Why am I getting new Explanation of Benefits (EOB) documents from medical services that I received last year?
At the start of the 2014-2015 plan year, UW unilaterally changed GAIP benefits in violation of our collective bargaining agreement. Some of these changes had negative financial implications for ASEs. As a result, we filed a Union grievance and an unfair labor practice complaint . To resolve the grievance and the unfair labor practice , the Union and the University agreed to implement retroactive changes to GAIP to ensure that services are covered at the correct levels for the 2014-15 plan year (October 1st, 2014 – September 30, 2015). To ensure correct coverage, UW and LifeWise have agreed to review and reprocess all claims from this period and to issue reimbursements for services that were covered at incorrect levels.
The list of services affected by the grievance is here: http://www.uaw4121.org/act-now-settlement-over-gaip-grievances-and-charge/#changes
I have been receiving bills from services for last year. Why am I getting these? Do I have to pay the new bills for the 2014-2015 plan year?
LifeWise is reviewing every claim from the 2014-15 plan year, one by one, in order and reprocessing them to ensure that all claims are covered at the correct levels. In some cases, this reprocessing might result in both bills and reimbursements. For most, the total amount reimbursed will exceed the total amount in new bills. It is possible, but very unlikely, that after all claims have been reprocessed some people could be billed more than they are reimbursed. However, the University has agreed that in these cases ASEs will not be responsible for the excess amount.
How likely is it that I am owed money as a result of this grievance resolution?
If you went to Hall Health in 2014-2015 there is a good chance that you are affected by this grievance. The determinations are made on a case-by-case basis. Review your EOBs and this list of services affected by the grievance: http://www.uaw4121.org/act-now-settlement-over-gaip-grievances-and-charge/#changes. If you have questions contact LifeWise and let us know if you have any problems.
Why doesn’t LifeWise send reimbursement checks along with the new EOBs?
Claims originally filed by your doctor’s office (for example, Hall Health) must be paid back through that office, rather than directly by LifeWise. Many of the claims to be reprocessed are from Hall Health and they are prepared to promptly issue reimbursements that are due to individuals.
I haven’t received any new EOBs yet, but I know I should be getting some. What should I do?
LifeWise has completed reprocessing of all claims from the 2014-15 year. If you have not received new EOBs for claims that you believe should be reprocessed, please contact LifeWise as well as the union at firstname.lastname@example.org. Please note that you should be able to access all of your EOBs, both reprocessed and originals, through the Lifewise GAIP website.
I thought some services and prescriptions that I needed last year weren’t covered so I didn’t file a claim. Looking at your list, it looks like my services/prescriptions should have been covered. Is there anything I can do about that now?
LifeWise has agreed to extend the claim filing period for members who assumed no coverage for a 2014-15 plan year benefit and therefore paid the claim out-of-pocket or had a prescription rejected and paid for subsequent prescriptions out-of-pocket.
You can still submit such claims up to the later of:
==> 60 days after receipt of an EOB (including a previously denied prescription)
==> 365 days after the date of service
I have received new EOBs for services I got in the 2011-2012, 2012-2013, and 2013-2014 plan years. What are these for?
During contract negotiations at the end of last year we became aware that claims for some services, primarily at Hall Health, were not paid at the correct benefit level for prior plan years to the detriment of some ASEs. We filed a grievance and the University agreed to reprocess these claims at correct benefit levels as well. The services impacted include Outpatient Hospital, Outpatient Physician Services, and Physiotherapy/Rehabilitation benefit provisions for the 2011-12, 2012-13 and 2013-14 plan years. LifeWise will also reprocess these claims and reimburse members who had these services during those years.
Can I see my EOBs online?
Yes, you should be able to access all of your EOBs, both reprocessed and originals, through the Lifewise GAIP website.