Useful Information

Enrollment Information
Lowering Out-Of-Pocket Costs
Effectively Using The Plan
Questions Before Getting A Scan
After Coverage Ends - COBRA
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Government Information Links
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Family Medical Leave Act - FMLA
Medicare Part D Guidance
Medicare & Over-65 Employees

Suggestions To Make The Plan Work Effectively
  1. Enroll Yourself And Your Dependants For Coverage On-Time
    It is extremely important that you enroll on-time to assure that there are no restriction on your coverage. When you become eligible, you have 31 days to enroll your self and any eligible dependents. If you or the dependents are not enrolled within the 31 day period, there may be some limits that you should understand. These are explained on this Web Site in the section titled, Your First Year On The Plan.

    When you get married or have a new family member, it is also important to enroll the new spouse or new dependent within 31 days of the event.

  2. Carry Your Identification Card
    Carry your current identification card with you at all times and show it when you receive covered services. If you have an older card, return it to your supervisor. Insist that the provider of care uses the proper claims filing address when they file the claim. The card has phone numbers for pre-certification, preferred provider networks and claims administration. Understand the difference between these phone numbers as follows:
    • Pre-Certification: Call (you or your physician or the hospital) when you have a scheduled service that needs to be pre-certified or as soon as possible after an emergency admission.
    • Preferred Provider Network: Call to verify the participation status of a medical care provider, before having a service or to complain about a provider billing over the Network payment level.
    • Claims Administrator: Call when you have a question about your or any or your dependents eligibility, want to know what is covered, want to know the status of a claim, or question a payment.

  3. Understand Your Drug Card And Your Medical Card
    If you have a drug card, understand the difference between the drug card and the medical identification card. Use the drug card only when obtaining prescriptions and the medical card only when obtaining medical services.

  4. Confirm Provider Network Participation Before Any Service
    Always confirm that a medical care provider you will see is in the network. Look up the status on the network Web Site (links are within this Web Site) or call the phone number on the ID card and ask the staff at the network for participation status. While the booklets are helpful, they may be out-of-date concerning the status of a provider's participation.

  5. Use Network Providers
    Use network providers to maximize your coverage under the Plan.

  6. Be Careful On Physician Referrals Made By In-Network Physicians
    Some in-network physicians make refer you to non-network physicians for specialized care or for other medical services. To assure that you maximize Plan benefits, ask for referrals to in-network physicians or other care providers. If you are referred to an out-of-network medical care provider, the benefit will be considered an out-of-network benefit and will be paid accordingly. While most physicians will assist you on staying innetwork, it is your responsibility to determine where you obtain services.

  7. Watch For Balance Bills
    Your network has negotiated a discount for most services. You are responsible for deductibles, coinsurance and co-payments, but not for "balance billing" from a physician or hospital. If the medical care provider bills you for the amount of charges over the network fees, you should not pay the bill. Your Explanation of Benefits (EOB) gives more detail about your responsibility. Keep the EOB and when you receive a physician bill, match the EOB for the date of service being billed. If the bill is for a "balance bill", call the medical provider and explain that your network has negotiated a discount and that they should not bill for the discount amount. If the problem remains after calling the provider, call the network (number on your ID card) or call the claims administrator (number on the ID card) or submit an inquiry from the Inquiry Section of this Web Site.

  8. Never Pay More Than The Office Visit Co-Payment
    When you visit an in-network physician, most plans have a co-payment amount due at the time of the visit. If your Plan has a co-payment for in network office visits, only pay the co-payment amount at the time of the visit.

  9. Reconcile You Benefits
    Track your medical services and the benefit plan actions to reconcile the physician and hospital bills with Plan payments. Match every medical provider bill with every benefit plan payment to determine if any provider bills are appropriate and accurate and to look for any "balance bills".

  10. Use Your Deductible Wisely
    Many Plans have a carry-over deductible, anything spent toward the deductible in October, November or December counts toward your deductible starting in January. If you can delay services that will be applied toward your deductible to these three months, it will help ease the deductible impact in the new year. Check to see if your plan has the carryover provision and, if so, plan accordingly.

  11. Provide Your Certificate of Creditable Coverage
    If you are a new employee and had previous coverage, provide a Certificate of Creditable Coverage to your new plan. If the coverage is creditable, it will help reduce the impact of limits on payment for pre-existing conditions.

  12. Don't Panic On First Billing Statement
    Providers often bill the Plan at the same time they bill the patient with a statement similar to the following: "Your Insurance Has Been Billed And Not Responded". Since your benefit Plan is just receiving the claim, of course there has been no response. It takes between 15 and 35 days to process claims that are complete when received or that have no issues that delay the claim for further research.

    If you receive a bill from your medical provider within 40 days of your service date, we suggest that you ignore the bill and wait for us to take action. It is likely that we will be contacting you in the near future with action taken on the claim.

  13. What To Do When You Receive The Second Billing Statement
    If for some reason you receive a second billing statement from your medical care provider, we suggest the following:
    1. Call your provider and check where the claim was filed. If it was not filed to the address on your ID card, ask them to file it to the proper address.
    2. If the claim was filed to the proper address, contact us by phone or through the Inquiry Section of this Web Site and provide the following:
      • Your Name
      • The Social Security Number Of The Covered Employee
      • Name Of Medical Provider
      • Date Of Service
      • Charge For The Service
      • Reason For The Call

      We will contact you with an answer to your question.

  14. Watch For Claim Denial Due To A Pre-Existing Condition
    If you have been on the Plan for less than a year, we suggest that you carefully review the section of this Web Site titled, Your First Year On The Plan. This location has important information that may impact your coverage and result in a claims denial if certain action is not taken by you.

  15. Watch For Claim Denial As A Potential Accident Claim
    If we receive a claim that could have been caused by a third party in an accident, we will ask for accident details. An example of this is a claim for a broken bone or laceration. Since many claims for these conditions are caused by an accident, we will suspect that your claim may be caused by an accident. Before we complete the claim, we will ask for "accident details" on the Explanation of Benefits (EOB). Please respond in writing, either through the mail or through this Web Site at Provide Accident Information.

  16. Watch For A Claim Denial On An Over-Age Dependant Student
    If we receive a claim for one of your dependents over the limiting age of your Plan (usually over age 19), we will ask for confirmation that the dependent is a full-time student. Please provide some record from the school-, such as a paid receipt, course record or schedule that proves that the dependent is a student.

    Send the documentation in writing, by mail or by fax. If you have the ability to scan the document, e-mail it to us at reachus@avalonbenefits.com.

  17. Keep And Read Your Summary Plan Description
    The Summary Plan Description is provided to you at the time of your enrollment and when the Plan makes periodic updates. Please keep it and become familiar with the description of benefits. It describes in detail the eligibility requirements, the benefit coverage and other important information and is the document used by the claims administrator to determine if an individual or a service is eligible for coverage.

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