Agile Help CenterEverest Reinsurance Company
Frequently Asked Questions
Does the plan require Pre-Certification?
All Inpatient hospitalizations and procedures done at an Outpatient Surgery Facility must be pre-certified. Everest Reinsurance Company's professional review organization must be contacted as soon as possible before the expense is to be incurred. If the Covered Person does not comply with the Pre-certification requirements as stated in the insurance certificate, the Eligible Medical Expenses will be reduced by 50%.
How does Usual and Customary Fees affect my benefits?
The Policy defines Usual and Customary Fees as the usual, fair and reasonable fee for medical treatment provided to a Covered Person (or any other form of medical care, procedure, drug or supply).
In determining a Usual and Customary Fee, the Company at its discretion, consults:
- one (1) or more standard industry sources to calculate services of comparable severity and nature in the same geographical area, the cost of the goods and services reasonably required to produce and deliver such treatment and/or the charge most commonly paid for such treatment. The standard industry sources utilize cost-based formula methodology and/or pricing data (updated semi-annually) to produce replicable and consistent cost and/or pricing parameters;
- the cost to the health care provider of performing or providing the medical treatment, including reasonable allowance for overhead and profit;
- fee schedules used by third parties such as Medicare or Medicaid, including Medicare allowable charge data for Medicare Part B;
- hospital cost data as submitted to Medicare, including Medicare allowable charge data for Medicare Part A;
- prevailing negotiated fee schedules for same or similar services performed in the same geographical area.
All benefits are limited to Usual and Customary Fees. Usual and Customary Fee definition may vary by state.
What if members change their minds after the purchase of STM coverage?
If not 100% satisfied with coverage and members have not already used any of the insurance benefits, they may return the certification to us within 10 days of receipt. Coverage will be cancelled as of the effective date and the plan cost will be returned. No questions asked!
What is the Pre-Existing Conditions Limitation?
Charges resulting directly or indirectly from a condition for which a Covered Person received medical treatment, diagnosis, care or advice within the 60* month period immediately preceding such person's Certificate Effective Date. A Pre-Existing condition includes conditions that produced any symptoms which would have caused a reasonable prudent person to seek diagnosis, care or treatment within the 60* month period.
*varies by state
Who is eligible to apply for this insurance?
Everest STM is available to members and their spouses, who are between 18 and 64 years old and their dependent unmarried children under 26 years old; and can answer "No" to all of the questions in the application for insurance. Child-only coverage is available for ages 2-25.
When does the STM coverage terminate?
Coverage under the Policy will cease at 12:01 a.m. for a Covered Person, based on the time zone in the place where the Insured resides, on the earliest of the following:
- The date premiums are not paid in accordance with the terms of the Policy, subject to the Grace Period;
- On the next premium due date after the Company receives a written request from the Insured to terminate coverage, or any later date stated in the request;
- The date an Insured performs an act or practice that constitutes fraud, or is found to have made an intentional misrepresentation of material fact, relating in any way to the Policy, including claims for benefits under the Policy;
- The date of the Insured's death or the termination date of the Insured's coverage, if the Insured's spouse is not covered under the Policy;
- The date the Insured obtains other insurance, excluding Medicare;
- The Certificate termination date stated on the Schedule of Benefits;
- The date that members enter full-time active duty in the armed forces of any country or international organization other than for reserve duty of 30 days or less;
- The date other major medical insurance coverage becomes effective for a Covered Person;
- The date that insurance under the Policy is discontinued;
- The first day of any policy month We elect to terminate the Policy by giving the Group Policyholder at least 30 advance written notice.