Coventry Health Care, Inc. (Coventry) is changing the process for releasing information that contains personal health information (PHI) or personally identifiable information (PII) to brokers. Effective November 15, 2010, brokers are required to submit a signed Member Designated Representative (MDR) form when requesting Explanation of Benefits (EOBs) and ID cards, except for temporary ID cards for new business. The MDR form helps ensure that our members are aware that you are requesting detailed information about them. You can download the form on our website in the Broker Tool Kit.

Please read the following background for additional information.

Legislation

There are many new legislative conditions that warrant updated business processes. Since the implementation of HIPAA privacy and security regulation in 2003, Coventry has continued to review privacy practices. Additionally, a portion of the American Reinvestment and Recovery Act (ARRA), called the HITECH Act (Health Information Technology for Economic and Clinical Health Act), encourages streamlining of procedures for releasing protected health information. HITECH also strengthens the HIPAA Enforcement Rule, which increases associated fines and penalties, regarding unauthorized disclosure of protected health information.

Examples of PHI and PII

An Explanation of Benefits (EOB) includes PHI and PII. A member ID card includes PII. While ID cards do not include Social Security numbers, Coventry has always considered the ID number as a key identifier that could potentially lead to health care fraud and abuse.

Serving Your Clients

As one of our valued brokers, you may continue to utilize the same services on behalf of Coventry members. The majority of inquires can be handled with limited PHI/PII, and without the MDR form on file. However, when requesting member id cards or EOB's without an MDR form on file, the request will be mailed directly to the member. If there is an urgent need of care or administrative need on behalf of the group, the broker may at times, receive a copy of the member id card.

Additionally, brokers who have access to Online Account Management^SM may request and print member ID cards from the portal; however, the employer group must first grant you access to Online Account Management. You can also ask a member to appoint you as a Member Designated Representative (MDR) on the member website, My Online Services (MOS).

If you have questions or need further information regarding this change, please contact your Coventry representative.

As a reminder, here is a list of items you will need to successfully enroll a small group.

1. Completed statements of health - either the Universal Statement of Health provided by the Bureau of Insurance or the Coventry Health Care Statement of Health/Enrollment Form. Groups over 26 may use the Employer Risk Questionnaire (ERQ).
2. Enrollment forms - required only if the Universal Statement of Health or ERQ was used
3. Waivers - enough waivers to confirm participation requirements have been met
4. Complete Group Application - including the Group Size Questionnaire in Section III, sold benefits, and rates
5. Binder check
6. Invoice from previous carrier or Certificates of Creditable Coverage - groups 2-14 that want to have the pre-existing condition exclusion waived
7. One of the following items to document business status: VEC/Wage and Tax form, business license, articles of incorporation, tax documents
8. One of the following to document eligible employees: VEC/Wage and Tax form with eligible employees marked, certified list of employees, payroll documentation

Please note that the Bureau of Insurance released a new version of the Universal Statement of Health this fall. A copy of it is in the Broker Tool Kit for your convenience.

Since the addition of the Multi-Option Adjustment (MOA) in BenefitExpress (BE) on March 1, 2010, we have been working behind the scenes to have that adjustment appear in your rates in BE without intervention from an underwriter.  Beginning with February 2011 effective dates, BE will now calculate and apply the MOA. 

This new functionality is based on the packaging of benefits, similar to how large group benefit packages are created. Rather than selecting a series of independent products, you will now select the products you would like to offer together, including pharmacy benefits.  BE will then evaluate the benefit relativities between them and apply whatever MOA is required.  Please note that although BE will allow you to package benefits that have more than a 30% difference between the highest cost benefit and lowest cost benefit, our underwriting guidelines still preclude you from offering benefits with that level of difference between them.

Please feel free to contact your Account Executive or Account Manager with any questions you may have.

Multi-Option Adjustment Automated in BenefitExpress
Coventry Health Care's Transition Rx program provides new members a transition service during the first 90 days of coverage. The 90-day transition period begins on the member's effective date. Under the program, members may obtain a one-time fill of certain covered prescription drugs - up to a 30-day supply - at the applicable copayment without being subject to the prior authorization, step therapy, and/or quantity limit requirements that normally apply to those drugs. Coventry Health Care will then send a letter to the prescribing provider advising that the one-time fill was made available under the Transition Rx program. We will include instructions on how to obtain prior authorization or access alternatives for the drug in the future.  Most commonly used prior authorization, step therapy, and once-daily quantity limit drugs are eligible under the transition program. Specialty injectables and other quantity limit drugs are excluded from the program.