FAQ

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Q: Can I provide coverage for my child, a full-time student in college?

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

Q: How can I contact BPA?

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

Mail:

Benefit Plan Administrators
402 Graham Avenue
Eau Claire, WI 54701
or
Benefit Plan Administrators
P.O. Box 1128
Eau Claire, WI 54702-1128

Contact Customer Service:

800-236-7789 (toll free)

715-832-5535 (local)

Hours:

M-F 7:30am – 4:30pm

Q: How can I correct information that BPA has on file, such as the spelling of my name, my address or date of birth?

You or your Human Resources department may call a BPA Customer Service Representative at 800-236-7789. You can also go to the “Online Customer Service” page of the website and look for the link containing this question. An electronic form will display where you can enter your correct information and submit it electronically to BPA.

Q: How can I get a copy of my Explanation of Benefits (EOB)?

Use the “My Claims” section of the website to identify which covered person the charges were for and the date of service.  When you find the claim you are looking for, click on that Claim Number to view the EOB on your screen.  You can also click on the “Original EOB View” link to view a copy of the original EOB that was generated.

 

Q: How can I get a copy of my Plan Benefit Booklet?

You should have received one when you joined the plan, but you can also view your plan benefits on the BPA website after logging in.

Q: 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.

Q: How can I obtain a copy of my ID card?

Go to the “Online Customer Service” page of the website and look for the link that contains this question. An electronic form will display where you can enter your information and submit it electronically to BPA.  If you are unable to access the website, please call BPA’s Customer Service at 800-236-7789.

Q: How can I verify all claims paid for my family for the year?

Please use the “My Claims” section of the website or contact our Customer Service Department for assistance.

Q: How do I add someone to my policy?

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 the number of days specified in your plan booklet 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 employer’s benefit specialist. You may also retrieve the needed forms from our website by clicking on “Forms” and then selecting the appropriate form.

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

Q: How do I file 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. Your provider will then submit the required information to us on a standard form for processing. If you had to pay for the service in full and need to submit the claim for processing, please use the Forms section of the website and complete the Health Claim form.

Q: How long will it take to receive my ID card?

Once your enrollment form has been completed and submitted to BPA, you should receive your ID card within 7-10 business days. If you need your coverage information prior to receiving your card, dial 800-236-7789 and speak to Customer Service.

Q: I received an Explanation of Benefits form; why was the benefit check not mailed the same day?

A recent change in the law governing self-insured employer groups requires BPA to send you a claim determination notice within 30 days of receiving your claim for benefits.

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 Customer Service at 800-236-7789.

Q: If my pharmacist has a problem processing my prescription, what should we do?

First, ask your pharmacist to contact the pharmacy help desk at the number listed on the front of your ID card to find a solution to the problem. If your pharmacist does not make the call, contact the PBM directly.

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 BPA, Attn: Medical Review Dept., P.O. Box 1128, Eau Claire, WI 54702-1128.

Q: What if I have expenses for an accident or illness that may be payable by Worker’s Compensation, car insurance or another third party?

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 on behalf of the plan, independently of you, to proceed against the party responsible for your injury or illness to recover the benefits the plan has paid. Under certain circumstances, the plan may also be entitled to be reimbursed for the benefits it has paid from a settlement or a judgment you receive from the party responsible for your illness or injury.

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

Benefit Plan Administrators
P.O. Box 1128
Eau Claire, WI 54702-1128

The  number for information returned by fax is 715-838-8507. When faxing information to BPA, 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 Customer Service staff will need this information if you call later to confirm receipt.

Q: What if my dependents have other coverage?

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.

BPA 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 or faxed to our Customer Service Department.
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; and
•  The names of the family members covered under the plan.

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

Benefit Plan Administrators
P.O. Box 1128
Eau Claire, WI 54702-1128

The number for information returned by fax is 715-838-8507. When faxing information to BPA, 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.

Q: What if my health care provider requests a copy of my eligibility and benefit information?

Providers can obtain this information directly from BPA’s website once they have signed up for access to patient information. You or your provider can also request this information by calling a Customer Service Representative.

Q: What is a Certificate of Creditable Coverage form and how does it affect coverage for pre-existing conditions?

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. It excludes coverage for the treatment of conditions which existed within 6 months prior to your enrollment date. This exclusion complies with state and federal laws and will not exceed a period of 12 months from your enrollment date or 18 months from your enrollment date if you are a late enrollee. Pre-existing conditions do not include pregnancy, pre- or post-natal care or any complications with pregnancy. Pre-existing also does not apply to participants or dependents under age 19. Refer to your certificate for more detailed information regarding the pre-existing condition limitation.

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 BPA (not a late enrollment), 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 BPA 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 any of the following:

•  A group health plan
•  A non-group or individual health insurance
•  Part A or B of Medicare
•  Medicaid
•  The Active Military Health Program or CHAMPUS
•  A medical program of the Indian Health Service, or of a tribal organization
•  A State sponsored health benefits risk sharing pool
•  The Federal Employee Health Plan
•  A public health plan as defined by government regulations
•  The Peace Corps Health Program.

If you had prior creditable coverage but had a claim rejected by BPA 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 “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 BPA and then return it to us by fax or mail.

Q: What is a preferred provider, and how does using one affect my benefits?

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. You can also log into BPA’s website and go to the “Benefit Information” page. Clicking on the logo of the PPO network shown on that page will take you to the PPO’s website.

Q: What is a Prescription Benefit Manager (PBM)?

More commonly known as your Prescription Drug vendor, a PBM contracts with independent pharmacies or a chain of pharmacies to provide prescription medicines at a discounted rate for retail and, frequently, mail order prescription drug programs. Your PBM name and phone number is located on your ID card. In addition, you can find out more information about your PBM by going to the “Benefit Information” page on the website and clicking on the link for the PBM.

Q: What is precertification for inpatient hospital care?

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 front of your ID card.

Q: Who can I put on this plan?

On most plans, an eligible dependent will be a covered person’s married spouse and each unmarried child who is not yet age 19. Some plans also allow unmarried children to be covered until ages 23 or 26. Verify the age limit in your benefits booklet.

The term “child” is defined as:

  1. a) A natural born child;
    b) A stepchild;
    c) An adopted child; or
    d) A child for whom the Covered person is the legal guardian.

Q: Who should I call if I don’t understand how a claim was processed?

You have a right to question and/or appeal the processing of a claim. To receive an explanation of how your claim was processed, you may use the Online Customer Service section of the website. You may also contact a BPA Customer Service Representative or email your inquiry to service@bpaco.com.