Benefits
Is there visit limitations for preventive vision exams for Abbyland Foods?
Abbyland:
Preventive Vision Exams:
How many SAS groups does SHP currently have?
1.Abbyland Foods
2.Marathon Bank
3.Schuette Inc
4.Ahlstrom Munksjo
5.Mid-State Technical College
6.City of Stevens Point
7.A&B Process Systems (terming 12/31/2022)
8.St. Croix of Park Falls
9.Custom Fabricating (transitioning to SAS from Commercial 1/1/2023)
Who would you go to with a claims question for Marathon Bank?
SAS Claims Group Alpha Split - SAS
Carol Hoffman - 19580
How many provider networks are associated with SAS groups?
4
SHP Provider Portal
Zelis (PhX) www.myzelis.com
Health EOS www.multiplan.com
The Alliance https://the-alliance.org/
Is a PA required for OT/ST if diagnosis is autism?
Exception As of 1/1/2021 No prior authorization required for OT/ST if diagnosis is autism for:
--City of Stevens Point
--Simplicity Credit Union
--Mid-State Technical College
--Marathon Bank
--Abbyland Foods
Carpal Tunnel Surgery/Release is there any exceptions listed?
Carpal Tunnel Surgery/Release - Covered
Who does Abbyland use for Subrogation Manager?
The Phia Group
Who is the Stop Loss carrier for A&B?
Stop Loss Carrier: Vendor is SwissRe
Which groups use Health EOS?
•Abbyland
•Marathon Bank
What groups use Northwood as their DME vendor?
All groups
Member had a sleep study done 3 weeks ago and now is being ordered by her provider to have another at home sleep study. Where would we find the benefit information if there was limitations?
Sleep Study - SAS
Summary of Benefits
Who does Ahlstrom Munksjo use for their PA process?
Hines and Associates - 2022
SHP contracted vendors - 2023
What is Stop Loss?
Stop-loss insurance is insurance that protects the group/ insurer against large claims. Stop-loss policies take effect after a certain threshold has been exceeded in claims.
Which groups use Zelis directory?
All groups
You have to call Hines and Associates to verify if a Prior Authorization has been submitted
What plans require PA for CT scans from Hines and Associates?
Ahlstrom Munksjo
Mid-State Tech utilizes who for Pharmacy?
Rx Benefits/Optum (1-800-334-8134)
Do we review for in-network/tier benefits on any of the SAS groups?
No SHP does not.
If the provider is found in the Zelis or HealthEOS directory are they considered in-network/Tier 1?
Treat as wrap network - if the provider is in Zelis or Health EOS Directory, then services go towards the in network level.
What groups use SHP and SHP contracted vendors to complete PA's?
•Abbyland Foods
•Marathon Bank
•Mid-State Technical College
•City of Stevens Point
•Schuette Inc
•St. Croix of Park Falls
Are Post-delivery charges for baby covered for dependent maternity?
Do groups use SHP for Cobra?
No. All groups use DBS
Do we administer workman's comp for any SAS groups?
•We administer the WC for all SAS groups and they are handled by Heather Lubnow
What is the exception to the Zelis and HealthEOS directory?
EXCEPTION: A&B Process Systems SimplyOne HMO Plan. If member needs to have services outside the network, they'll need to get prior auth
Anabolic Steroids injections covered with PA?
Anabolic Steroids – Not Covered
Epidural Steroid Injections - SAS