HR Professional: Administrative Guide for Group Life and Disability Benefits

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Guide for group benefits

Guide overview

This guide provides an explanation of the enrollment, billing, claims, and policy service procedures for Humana Specialty Benefits and should be used as a reference guide only. Information in this guide is subject to change at any time at the discretion of Humana Specialty Benefits.

No information in this guide will supersede the terms and conditions of the Master Policy/Certificate or is to take the place of any direction provided by authorized employees of Humana. The information contained in this guide may vary from group to group. Please be sure to review your Master Policy/Certificate when quoting specific policies and procedures. This guide is provided solely to offer an administrative guideline for our clients.

Your account executive

Throughout your relationship with Humana Specialty Benefits, your account executive is available to help you with any issues or questions.

The Customer Service Call Center

When your employees enroll in a policy from Humana Specialty Benefits, they not only receive a quality product but quality service as well. Each policyholder can receive assistance from your account executive or from our Customer Service Call Center.

The call center has a dedicated team of specialists qualified to handle all inquiries concerning policyholder service and claims.

The call center’s hours of operation are:

Monday8 a.m. to 5:30 p.m. Eastern time
Tuesday9 a.m. to 5:30 p.m. Eastern time
Wednesday – Friday8 a.m. to 5:30 p.m. Eastern time

All Customer Care specialists have access to information concerning claim status, billing procedures, and payments. Humana Specialty Benefits also can provide an interpreter for any language.

Contacts

                                                                                 
Premium payment address

Humana Inc.
c/o Wachovia Bank
P.O. Box 75117
Charlotte, NC 28275-0117

Evidence of Insurability address & phone number

Humana Inc.
Attn: Small Business Underwriting
1100 Employers Blvd
Green Bay, WI 54344

kmgcoreuw@humana.com

800 327-9728

Enrollment address

Humana Specialty Benefits
P.O. Box 7777
Lancaster, SC 29721-7777
 

Life claims informationHumana Specialty Benefits
PO Box 2000
Lancaster, SC 29721-2000
Long & Short Term Disability information

Humana Specialty Benefits
Attention: Group Claims
PO Box 2993
Hartford, CT 06104-2993

Customer Service: 1-800-957-7121
Fax: 1-860-392-3672

Correspondence addressHumana Inc.
P.O. Box 3000
Lancaster, SC 29721-3000

Billing administration

List Bill

List bill is an invoice detailing coverage at an individual level.

Bills are generated online through the Electronic Bill application. The group contact receives an e-mail notification each billing cycle that the group’s bill is ready to be viewed. Log-in information will be provided before receipt of first bill. Clients who elect on-line billing do not receive paper invoices in the mail.

Remittance

Payment can be remitted by*:

  • Automated Clearing House (ACH)**
  • Check
  • Electronic Fund Transfer (EFT)

* A remittance form is required to accompany premium payment when the payment is not being applied as billed. This form may be e-mailed to your billing representative or mailed in with payment.

**A Payment Administration Form is required when remitting via Automated Clearing House (ACH) transaction.

Ongoing billing information

Premiums are due on the premium due date indicated on the list bill, and must be received before the end of the grace period to maintain insurance in force.

Bills are generated on the 15th of each month.

The next month’s billing statement will reflect terminations and adjustments received before 10th of the prior month. Example: Changes and adds are submitted on August 5th. These changes will be reflected on the September invoice.

Self Bill

Groups with more than 100 employees have the option of self billing. Self billing means that Humana will not maintain any eligibility records. The client is responsible for maintaining eligibility and volume amounts for each employee. Upon claim filing, proof of eligibility must be provided in the form of a signed enrollment form or confirmation statement from the HR Assist application.

Ongoing billing information

Premiums are due and payable on the premium due date indicated in the Master Policy, and must be received before the end of the grace period to maintain insurance in force.

Premiums for new employees becoming effective during a given billing month (except on the premium due date) are waived. Premiums for terminated employees are due for the month in which they terminate (except if they terminate on the premium due date). It is assumed that additions and terminations will tend to offset each other during a policy year.

  • A remittance form must accompany all payments submitted for self billed groups. Remittance forms must include the following information:  
    • Policyholder name
    • Group number
    • Account number
    • Premium due month
    • Coverages
    • Number of lives/volume
    • Premium rate
    • Adjustments
    • Gross premium due
    • Compensation (if applicable)
    • Calculation of check amount
    •  

    Remittance forms may be mailed in with payment or can be e-mailed to your billing representative.

Double coverage for employees

When an employee and spouse/domestic partner are actively employed at the same group, the employee and dependent child(ren) can only be covered under one policy. For example, the employee is covered only under his or her policy, or is under the domestic partner’s policy but not both.

Employees and spouses also may not be cross covered when employed by the same group. The employee and spouse are eligible for employee coverage, but may not cross cover each other as spouses under their respective employee coverage.

Newly hired employees

An employee becomes eligible for coverage when he or she becomes a member of an eligible class and completes the eligibility requirements shown in the Master Policy. Employees have 31 days from date of eligibility (waiting period) to apply for coverage.

Newly hired employees may enroll by:

  • Completing an enrollment form
  • Enrolling through the HR Assist application

If an enrollment form is completed it should be retained by the client and a copy sent to kmgcoreunit@humana.com.

Forms may also be mailed to:
Humana Inc.
P.O. Box 7777
Lancaster, SC 29721-7777

Forms to complete are as follows:

  • LTD/STD 1493
  • Life 1465

*Forms may be state specific.

If an entry is made into HR Assist, it will serve as proof eligibility at claim time and an enrollment form does not need to be completed.

New employee who has met eligibility requirements is to be offered insurance coverage. If an employee declines insurance, a Waiver of Group Insurance Form (1504) must be completed, signed, and retained in the employee’s record.

If an employee, spouse, or dependent is eligible for and wishes to enroll for an amount of insurance greater than the guarantee issue limit stated in the policy, an Evidence of Insurability (EOI) Form (1474) must be completed.

Evidence of insurability requirements

  • Required when an employee or spouse is applying for coverage in excess of guarantee issue limit
  • Required when an employee or spouse wishes to increase their coverage outside the enrollment period
  • Required for employee or spouse who is applying for coverage after the eligibility period
  • Required for employee or spouse who is reapplying after one individual cancels coverage

Increase life coverage amounts at open enrollment

Subject to the limits in the Master Policy, any employee, spouse, or dependent can increase the coverage amount or anytime during the policy year if an EOI Form is submitted.

To increase coverage amount:

  1. The employee should complete the Request for Change Form (1475)
  2. If the employee is applying for an amount of insurance greater than the guarantee issue limit stated in the policy, an EOI form (form 1474) along with the Request for Change Form (1475) must be completed

Forms are submitted to the addresses noted on page 4.

Late entrants - applying for coverage outside enrollment period

New employees must enroll themselves, spouses, and dependents for coverage within 31 days after the eligibility date in the Master Policy. If the employee/spouse/dependent does not enroll in that period, the EOI Form (1474) must be completed along with the appropriate enrollment form (see list of forms for form number).

Effective dates of individual benefits

  • Benefits up to the guarantee issue limit are effective on the date of eligibility the employee is actively at work
  • If an employee must submit an EOI form, the coverage will become effective on the date indicated in the Master Policy if that employee is actively at work
  • If an employee is not actively at work on the date the benefits become effective, benefits do not become effective until the first day that employee is actively at work

Certificates

Certificates outlining the applicable group insurance coverages are provided in PDF form. Printed copies are available upon request. Certificates are not member specific, but specific to the group offering.

Changes in benefits

If an employee becomes eligible for an increased amount of insurance due to transferring from one class to another or because of a change in benefits, the employee must complete and sign the Request for Change Form (1475). Retroactive premium adjustments will appear on the next bill.

An EOI Form (1474) must be completed for an insured employee who, as a result of a change, becomes eligible for an amount of insurance greater than the guarantee issue limit stated in the policy.

Termination of benefits (life only)

An employee’s insurance will automatically terminate as specified in the policy. If an employee terminates employment, advise that he or she may have the right to continue coverage, and provide the Notice of Conversion Right Form (5258).

Portability is available to employees who are no longer actively at work.  Ported coverage allows the insured to keep their existing coverage while continuing to pay the same group rate.

Limited Portability means that the insured can continue ported coverage for a maximum of three (3) or five (5) years in accordance with state mandates. This is contingent upon the group’s master policy staying inforce.

Full Portability – means that the insured can continue ported coverage for an unlimited amount of time until the group’s master policy terminates.

  • Portability is not available for retirees or totally disabled employees. If an employee is currently out on disability or retired, they would be eligible to convert to an individual whole life policy
  • Portability is typically limited to employees only on supplemental life plans

The insured has 46 days to submit an application and pay premium on the ported policy. The employer and insured must complete the Group Term Life Insurance Portability Form (1488). Upon completion this form should be returned to the address noted on the form.

Basic and supplemental life coverage can be converted to a whole life plan when an insured is no longer eligible under the plan. Examples of this include, but are not limited to:

  • A child has reached the maximum dependent age
  • A divorce occurs and the spouse is no longer eligible for coverage
  • A employee moves from full time to part time employment
  • Ported coverage has expired and the insured wishes to continue coverage

An insured has 31 days from when their coverage is terminated to convert the basic life coverage to individual whole life coverage.  The insured must have been covered under the plan for at least one year.  The insured should complete the Policy Service Request for Term Life Conversion (6016 C) and return it to Kanawha upon a qualifying event.  Converted coverage will become effective on the first of the month following the conversion request.

An employee who wants to terminate coverage must complete the Request for Change Form (1475). Terminations should be noted on a remittance form and sent to your billing representative with payment. Retroactive premium adjustments will appear on the next bill.

Change smoker classification

If any employee, spouse, or dependent wishes to change from a tobacco user rate to a non-tobacco user rate, the employee must complete a Request for Change Form (1475) indicating that he or she has not used any form of tobacco in the past 12 months. Mail the Request for Change Form to medical underwriting for approval:

Humana Inc.
Attn: Small Business Underwriting
1100 Employers Blvd
Green Bay, WI 54344

We will notify a paramedical company to contact the employee for a urine specimen. When the results of the urine specimen have been received, the employer and employee will be notified by letter of the decision.

Personal changes

Request for Change Form (1475) must be completed for any personal changes (i.e., name, address, beneficiary). E-mail the form to kmgcoreunit@humana.com for recording. The employee should keep a copy of the form.

Domestic partners

An employee who wishes to enroll a domestic partner must complete the Affidavit of Domestic Partnership form (5841).

Life claims

For death, accidental death and dismemberment (AD&D), or terminal illness (accelerated life benefit) benefits, an insured must complete a Claim Statement Form (5114). Please refer to the form for documentation needed for the specific benefit requested.

If a loss of a limb or eyesight is a result of an accident and this loss occurs within 90 days of the accident, a Proof of Disability Form (5088) also must be completed.

In the event of terminal illness, medical records diagnosing the terminal illness also must be provided.

Extension of employee life insurance during total disability (waiver of premium)

If an insured employee becomes totally disabled before age 60, the Extended Death Benefit may apply. For determination, the Proof of Disability Form (5088) must be completed by the employer.

Accidental Death and Dismemberment benefits

(If your plan contains these benefits.)

Paralysis Benefit – In the event of paralysis resulting from a covered accident, complete and submit the Claim Statement Form (5114). Indicate the benefit for which claim is being made along with the accident report and all medical records diagnosing and documenting the paralysis and cause.

Seat Belt Benefit – In the event of a covered accidental death resulting from an automobile accident and the insured was wearing a seat belt, complete and submit the Claim Statement Form (5114). Indicate the benefit for which claim is being made along with a certified copy of the death certificate and police report.

Seat Belt and Airbag Benefit – In the event of a covered accidental death resulting from an automobile accident and the insured was wearing a seat belt and the air bag deploys, complete and submit the Claim Statement Form (5114). Indicate the benefit for which claim is being made along with a certified copy of the death certificate and the police report. If the police report does not indicate if the air bag deployed, a statement from the body shop or towing company is required.

Education and Training – In the event that an insured dies as a result of a covered accidental death, and the deceased is survived by a child who is or becomes a full-time student within 365 days of the date of death, complete and submit the Claim Statement Form (5114). Indicate the benefit for which the claim is being made along with a certified copy of the death certificate, the accident report, and a copy of a school transcript verifying full-time student status.

Licensed Day Care – In the event that an insured dies as a result of a covered accidental death and the deceased is survived by a child who is or becomes enrolled in a licensed day care within the time specified in the policy, complete and submit the Claim Statement Form (5114). Indicate the benefit for which claim is being made along with a certified copy of the death certificate, police report, canceled checks made payable to the daycare facility, detailed hours the child attended the facility on a daily basis, and a copy of the facility’s license.
Transportation Benefit – In the event of a covered accidental death occurring more than 100 miles from the insured’s primary residence, complete and submit the Claim Statement Form (5114). Indicate the benefit for which claim is being made along with a certified copy of the death certificate and police report.

Common Carrier – In the event of a covered accidental death on a common carrier, complete and submit the Claim Statement Form (5114). Indicate the benefit for which claim is being made along with a certified copy of the death certificate, the police report, and a copy of the passenger fare ticket for the insured.

Coma Benefit – In the event of coma resulting from a covered accident, complete and submit the Claim Statement Form (5114). Indicate the benefit for which claim is being made along with the accident report and all medical records diagnosing the coma and documenting the cause.

Occupational Assault – In the event of a covered accidental death resulting from occupational assault, complete and submit the Claim Statement Form (5114). Indicate the benefit for which claim is being made along with a certified copy of the death certificate and police report.

Short-term disability (STD) claim submission

All short-term disability claims are to be submitted by using the STD Claim Form (LC5180-18).

Humana Inc.
Attention: Group Claims
PO Box 2993
Hartford, CT 06104-2993

All questions concerning salary, last date worked, and the individual eligibility are verified directly with the employer. If there are any questions of either the claimant or the physician, they are contacted directly via phone to get the timeliest responses possible. All documentation from the claimant, employer and physician must be received before a claim will be considered for payment.

If the claim is approved for payment, benefits are determined based on plan provisions. Benefits will continue to be received based on the occupational definition under the policy, medical evidence provided, and the physical restrictions and limitations present.

If the medical evidence presented does not substantiate the period of disability, the claim may be referred to our medical staff. For clarification of medical evidence, our staff will contact the attending physician first. If sufficient evidence cannot be obtained, the claim will be denied. A letter will be sent that clearly outlines the reason for denial, information needed to reconsider the claim, and information on how to file an appeal. The employer is always provided a letter advising of the reason for the denial. The letter will not contain confidential information.

Transition short-term disability (STD) to long-term disability (LTD)

If your plan also provides LTD benefits, the claim will be automatically referred to the LTD examiner. There is no need to file a separate LTD claim form. The examiner will open a case file and conduct a claimant interview. Additional information will be gathered to allow for appropriate disposition of the claim.

Long-term disability (LTD) claim submission

All long-term disability claims are to be submitted by using the LTD Claim Form (LC4571-18).

Humana Inc.
Attention: Group Claims
PO Box 2993
Hartford, CT 06104-2993

Claim submissions must include documentation noted on the claim form, along with a job description from the employer. Claim forms should be submitted at least halfway through the policy elimination period.

The claim examiner reviews the claim for specific criteria including:

  • Eligibility
  • Medical certification
  • Offsets
  • Additional information required:
    • Medical records
    • Specific questions of the treating physician (diagnosis specific)
    • Workers’ compensation records, etc.

This process will occur within five days of receipt of the claim.

If additional information is required, the examiner will conduct a claimant interview by phone to clarify discrepancies with claim submissions. The examiner also may follow up with the attending physician or employer to obtain additional information.

When all requested information is received, the LTD examiner reviews the documentation to determine if criteria have been met. This includes but is not limited to the following:

  • Are the limitations consistent with the diagnosis and objective medical documentation?
  • Is there objective medical documentation certifying total disability from the last day worked?
  • Does the medical documentation substantiate total disability beyond the elimination period?
  • Is the length of disability reasonable based on diagnosis, age, and job duties?

Depending on the individual claim circumstances, the claim also may be referred to one of our nurses or to a physician for review.

If the claim is subject to the pre-existing condition limitation under the policy, an investigation will be conducted to determine if the limitation applies.

When sufficient information is received to make a claim determination, the claim will be finalized and all parties advised of the decision. Approval and denial letters are generated the day of the decision. If the claim is approved, initial compensation is released the same day.

List of forms

Group Term Life Enrollment Form (Employer Groups) 1465
Group Term Life Enrollment Form (Association Groups) 1466
Group Term Life Insurance Evidence of Insurability (EOI) Form 1474
Group Term Life Insurance Portability Election Form 1488
Employee Request for Change Form 1475
Claim Statement Life/AD&D 5114
Waiver Claim Form 5088
Waiver of Group Insurance Form 1504
Group Disability Enrollment Form 1493
Group Disability Evidence of Insurability 1490
Notice of Conversion Right 5258
Affidavit of Domestic Partnership 5841
Statement of Termination of Domestic Partnership 5847
STD Claim Form LC-5180-18
LTD Claim Form LC-4571-18
Group Insurance Beneficiary Designation/Change 6249
Absolute Assignment of Group Life Insurance Benefits 6271
Administrative Guide for Group Benefits
Submitting Claims Short-term and Long-term Disability

Supplies

All forms can be accessed through KMGAmerica.com.