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Policies and Notices

Health Tradition Standards and Practices

Privacy and Personal Information

Privacy and Personal Information

Health Tradition is committed to protecting the privacy of its members.

Personal information

By law, we are required to keep your personal health information private. Any private health information collected and maintained by the Plan is used solely for the purpose of providing you with the highest quality of healthcare coverage and services. Health Tradition takes precautions both in the use and disclosure of information to minimize the risk of inappropriate use or disclosure of your health information. To have someone act on your behalf to inquire about claims or referrals, resolve issues for you, make changes to your account, or file a complaint, you must send Health Tradition a signed document that authorizes that person as your representative. You must indicate the information that can be discussed with the representative as well as those that cannot. You can limit the types of information and the time frames for the authorization.


The Health Insurance Portability and Accountability Act (HIPAA)

HIPAA was enacted by Congress to create a national standard for protecting the privacy of patient’s personal health information. The law requires health care entities, including health plans, to use standards for processing electronic bills, payments, and any other health information communicated via electronic means. The regulation also requires new safeguards to protect the security and confidentiality of a person’s individually identifiable health information (IIHI). The Department of Health and Human Services has issued HIPAA privacy and security standards that provide for the protection of patient information from inappropriate use or disclosure. These standards do not limit a provider from using a patient’s information when providing appropriate treatment, sending information to insurance companies for reimbursement or using information for quality control or operational improvement. For a detailed explanation of how Health Tradition member information is used, please refer to the Notice of HIPAA Privacy Practices below.


Security

It is important to note that electronic mail (email) can be intercepted. Never include private information about yourself or your family members in an email. If your communication is extremely sensitive, you may want to send it by regular mail instead. From time to time we will provide links to other websites, not owned or controlled by Health Tradition Health Plan. We do this because we think this information may be of interest to our site’s visitors. While we do our best to ensure your privacy, we cannot be responsible for the privacy practices of any other websites. A link to a non-Health Tradition Health Plan website does not constitute or imply endorsement by Health Tradition Health Plan. Additionally, we cannot guarantee the quality or accuracy of information presented on non-Health Tradition Health Plan websites.


Copyright

This website is subject to the copyright laws of the United States. The information on this website is provided as a service to our readers, and exclusively for their personal use. It may not be distributed, modified, or used without our prior written consent. Unauthorized commercial use, copying, reproduction, republishing, uploading, downloading, posting, transmitting, or duplication of any of the material is prohibited.


Additional information

For additional information regarding our general privacy policies or procedures, please contact Customer Service.

Regulation and Compliance

State and Federal Regulations for Health Insurance

Health Tradition is required to meet state and federal regulations for health maintenance organizations. Among those are the Health Insurance Portability and Accountability Act (HIPAA), Employee Retirement Income Security Act (ERISA) and the Patient Protection and Affordable Care Act. Health Tradition is also accountable to the Office of the Commissioner of Insurance for the State of Wisconsin for compliance with state regulations.


Health Care Reform

Health Care Reform, sometimes referred to as “ObamaCare” is officially known as PPACA – Patient Protection and Affordable Care Act, or simply the Affordable Care Act. It has many provisions, becoming effective on different dates between 2010 and 2018.

Most of the newly mandated benefits have always been covered by Health Tradition plans.

Health Tradition Health Plan is committed to meet or exceed the provisions of all insurance laws on or before the effective dates. You may have already received notices of updates to your Certificate of Coverage explaining PPACA changes which became effective in 2010 and 2011 such as:

  • Adult dependent coverage up to age 26, regardless of marital or student status
  • More preventative health screenings without deductibles or co-pays
  • Better coverage for certain mental health conditions
  • Clarified or required standardized language for benefits that you already had

You may also notice some minor changes to forms and statements from Health Tradition since the law now requires all insurers to use standard templates for these forms. Implementation of some new provisions has been delayed by either the federal government or the Wisconsin Office of the Commissioner of Insurance (OCI). Health Tradition Health Plan will continue to keep you informed if any changes will impact you or your current coverage.


Become knowledgeable about health reform

This new law is anything but simple, and the amount of information available can be overwhelming. Due to multiple political perspectives, information you hear can be distorted or misleading. To ease your search for reliable information, we have provided these links to official information on Health Care Reform.


Links to reliable information

Federal

Department of Health and Human Services (HHS) – Health Care Reform Website

National Association of Insurance Commissioners (NAIC) – Health Care Reform Website

Wisconsin

Wisconsin Officer of the Commissioner of Insurance (OCI)

Fact Sheet on HealthCare Reform for Wisconsin Residents

For Employers

Department of Labor Health Care Reform Website

IRS Tax Credits Website


Employee Retirement Income Security Act

ERISA is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans. ERISA requires plans to provide plan information to participants, provide fiduciary responsibility, have formal grievance and appeals processes and gives participants the right to sue for benefits and breaches of fiduciary duty.

http://www.dol.gov


Women’s Health and Cancer Rights Act

On October 21, 1998, President Clinton signed into law the Women’s Health and Cancer Rights Act of 1998. Under this legislation, group health plans that provide coverage for mastectomies also are required to cover reconstructive surgery and breast prosthesis (such as implants) following a mastectomy.

Under this law, members of Health Tradition Health Plan receive coverage for the following mastectomy-related procedures:

  • Reconstruction of the breast on which the mastectomy was performed
  • Surgery and reconstruction of the unaffected breast to produce a symmetrical appearance
  • Breast prosthesis (artificial substitute)
  • Treatment for physical complications of all stages of the mastectomy, including lymphedema

For questions regarding this information, please contact Health Tradition Customer Service.


Office of the Commissioner of Insurance

The Office of the Commissioner of Insurance (OCI) for the state of Wisconsin was created by the legislature in 1871. The original intent of OCI has not changed drastically over the years. In 1871, OCI was vested with broad powers to ensure that the insurance industry responsibly and adequately met the insurance needs of Wisconsin citizens. Today, OCI’s mission is to lead the way in informing and protecting the public and responding to its insurance needs.

http://www.oci.wi.gov

Claims

Claims and coverage

General information about your health plan

Out-of-Network liability and balance billing

Most often, you will only be covered for care that is received from in-network health care providers. However, care received from out-of-network providers may be covered if certain conditions are met, or for emergency or urgent care.

Claims for non-urgent or non-emergency care received out-of-network are generally not covered by your benefit plan if you did not receive prior authorization or a referral approved by Health Tradition. You may receive a denial notice instead of payment, and may be billed directly by the out-of-network provider for charges other than copayments, coinsurance, or any amounts that may remain on a deductible. This is often referred to as balance billing.

For more information regarding balance billing, please refer to this document: Your Rights and Protections Against Balance Billing


Submitting a claim directly

Out-of-network healthcare providers will generally file medical claims for you; simply provide your membership card. When you have a claim for services received from an out-of-network provider, you should notify Health Tradition in writing as soon as reasonably possible.

However, an out-of-network provider may instead require immediate payment. If you are required to make immediate payment, you may be eligible for reimbursement. To have services processed towards your benefit, please follow these simple steps.

  • Obtain an itemized bill and receipt of payment from the healthcare provider. Each bill should include items such as the patient’s full name, date(s) of service, type(s) of service, diagnosis, healthcare provider’s name, address and itemized statement charges.
  • Fill out Member Reimbursement Claim Form.
  • Submit the original itemized bill, receipt of payment, and member claim form to:
    Health Tradition Health Plan
    P.O. Box 21191
    Eagan, MN 55121

Health Tradition will process the claim, resulting in charges being applied towards deductible and coinsurance. If applicable, payment for covered services will be mailed directly to the healthcare provider unless you provide proof of payment. If you provide proof of payment, the reimbursement will be sent to you.


Grace periods and claims pending during the grace period

Claims must be filed within the required 90 days unless these three conditions are met, or you do not have legal capacity.

  • It was not reasonably possible to give proof within that time
  • The information is furnished as soon as possible
  • No later than 15 months after the date services were received

Retroactive denials

A retrospective review (post-service review) applies when the claim is received after the service has already been provided, or when notification of an admission occurs after the member has been admitted and discharged. The request for the retrospective review may be made by the member, or by the facility which provided the services.

No retrospective reviews will be conducted more than 24 months after services were provided, or 24 months after the discharge date. If Health Tradition does not receive the required information within 45 calendar days, the claim will be denied.

Retroactive denial can be avoided by obtaining prior authorization, or by notifying Health Tradition upon admission.


Medical necessity and prior authorization

Medical necessity describes care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. Prior authorization is pre-approval by Health Tradition for a covered service before the service is received.

Learn more


Prescription drug claims

Your prescriptions are covered using Health Tradition’s drug formulary, subject to deductible, copay and coinsurance shown in your Summary of Benefits and Coverage (SBC).


Information on Explanations of Benefits (EOBs)

An EOB is a statement an insurance company sends to explain what medical treatments and/or services it paid for on an enrollee’s behalf, the company’s payment, and your financial responsibility.

Learn more


Coordination of benefits (COB)

When you have coverage under two plans

If both Health Tradition and another health plan cover you or your family, these plans will coordinate benefits and share the responsibility for paying your eligible medical bills. Coverage with more than one health plan most often occurs when two spouses work for different employers and each enrolls the other and/or children in their health plan. In this case, one health insurance plan becomes primary and one becomes secondary (you will not be reimbursed for more than the cost of any health care service you receive).

 

If Health Tradition is primary

You will need to file your Explanation of Benefits (EOB) forms with your secondary insurance plan. An EOB is a form sent to you after a claim has been processed outlining how much money the plan paid and the amount you are personally responsible for paying.

 

If Health Tradition is secondary

You will need to file your primary insurance plan’s EOB forms (or Medicare Summary of Notice) with Health Tradition. It is your responsibility to provide us with complete information about your other health insurance plan(s). If we do not have complete information, we cannot process your claims correctly. Your EOB will report a denial of payment for lack of information when the other health insurance plan information is not sent along with your claim.

For members who are Medicare eligible, please contact us directly for more detailed information on filing order.

Coordination of benefits for prescriptions

Coordination of benefits does not apply to employer group plan members who have other commercial coverage (non-Medicare or Medicaid). Members must choose one of the coverage plans available to them for prescription coverage.

If you have questions about prescriptions or this process, please contact Customer Service.

Learn more

 

No Surprises Act and Transparency in Coverage Rule

For more information about balance billing under the No Surprises Act, please read Your Rights and Protections Against Surprise Medical Bills.

Machine Readable Files

The files below contain cost information that can help you understand how much you might pay out-of-pocket for certain covered items and services. Please note that the amounts in these files may not represent the final amount that you will pay out-of-pocket.
 
There are certain factors that may impact whether a particular item or service is covered, and determine your final out-of-pocket costs. These include, but are not limited to:

  • Your plan’s deductible, copayment, and/or coinsurance amounts.
  • Prior authorization requirements, which are based on whether the item or service is:
    • Needed to diagnose or treat an illness or injury;
    • Medically necessary; and
    • Medically appropriate.
  • Whether the provider is in-network or out-of-network.
  • Your plan’s maximum out-of-pocket limit, and whether you have met it for the current plan year.
  • Stated benefit limits. 

For more information, please see your member certificate and benefit summary, or call Customer Service at 877.832.1823.
 

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