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Who is Cardea-Health Solutions Limited?
Cardea-Health Solutions Limited is a claims processing company which provides administrative services to Group Health Plans, primarily self-funded plans.
   
What services does Cardea-Health Solutions provide?
Cardea-Health Solutions services Medical, Dental and Vision claims and provides benefit payment and disbursement. We also provide assistance with plan administration and queries. Cardea-Health Solutions also gives its members access to a network of healthcare providers.
   
How can Cardea-Health Solutions be contacted?
119 Henry Street

Port of Spain

Trinidad

West Indies.

Telephone: +1 868 623-0576/ 9 or 623-5322/5

Facsimile: +1 868 624-9505
   
Who can I contact at Cardea-Health Solutions?
Mr. Edison Raphael, Managing Director
Ext. 287

Mrs. Paulesca Romany-Fournillier, Supervisor
Ext. 329

Mr. Ashley Romany, Account Assistant
Ext. 277

Anil Joseph, Account Assistant
Ext. 252

Alya Abdulla Ali Taib, Account Assistant
Ext. 315
   
My company has a Health Plan administered by Cardea, how do I or my dependants enroll?
An Employee enrolls in the Plan by completing an Enrollment Form for him/her and for his/her eligible dependants at the time of enrollment. This Employee and his/her dependants are guaranteed automatic enrollment unto the health plan on the basis that this form is submitted to Cardea within 31 days of his/her employment confirmation date.

For Employees who acquire new dependants while covered on the Plan, he/she will apply by completing the necessary Enrollment Form in respect of such new dependant and submit same to Cardea within 31 days of acquiring these dependants.

Please note that all late enrollments will have to be accompanied by an additional Health Statement (provided by Cardea) and will be subject to Cardea’s underwriting practices in place at such time.
   
Cardea administers my company’s health plan, can my family join?
The eligible dependants of an active Employee are-
 
The Employee’s legal wife or husband, (but not including spouses who are legally separated from the Employee) or
The person living with the Employee in a recognised husband and wife relationship, who is registered as such in the records of the Company, and
The Employee’s unmarried children, step-children and children legally adopted who are under your plan’s stipulated eligible age and living in the Employee’s household and have the same permanent residence as the Employee or absent therefrom only to attend school. Such children must be registered as dependants in the records of the Company.
 
The Employee’s children who are over your plan’s stipulated eligible age but under the maximum dependant child age set out by your plan shall only be eligible if they have the same permanent residence as the Employee and if they are full-time students at an accredited college or university and coverage under the Plan was effected prior to such children attaining nineteen (19) years of age. Proof of attendance must be submitted to Cardea annually.
   
How to claim?
Instructions
 
Claims would be paid according to:
 
The dollar limits listed on the schedule of benefits
Plan rules
The application of Reasonable and Customary charges for surgical procedures
 
Eligible expenses for treatment incurred outside of the Provider Network will be reimbursed in accordance with the schedule of benefits and the rules of the plan.
 
You and your provider should complete the claim form and submit it with all original itemized bills and receipts.
All claims must be submitted within 90 days from the date of incurring the expenses.
Do not hold your claim until the end of your treatment. You should submit your claim after each visit during the course of your treatment.
Failure to submit your claim within 90 days will result in your claim being time barred for payment.
 
Detailed bills must support all expenses other than doctor’s visits. Only original bills and receipts are acceptable.
 
Hospital bills must include:
Number of days hospitalized
The charge for each day
Itemized charges for other hospital services
Receipts for Surgeon’s and Anesthetist’s fees
 
Drug bills must include:
The date of purchase
Name of patient
Name of prescribing Physician
Prescription number
Name, quantity and cost of drugs itemized (if more than one)
 
X-Ray/Lab Test bills must include:
The date
Name of patient
The cost and type of service rendered
   
How to use the Provider Network?
In order to access treatment at one of the listed providers, a member has to produce the Med Access Health Plan Identification Card and some other form of Identification to the physician/health institution.
Once it has been established that the member is covered by the Group Health plan, the provider will provide treatment without advance payment.
You are required to sign a claim form each time you visit one of the Physicians listed on the Network.
Expenses for Physician visits accessed at a Hospital, even if the Hospital is listed on the Network is on a reimbursement basis.
For Prescription Drugs you are required to take two copies of the Prescription, which must be completed by a participating Physician, to the Pharmacy on the Provider Network. At the Pharmacy you will be required to produce the Med Access Plan ID Card and some other form of identification as well as to sign the Prescription Drug Claim Form when the Prescription has been filled.
   
Do I need my MedAccess card to use the Provider Network?
In order to access the Provider Network, each employee and dependant spouse would receive a Med Access Healthcare Card. This card must be presented to the Provider along with another acceptable form of Identification (Driver's Permit, Electoral Identification Card or Passport).

In the event of a medical emergency while overseas, a 24-hour toll free number is located at the back of the Med Access Card.

This provides access to Cardea's International Manage Care Partners who will assist members in accessing emergency treatment.
   
What is the reimbursement percentage?
The Plan will reimburse the percentage stipulated in the Schedule of Benefits for Medical, Dental Care and Vision Care expenses incurred by enrolled Employees. The Employee is responsible for the difference of the expenses.
   
What is a Pre-Existing Condition?
Upon joining a Group Health Plan, if an Employee within the three months prior to the effective date of participation was under a medical practitioner’s care or received any type of medical treatment or advice because of a medical disability or ailment, that condition is considered a pre-existing condition and expenses incurred by an Employee are not covered by the Plan.
   
What are Eligible Expenses?
'Eligible Expenses' shall mean the actual expenses and charges incurred by an Employee enrolled in the Plan, which are reasonable and customary for necessary Medical, Dental or Vision Care and services administered by or ordered by a physician licensed to practice medicine.
   
What are Reasonable and Customary Charges?
'Reasonable and Customary Charges' shall refer to charges for Medical, Dental or Vision Care and services administered. Charges are considered reasonable and customary to the extent that it does not exceed the general level of charges being made in the area where the charge is incurred.
   
Are referrals required for Specialists' visits?
Yes, with the exception of Gynecologist and Pediatric visits.
   
Why aren't all drugs prescribed by doctors covered?
Most health benefits plans only pay for controlled drugs (antibiotics, narcotics, injections).
   
Are visits by chiropractors, chiropodists, podiatrists etc… covered?
No. Only doctors that are registered with the Medical Board of Trinidad and Tobago will be considered for reimbursement (unless otherwise stated in your Plan’s contract).
   
What services are not covered by most health plans?
Cosmetic services, supplies or treatment
Experimental Services
Charges in excess of benefit maximums
Services determined not to be medically appropriate and/or necessary
Infertility nor Birth Control
AIDS
   
Is it necessary to submit original receipts when claiming?
Yes
   
In addition to the annual benefit, what are some of the most common limitations on Vision Care Benefits?
12 consecutive months for lenses and exams and 24 consecutive months for frames.
   
Does my Dental Care Benefit extend to cosmetic services like teeth whitening and implants?
Most plans do not cover these procedures.
   
What is Pre-Certification?
Pre-Certification is required in advance for all non-emergency treatment and elective surgical procedures.
 
Services requiring Pre-Certification are as follows:
All non-emergency inpatient admissions (Room and Board per day)
Surgical Procedures
In-Hospital Services
MRI/CT Scans and X-Rays
Maternity/Delivery
Operative and Diagnostic Endoscopies
Transplants
Dental and Vision (Within the Provider Network)
 
Have your Physician complete the Pre-Certification form with a description of the diagnosis (diagnostic test/treatment/Procedure recommended) as well as the actual costs and fax to Cardea for approval. Cardea would respond advising of the plan’s liability and the Member’s liability. Cardea will make arrangements to pay the plan’s liability directly to the provider and the employee will be responsible for the balance of the cost.
 
Surgery, diagnostic and other listed procedures performed during an emergency, DO NOT require Pre-Certification.
   
I am covered under my spouse’s health plan; can I still enroll in my company’s health plan?
You are still eligible to join the plan even if your spouse is covered under another plan. The benefits to be derived from your plan shall be co-ordinated with the other plan’s benefits in accordance with the following:
 
On submission of each claim form, Co-ordination of Benefits section must be completed for persons who have duplicate coverage.
Claims for you are to be submitted first through your plan.
Claims for children are to be submitted first through the plan covering the male spouse.
Claims for your spouse are to be submitted first through his/her plan.
 
The initial payment would be made by the plan covering the member as an employee and the other plan pays the difference up to the plan’s limit.