT/CHANGE FORMS

Please check forms for completeness:

• Date of hire for new effectives
• Effective date
• Termination date
• Group Number MUST be on forms
• Date(s) of birth
• Address
• PCP for HMO’s
• Subscriber signature (new effectives, changes, voluntary cancellations)
• Legible handwriting

2. Late enrollees may enroll for coverage during open enrollment or at the time of a qualifying event. When enrolling someone off anniversary, the effective date should be the date of the qualifying event. The health documentation when adding someone off anniversary.

• Loss of coverage documentation
• Adoption/placement papers for an adopted dependent
• Court order for legal guardianship
• Divorce decree when necessary
• Additional information as requested by the health plan

There is a time restriction when enrolling someone due to a qualifying event. The enrollee should notify you within 30 days of the qualifying event. The health plans allow 60 days from the date of the qualifying event for the transaction to be processed.

3. Daily Proration – For SMHG we use a daily proration calculation using the number of days in the month.
ie; If the rate is $675.00 – you need to divide the rate by the number of days in the month. So for January the daily proration would be $675.00/31 = $21.77 a day.

IF the cancel date is 1/27 then that person would have 27 days of coverage for January, so the rate for January would be $587.79.
The calculation is based on the last day of coverage for terminations and the first day of coverage for new hires.

Cancel dates: We use the last day of coverage for the cancel date. We upload to the BCBS system and the BCBS system date to accommodate their system.

General Items

• Forms should be mailed to GBS. If it is an emergency enrollment, employers can fax the form. It is extremely difficult to read faxed forms.

• Sometimes GBS receives faxed birth certificates, Medicare cards, full time student documentation, loss of coverage documentation, etc., without any notes or cover sheets. Occasionally it is extremely difficult to identify where this information belongs. It would be helpful to have a cover sheet.

• Employees/retirees need to contact customer service if they need new ID cards (In case of lost or missing ID cards)

Benefit Summaries and Plan Rates

Benefit Summaries and Plan Rates