Dear Anthem Member:
Thank you again for your continued patience as we navigate the transition from Aetna back to Anthem. Aetna and Anthem have been diligently working to process claims and apply deductible and out-of-pocket maximum credits for the period of Jan. 1, 2023–May 31, 2023. All involved acknowledge how important this is. We anticipate the process will take 4-6 weeks, if not sooner, and recognize this processing time may result in temporary higher upfront healthcare expenses for some individuals and families.
We are pleased to share that HR has successfully obtained Anthem’s approval to implement a manual application of credits toward your deductible and out-of-pocket maximum in specific situations. These manual credits aim to alleviate the financial burden associated with potentially high healthcare costs and ensure that you receive the necessary care without undue hardship. Learn more about deductibles and out-of-pocket maximum credits here.
Who is eligible for manual credits and what is the process for requesting them?
If you are undergoing or underwent surgery and/or are/were hospitalized and have encountered extraordinary medical expenses you may be eligible for manual credits to be applied towards your deductible and out-of-pocket maximum. In this scenario, please contact the benefits team so they can reach out to Aetna on your behalf and forward your deductible and out-of-pocket maximum information to Anthem directly.
If you are undergoing therapy and your provider has not agreed to delay your billing or any alternative arrangement you may be eligible for manual credits to be applied towards your deductible and out-of-pocket maximum. In this scenario, you will need to (a) provide the benefits team with your Explanation of Benefits (EOB) from Aetna and (b) complete this form to be submitted with the EOB(s). Please disregard the timeframes and mailing instructions on the form. Since HR is assisting with this process, the benefits team will forward these documents to Anthem’s dedicated LMU team to process. This will take three to five business days.
Accessing Explanation of Benefits
- Single Coverage: Members can log in from the Aetna home page and select the purple button to the right for “Member Login” and proceed to log in. In the overhead menu, choose “Claims,” then “Explanation of Benefits (EOB) Statements.” The last EOB at the top is the most recent and will have the most current YTD totals.
- Family Coverage: For members with family coverage/dependents, Anthem requires each dependent’s EOB so that they can review each individual’s deductible amounts. If you do not have your dependent’s EOB, you can request one by calling Aetna’s member services:
- Aetna Managed Choice POS/ Aetna Managed Choice POS HDHP: 800.240.2386
- Aetna HMO: 800.291.2953
Important Information About Manual Credits
The credit may not reflect the most up-to-date deductible and out-of-pocket maximums if your doctor has not yet submitted the claims to Aetna or indicated that the deductible and out-of-pocket maximum credit is what reflects on Aetna’s system at the time of the transfer.
Also, please note the application of manual credits is subject to review and approval by the Anthem internal team, as well as compliance with applicable regulations and guidelines. While we will make every effort to accommodate eligible requests, there may be instances where manual credits cannot be applied due to specific limitations.
What if I do not fall into one of the above scenarios?
If you are planning to visit your provider for preventative services or a casual visit you should only be responsible to pay your co-payment, if anything. You should not be asked to pay your deductible during this visit. Please refer to your Summary of Benefits to see which services require you to meet your deductible. Since this is considered a non-urgent scenario, the processing of claims and the application of the deductible and out-of-pocket maximum credits will be processed within the 4-6 weeks timeframe.
We have learned that some Anthem customer service agents have offered members an alternative solution to take certain steps individually to have deductible records transferred from Aetna. We believe this option will take even longer than the 4-6 weeks timeframe so HR recommends you disregard it.
What if I have met my deductible and have had to pay my provider again?
Once Anthem has received the information on deductible, out-of-pocket maximum, and the plan accumulators with the details from Aetna, claims will be reprocessed by Anthem. An EOB will be generated and sent to both you and your provider (per Anthem’s contract with their providers, Anthem must pay the provider). Anthem will then issue payment to the provider, and you will be reimbursed by the provider. Once the deductible is applied, the reprocessing timeframe of claims by Anthem may vary. Please note the reimbursement timing may also vary by each provider. Please reach out to the benefits team if you are having challenges obtaining your reimbursement.
What if I have paid out-of-pocket expenses for my prescriptions?
- HDHP: The reimbursement to the member will depend on when the Rx was obtained and when the deductibles have been updated. Typically, if the Rx is received shortly before the deductibles are applied, members can go back to the pharmacy for reimbursement. The timeframe for pharmacy reimbursement can vary.
- PPO: Deductible does not apply to Rx copay.
- HMO: Deductible does not apply to Rx copay.
We continue to be here to support you and our benefits team is committed to assisting you throughout the process. As a reminder, we have formed an Anthem Transition Community Care team in HR. For help with transition coverage issues, please contact Deep Malik, LMU Director of Benefits, who is working with several team members who are dedicated to responding rapidly to your inquiries and requests.
Sincerely,
LMU Human Resources