Advocates of Excellence

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Helps members with rare, serious or complex medical conditions identify top medical institutions, critical illness providers and specialized medical programs across the country.
 

Care Coordination

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The Personal Health Advocate helps members coordinate care among physicians and medical institutions in various ways:

§          Explain tests, treatments, and medications recommended.

§          Assist members through a complex medical condition.

§          Facilitate transfer of medical records, reports prior to a scheduled appointment with a new physician.

§          Arrange for covered homecare service or equipment.

§          Facilitate review of records/results with another physician for confirmation of diagnosis.

§          Schedule or coordinate appointments for services.

§          Arrange for evaluation for patient participation in a clinical trial.

§          Arrange hospice and other services for terminally ill patients.

§          Facilitate transfer from a community hospital to a tertiary care facility.
 

Claims Assistance

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Personal Health Advocates help sort out and solve claims and related paperwork problems. 

Examples of other services include:

§          Research member’s outstanding out-of-pocket responsibilities and resolve errors with providers or health plan.

§          Correct balance-billing problems.

§          Resolve eligibility problems and benefit and claims denials.

§          Resolve issues regarding medical or wellness benefit application.

§          Coordinate benefits between dental, medical, workers comp and disability characters.

§          Resolve incorrect plan procedure interpretations.

§          Resolve incorrect application of provider network status.

§          Correct errors in processing of “blind” network provider discounts.

§          Facilitate information from provider to payor to resolve unpaid claim.

§          Resolve coordination of benefits disputes between multiple carriers.

§          Resolve errors in the application of deductibles and co-payments.
 

Physician Locator

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Helps members identify primary and specialist physicians, hospitals, dentists, and related healthcare providers.  Our first focus is on network relationships to help members use their benefits to their best advantage.
 

Fee Negotiation

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Health Advocate can attempt to negotiate fees with healthcare providers to lower the member’s out-of-pocket costs.
 

Coverage Advantage

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If there are questions of coverage for a particular service, or if coverage for clinical care has been denied, the Personal Health Advocate can help members through the review and appeals process. 

Examples:

§         Obtain exceptions for a member to see providers outside of capitation.

§         Coordinate referrals for required services.

§        Obtain transitional care coverage when medically necessary.

§         Resolve incorrect denials of benefits as non-covered, not medically necessary or ineligible.

§         Counsel members regarding current benefit costs and the cost of alternative approaches.

§         Assist members in obtaining coverage for and access to medical equipment, devices, and  supplies.  (e.g. Hearing aids, diabetic supplies, compression stockings)

§          Assist in transition for out-of-network to in-network providers.

§         Assist with preauthorization and predetermination procedures.

§         Locate “hard-to-find” IV drugs or home care services to facilitate hospital charge.

§         Assist employees with disability coverage questions and help them return to work.

§         Resolve issues involving disabled dependent rules, Family Medical Leave, COBRA, etc.
 

Senior Care Navigator

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For employees or family members approaching retirement or already retired, we offer access to a wide array of services specifically geared for seniors.  Our Personal Health Advocates understand senior members’ needs and can help members select the appropriate professionals.  Among the kind of issues we have worked on are:

§          Locate alternative care facilities.

§          Obtain coverage for medical supplies.

§          Provide information on adult day care programs.

§          Coordinate coverage for home care services with Medicare and Medicaid.

§          Assist with transition of insurance coverage and benefits from private insurance to Medicare.

§          Locate physicians who make house calls.
 

CareQuest

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Helps locate and makes arrangements for members’ special service needs.  The individual member is responsible for payment of any specific services arranged on a fee-for-service basis that are not covered by an insurance plan. 

Examples of these services include:

§          Locate homemaker, day care or rehabilitation services not covered by insurance.

§          Locate inpatient private duty nursing.

§          Find a group home for individuals with special needs.

§          Locate home health aides.

§          Help complete applications for individual coverage options, including Medicaid and Medicare.
 

Rx Advocate

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The Personal Health Advocate can provide members with assistance on prescription drug issues including formulary and benefit questions.

§          Provide information on generic drugs.

§          Locate lower cost sources for prescription drugs that are not covered by health plan.

§          Assist members in obtaining mail order prescriptions.

§          Resolve disputes between members and pharmacies regarding formulary rules.

§          Obtain coverage for medications that require mail order.