# Presentation: 497400

## Travel and Foreign Claims

**All-Employee Brown-Bag**
**Monday, May 23, 2005**
**Building 2-100B Conference Room**
**Presented by the Health Care Facilitator Program**

**Notes:**
Remind about the HCF program services.

## Today’s Meeting

**Session I:****  General presentation until 12:30 (short-term travel)**
**Handouts available after meeting**
**Session 2:****  Extended session for CERN-based employees (living/working outside U.S.), immediately following.  Participants:**
**Gary Lee, HR Center Manager**
**Carolyn Charles, HR Generalist**
**Lisa Ersparmer, Sr. Travel Specialist**
**Richard Takahashi, Benefits Manager**

## Short-Term Travel

**Conditions of coverage **_**outside**_** service area**
**Medical care that ****is**** covered**
**Medical care that is ****not**** covered**
**Emergency Services (ES) **
**Urgently Needed Services (UNS)**
**Notification and authorization requirement**
**The claim reimbursement process**
**Claim packet**
**Mailing address**
**Helpful tips**

**Notes:**
Outside applies to within CA, US, and out of country.
Definition of ES and UNS were referenced from the plan’s EOC booklets.
Helpful Tips, a handout material.

## Do you know ...

**Which of the following health plans (Blue Cross PPO and Plus, Kaiser, HealthNet, and Pacificare) offer ****worldwide**** service coverage?**
**Blue Cross PPO and Plus only**
**Blue Cross PPO only**
**Blue Cross PPO and Kaiser only**
**All of the above**

## Answer:  D.  All of the above.

**BC PPO – **
**	****Any provider worldwide for all covered services**
**BC Plus, Kaiser, HealthNet, and PacifiCare – **
**	****Any provider**** ****worldwide ****for emergency and urgent care services only**

**Notes:**
Emphasize CA plans.

## What are Emergency Services?

**Medically necessary ambulance or ambulance transport services provided through the 911 emergency response team.**
**Medical screening, examination, and evaluation by a physician to determine if an emergency medical condition or psychiatric emergency condition exists.  **
**If condition exists, ES include the care, treatment and/or surgery by a physician necessary to stabilize or eliminate the emergency medical or psychiatric condition within the capabilities of the facility.**

**Notes:**
Give this example of a member’s denied coverage:  member called 911 for a son’s bleeding injury on the head.  Ambulance arrived, applied first-aid, and determined son’s injury was not “truly” a case of an emergency.  Suggested to take son to ER for check up.  At ER, son was seen and it appeared he did not need any “emergency” care ... no sutures, just put a “band-aid” on it.  Member received a bill.  Kaiser, apparently, would not pay for the claim.  Reason:  (1) member never notified the plan of the ES, (2) when claim was reviewed by the plan, it was determined case did not qualify for ES.
Correct action:  Member should have called PCP or the plan as soon as reasonably possible.  Member’s direction to go to ER was not from the PCP or plan, it came from a non-provider.

## What is an Emergency Condition?

**Manifesting itself by ****acute symptoms of sufficient severity**** such that the absence of immediate medical attention could reasonably result in any of the following:**
**Place health in serious jeopardy**
**Serious impairment to bodily functions**
**Serious dysfunction of any bodily organ or part**
**Active labor**
**Inadequate time to effect a safe transfer to another hospital prior to delivery, or **
**Transfer poses a threat to the health and safety of member or unborn child**

## What are Urgently Needed Services?

**Medically necessary health care services required to ****prevent deterioration**** of member’s health, resulting from an unforeseen illness or injury for which ****treatment could not be delayed until the member returns to the plan’s service area.**

## What is NOT Covered?

**Routine follow-up care ****to emergency or urgently needed services, such as treatments, procedures, x-rays, lab work, doctor visits, rehab services, skilled nursing care or home health care**
**Maintenance**** therapy and Durable Medical Equipment including, but not limited to, routine dialysis, routine oxygen, routine lab testing, or a wheelchair to assist you while traveling outside your plan’s service area**
**Medical care for a known or chronic condition ****without acute symptoms**** as defined under ES or UNS**

## Notification and Authorization

**Regardless of where you are in the world, you or someone else on your behalf, ****must notify**** your PCP or plan within ****24 hours****, or as soon as reasonably possible, following receipt of ES or UNS**
**Any medically necessary ****follow-up**** services either prior to or following discharge from the hospital ****must be authorized**
**Your PCP or plan reserves the right, in certain circumstances, to transfer you to a participating hospital in lieu of authorizing post-stabilization services at the treating hospital**

## Claim Reimbursement Process

**Obtain receipts and copies of all relevant medical documentation**
**Itemized statement**
**Name, address, telephone # of provider**
**Date of services (DOS)**
**Medical code/description**
**Amount paid in foreign currency**
**Complete foreign claim form**
**Submit claim**
**Use plan’s California mailing address**
**Within 6 months from DOS**
**Receipt of reimbursement**
**4-6 weeks from date of receipt**
**Mailed to mailing address by BC**
**Contacts**
**Plan member services**
**LBL HCF office**

**Notes:**
Incomplete claim information can result in a delay in processing.

## Helpful Tips

**Always**** present health plan ID card to provider**
**Make copies of all health plan ID cards**
**Keep a list of all medication**
**Fill/re-fill prescription before travel**
**Let PCP know of planned vacation, trips**
**Keep a list of PCP’s and health plan’s telephone #s (during business and non-business hours)**
**Keep a list of emergency contacts in U.S.**
**Research info about health care accommodations and/or restrictions of the places to visit**

**Notes:**
Recommend to contact member’s plan or doctor and get their during business and non-business hours contact info, from a foreign country.

## Reminder

**All:**
**Please pick up handouts before you leave**
**CERN-based employees:**
**Please stay for an extended session addressing benefits coverage and relocation issues**
***and***** ****THANK YOU**** **
**for attending today’s presentation!**