Assign Forms – Level Health

Coordination of Benefits. PHI Release. Actively at Work. Accident Investigation.

Assign Coordination of Benefits

From the specific members page, click the tab ‘Forms’, then click ‘Assign Form’, then click ‘Coordination of Benefits’
Answer the following questions:
- Is the subscriber of your current coverage retired?
- Are you, or any member of your family, also covered by another group health plan or medicare?
- What kind of coverage is this?
Once you click submit, the member will be notified to fill out the form
Members have access to this form by default but will not prompted without completion of this step

The dependent needs to submit the PHI Release to allow the subscriber to view their account.

From the specific members page, click the tab ‘Forms’, then click ‘Assign Form’, then click ‘PHI release’
Add authorized individuals and the when their authorization expires
Members have access to this form by default
In accordance with federal and applicable state privacy laws, a child age 13 or older must complete and sign a Protected Health Information (PHI) Authorization before a parent, guardian, or other individual may access the child’s medical claims information or communicate with the plan or its administrators on the child’s behalf

When a member hits 75% of their specific deductible, the employer HR contact is automatically sent an ‘Actively at Work’ form from the Level Health portal to verify eligibility on the plan
It is important for each group to be designated an HR contact so this process can be kicked off
A stop-loss carrier asks for an Active-at-Work (AAW) form to confirm that the employee was actively working and therefore eligible for coverage
If the form is not completed by HR upon the time of submission, a follow up email will be sent to the HR team with a cc to the broker indicating that e completed form should be completed within seven (7) calendar days of receipt of that notice.
- Failure to do so may result in:
  - A hold on claims processing, and/or
  - A potential delay or impact on submission to the stop-loss carrier, which may affect reimbursement
If the AAW form isn’t completed or doesn’t support eligibility, the carrier can deny reimbursement — even if the claim is otherwise covered under the health plan

From the specific members page, click the tab ‘Forms’, then click ‘Assign Form’, then select ‘Accident Investigation’
It is automatically sent out on claims that are received with accident related DX codes or if there may be any indication of third part liability
This form is important to obtain context around any accident or injury and to make sure there are no other responsible parties relating to payments
For Cash Pay, we don’t always have diagnosis codes to go off of, but use your best judgement as to when you assign an Accident Investigation form (Ex: broken arm, retina detachment, skin laceration, car accident (MVA), etc)
Claims arising from a motor vehicle or motorcycle accident will be denied pending receipt of written confirmation from the applicable automobile insurance carrier stating that no coverage applies or that available benefits have been exhausted
The Plan does not provide benefits for any injury or illness arising out of or in the course of employment. Claims related to an employment-related injury or illness will be denied and must be submitted to the applicable Workers’ Compensation carrier.

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