Evergreenmd.org



Question Response General Questions 1 Where can I find more information about the Evergreen Health (Evergreen) Receivership? Go to to see the receivership orders, Frequently Asked Questions (FAQs) and other notices. If you have additional questions, please contact us as follows: If you are a provider, then call Provider Relations at 443-475-0105 or email providers@. If you are a group program administrator or broker, then please call Sales & Enrollment at 443-863-8910 or email sales@. If you are a policyholder or member, then please call 443-451-4979. 2 What does liquidation mean for policyholders? All Evergreen policyholders had to enroll with a new Health Maintenance Organization (“HMO”) or carrier in order to continue health insurance coverage after September 30, 2017. If you have questions, please contact your group administrator. The liquidation order approved a special thirty (30) day open enrollment period for Evergreen group members beginning on September 1, 2017 and ordered cancellation of all Evergreen member policies effective 11:59 pm Eastern Daylight Time on September 30, 2017. 3 Will I get credit for my deductible and out of-pocket maximum amounts, already paid to Evergreen for this plan year? No. 4Will my deductible and out-of-pocket maximum reset with my new HMO? Will I have new copays and other member responsibility charges under my new HMO coverage? Yes, Evergreen will continue to process claims and apply cost-sharing for claims incurred while you were enrolled with Evergreen. Your new HMO will apply cost-sharing to claims incurred based on your enrollment period with them, under the terms and conditions of your new plan coverage. That means your copays, deductibles, covered services and prescriptions may change, based on the plan your group health administrator or broker has selected. If you have questions, please contact your group administrator. 5 Evergreen members are not eligible for the protection afforded by the Maryland Life & Health Insurance Guaranty Corporation. Why and what does that mean? Evergreen is a Health Maintenance Organization (HMO), and HMOs are not covered by the Maryland Life & Health Insurance Guaranty Corporation. That means the Maryland Life & Health Insurance Guaranty Corporation cannot make any claim payments on behalf of Evergreen, so any payments must be made from Evergreen’s remaining available assets.6When can I expect to get my Loss of Coverage and Proof of Creditable Coverage letters? Letters were mailed out after the end of the open enrollment period. Coverage Questions Claim Questions 7Please explain how September claims will be paid? Claims with dates of service on or after September 1, 2017 for members of those groups that do not move to a new HMO effective September 1, 2017 will be paid by Evergreen in the normal course of business. Claims for members whose groups moved effective September 1, 2017 will be paid by the new HMO at the amounts allowed by the new company. 8 Please explain the difference between the pre-receivership claims and post receivership claims handling procedure. Post receivership claims (dates of service on or after July 31, 2017) will be paid as administrative expenses and we estimate they will be paid at 100%. Pre receivership claims (dates of service before July 31, 2017) will be paid as a part of the receivership claims process. Claimants will have to file a Proof of Claim form (see FAQ #15 below for more information about the form). After the claims filing deadline of July 31, 2018, the Receiver will review the claims and make a recommendation to the court. When all of the claims have been approved, the Receiver will make a payment to the claimants. The amount of the payment will depend on the amount of Evergreen’s remaining assets. If the funds available are not sufficient to pay the claims at 100%, the claims will be paid at a lower percentage. 9 When is the claims filing deadline, and how do I get a proof of claim form? The claims filing deadline is July 31, 2018. Proof of Claim forms were mailed on March 7, 2018.10 Will claims with a date of service after October 1, 2017 be paid? Claims with a date of service on or after October 1, 2017 will be paid by the new carrier or HMO if the group purchased new coverage. All Evergreen policies will be cancelled no later than September 30, 2017. Claims with a date of service after that date will only be paid by Evergreen in certain potential situations involving a hospitalization that began on or before September 30, 2017 and which extended into October. 11 Evergreen had a "national" plan that used the Private Healthcare Systems (PHCS) network. How will those claims be paid? All claims will be paid in the same manner based on the dates of service in accordance with the terms of the contract. Claims with dates of service on or after July 31, 2017 will be paid now. Claims with dates of service prior to July 31, 2017 will be paid at a later date as a part of the receivership process. 12 Are PHCS providers considered “in-network”? Will PHCS claims be covered for dates in September 2017? PHCS providers are considered Evergreen “in-network” providers. Claims from PHCS providers with dates of service on or after September 1, 2017 will be processed at amounts allowed by the new HMO, or if there is no new HMO, those claims will be processed by Evergreen as “in-network” providers. 13 Is payment in full in the ordinary routine (a little over 30 days from date of service) for post-receivership services planned? The ordinary routine would have some payments begin about day 45, that is, about September 15, 2017. Staffing changes might slow this some. Is cash on hand limiting the Receiver's payments for post-receivership services? The Receiver plans to pay the post receivership claims in the ordinary course of business as soon as possible. Neither staffing nor cash on hand is currently limiting payments. post-receivership services? It could be made anytime under the order, it appears. 14 Is there a preview range for the dividend for pre-receivership policy health care claims? General unsecured claims? We understand your question to be when the pre-receivership claims will be paid. The pre-receivership health care claims, and any general unsecured claims will be paid after the claims filing deadline set by the court. Those payments will be based on the amount of the remaining assets and the priority assigned by Maryland Statutes (Section 9-277) to the type of claim. 15 I do not agree with how a claim was processed, should I file a claim reconsideration or appeal? Yes, please continue to file claim reconsiderations and appeals as normal. 16 Please confirm the members are only responsible for their cost share. The Providers cannot balance bill what is owed by the carrier. If the provider is in-network with Evergreen, the member is only responsible for paying the member’s cost share up front. This could be the copayment or any deductible or coinsurance. In-network providers must submit claims on the member’s behalf. If the provider is not in-network with Evergreen, the provider may choose to bill up front for services. The member should submit claims for reimbursement if the provider does not submit the claim on the member’s behalf. Maryland has statutory provisions that forbid providers from balance billing for covered services. All provider contracts have a "Hold Harmless" clause that applies to in-network providers. Non-contracted providers that are subject to Maryland law are effectively subject to the "Hold Harmless" provision as well. The liquidation order also forbids providers from billing members for amounts owed by Evergreen. Please see the last paragraph of the liquidation order. 17 I have a client that is having problems with a provider due to the Evergreen receivership. Who can they contact for help? Please have the member call 443-4514979. 18 Who should members contact if doctors try to bill them for unpaid claims from prior to July 31, 2017? Members are getting notices from collection agencies from participating providers because they have not been paid by Evergreen. How does a member handle that? Please have the member call 443-4514979 or contact the Maryland Attorney General’s Health Education and Advocacy Unit at 410-528-1840 or heau@oag.state.md.us. 19 Do the rules on continuity of care and balance billing apply to out of state providers? Depending on the circumstances, the terms of the liquidation order could apply to out of state providers. Please refer to the last paragraph of the order for more information. Operational Questions 20 How should claims be submitted to Evergreen? Continue to submit claims through the normal process of EDI (Payer ID 93240) or mailing to Evergreen Health, Claims Processing Center, PO BOX 331429, Corpus Christi, TX 78463. 21 Please confirm that for the foreseeable future all claims for Evergreen related claims will continue to be processed through the current Evergreen claims system. Yes, all Evergreen related claims will continue to be processed through the current Evergreen claims system. 22 How can I see how my claims are being processed? Your practice can access member eligibility, claims and prior authorization information through the Evergreen Health Provider Portal. To request access to the Portal, please visit . For assistance in accessing or using the Portal, please contact Evergreen Provider Relations at providers@. September Premium Refunds 23 Will Evergreen refund September premium payments to the group if new coverage is obtained through another HMO before September 30, 2017? Yes. Proof of other enrollment will be requested prior to the refund being issued. The receiver will be establishing a process whereby proof of new coverage can be received to allow for payment of a refund. 24 If a group moves to another carrier effective September 1, 2017 that is not one of the HMO products listed in the communication, will they still be eligible for a refund? Yes, as long as the group shows proof of coverage as of September 1, 2017. 25 Regarding premiums refunded, will the employer receive a check? If premiums were paid through a Third Party Administrator (TPA), will the credit or check go back to the TPA and therefore the TPA credit payments to the employer? Premiums will be refunded to the employers that paid directly to Evergreen. Premiums for groups that paid through a broker or TPA will be refunded to that broker or TPA. Requests for refunds should be sent to: questions@ and should include proof of new coverage. Refund requests will be validated and checks will be cut once a week. Broker Questions 26 When will broker commissions be paid? There will be a Proof of Claim process which will enable brokers to file a claim for commissions. Maryland’s Receivership Statutes place commission payments at a lower level than member and physician claims and claims of the federal government. Commission payments will be paid in liquidation only if funds of Evergreen are sufficient to pay all of the higher priority claims. 27Could brokers be open to any potential E&O (Errors & Omissions) exposure? The Receiver cannot give legal advice. Explanation of Benefits and Rights (EOBR) 28 I received an Explanation of Benefits and Rights (EOBR) from Evergreen. What is this, and how is it different from Explanation of Benefits (EOBs) that I have received in the past? Your EOBR is similar to the EOBs that you have received because it provides information about how your claim was processed. It also informs you of any cost share that you may owe the provider of services. In accordance with the court order, however, payment has not yet been issued to the provider. 29 I disagree with the way that the claim has been processed. What can I do? You can contact Evergreen Health Member Services at (443) 451-4979 to discuss how the claim was processed and request reconsideration. You can file an appeal following the process described on the EOBR. For additional assistance or help preparing your appeal, you can also contact the Health Education and Advocacy Unit, which is part of the Consumer Protection Division of the Maryland Office of the Attorney General. You may do so by calling 877261-8807, or visiting them online at the following link. 30 My provider is billing me for more than the amount I owe on my EOBR. What can I do? Under Maryland law and the court order, providers are prohibited from billing you for more than the amount you owe on the EOBR. Please contact Evergreen Health Member Services at (443) 451-4979 so we may assist you in this matter. Explanation of Pending Payments 31 I received an Explanation of Pending Payment (EOPP) from Evergreen. What is this? The EOPP is your remittance advice for all unpaid claims that Evergreen has received and processed for dates of service prior to the July 31, 2017 receivership order. It provides your practice with information about how these claims have been processed, as well as any member cost share that the member owes. 32 How is the EOPP different from other Explanations of Payments (EOPs) that I have received in the past? The only difference is that your practice has not received payment from Evergreen. In accordance with the court order, Evergreen cannot pay pre-receivership claims at this time. The Receiver of Evergreen will be mailing instructions on how to file for payment of your pre-receivership claims in the near future. 33 What can I bill members for? Your practice can bill members for their member cost sharing responsibility – deductibles, coinsurance and copayments. Your practice can also bill members for non-covered services. These amounts are defined on your EOPP. In accordance with the court order, your practice cannot bill members for balances owed by Evergreen. If Evergreen learns that your practice is balance billing in violation of the court order, your practice will be referred to the Health Education and Advocacy Unit of the Maryland Office of the Attorney General. 34 I disagree with the way that the claim has been processed. What can I do? You can contact Evergreen Health Provider Services at (443) 451-4979 to discuss how the claim was processed and request reconsideration. If you believe that the claim was incorrectly processed, you can submit a claim reconsideration by using the Provider Claim Reconsideration form available on website here. You can also submit a claim appeal request by using the Claim Appeal form available on our website here. 35 I recently received an EOP from Evergreen where I was paid for claims. Why did you pay those claims but not the claims on my EOPP? Claims for dates of service on and after the July 31, 2017 receivership order are being paid in the ordinary course of business. Proof of Claim Questions36I received a Proof of Claim (POC) form. What is it and what do I have to do?EHI is in liquidation. The POC is required to establish your claim in the estate if EHI still owes you money. Your Proof of Claim form must be properly completed, signed and postmarked no later than July 31, 2018 by 11:59:59 p.m. (Eastern Time). It must be mailed to the address on the back of the POC form. Proof of Claim forms will not be accepted by email or fax. If you are not owed any money by EHI, you do not have to file the form. If you do not have all of your documentation ready to send, you can submit the form without the documentation to establish your claim and submit the supporting documents at a later date, but before July 31, 2018. You must keep us apprised of any address changes. Medical Provider address changes can be sent to providers@ with “Address Change” in the subject line and must be accompanied by an updated and properly executed W9 form. Member address changes can be sent to Client_Advocacy@.37I prefer to hand deliver my POC form and/or supporting documents. What do I need to do?Please contact Evergreen either via email at EvergreenPOC@ or by calling customer service at (443) 451-4979 to schedule a time to deliver the documents. 38What if I already submitted my POC form but need to make a change/add additional information?You can send additional information you would like to have considered to the address listed on the back of the POC form. This information must be sent by July 31, 2018.39Where can I get additional information about the liquidation proceedings?Please visit for information about the receivership and liquidation, including court documents, important deadlines and procedural information.40What if I missed the July 31, 2018 deadline? Can I still file a POC?Proof of Claim forms received after the filing deadline are barred from filing a claim against EHI under the terms of the Court Order. The order can be read in its entirety here: Court Approval of Bar Date and Claims Procedures 41Do I need to submit a W9? If you are a business entity or a self-employed contractor who provided services to OHC, you must submit a W9. Any payment to you from this proof of claim is contingent upon a current W9 being on file. If you are not a business entity you do not need to submit a W9. 42What determines the priority of claims payment?Maryland Statute 19-706.1(g)(2) and 9-227 (d) of the Insurance article set forth the priority of claims payment. 43What if I have other questions? For questions not addressed in this FAQ, please send an email to: EvergreenPOC@. We will periodically update the FAQ’s with common questions.Q&A for Completing the POC Form44What is a contingent or unliquidated claim?A contingent claim is one in which there is a ‘triggering event’ or some condition precedent for the claim to exist. An example of a contingent claim would be a situation where the liquidated company was the principal debtor on a loan and the claimant is the co-signer; in this scenario, the “triggering event” is the liquidation, and the claimant could file a claim for amounts for which they are now liable.An unliquidated claim is a claim in which the exact amount of the claim has not been determined. Q&A for Providers45I’m a medical provider who rendered care to a member and have unpaid claims. Do I use the POC to file my claims?You must file a POC form to receive payment for claims incurred before July 31, 2017. Your POC form must be properly completed and postmarked no later than July 31, 2018 by 11:59:59 p.m. (Eastern Time) and mailed to the address on the back of the POC form in order to establish a claim against the estate of EHI. A detailed itemization of the unpaid claims must be submitted with this form. An itemization template is available for download at Provider Itemization Template. The itemization can be submitted on a flash drive. Do not include the actual medical claims with this form. The medical claims must be submitted via the normal established claim filing procedure. 46Do I have to file a POC for claims incurred on or after July 31, 2017?No, these claims should continue to be submitted via the normal process. All claims must be submitted no later than July 31, 2018.47Is a POC required for each claim or can multiple claims be on one POC?No, a separate POC is not needed for each medical claim. Providers should attach a detailed itemization of the unpaid claims and submit with one POC form. Do not include the actual medical claims with the form. The medical claims must be submitted via the normal established claim filing procedure. The deadline for submitting claims is July 31, 2018.48What qualifies as a detailed itemization of unpaid claims?You may satisfy the requirement for supporting documentation of paid claims with a balance due by submitting copies of the Explanation of Pending Payment (EOPP) forms you have received from EHI. For any claims you have not yet received EOPPs from EHI for, please provide the original billed amount, as well as Claim # (if known), Provider, Policy #, Patient Name, DOS, Procedure (CPT) or HCPCS code(s).Please also include a table or Excel spreadsheet reconciling billed, paid by, and remaining amounts due from EHI for the above claims, equaling the Total Amount of Claim you entered on Page 1 of the POC. An itemization template can be downloaded from the EHI website at (insert URL).If you do not have all your POC documentation ready to send, we suggest you submit the form without the documentation to establish your claim and submit the supporting documents at a later date, but before July 31, 2018. Failure to submit supporting documentation may result in denial of your claim in full or in part.49When will I know the amount/value assigned to my claim? The Receiver will follow the Procedures for Claims as approved by the Court and notify you of the value of your claim(s) accordingly. The Procedures for Claims are available at Court Approved Procedures for Claims. 50What if I don’t agree with the amount/value assigned to my claim? A claimant will have until the date specified in their Notice of Determination to file an objection to the amount/value. Instructions on how to file an objection will be provided with the Notice of Determination. 51When Can I Expect to Receive Payment of my Pre-Receivership Claims?At this time it is too early in the receivership proceedings to know the timing and extent of payment of pre-receivership claims. There are many factors that impact the timing of distribution payments. Evergreen’s website will be updated periodically with the status of the liquidation proceedings.52Do I need to submit a W9?Yes, we must have a current W9 on file in order to issue payment.53Can I bill patients if I don’t get paid?No. Maryland law prohibits providers from billing patients for the insurance company’s portion of the cost of medical care. This law applies to all providers of care, including physicians, hospitals, and pharmacies. You may only bill the patient for their member cost-share, but not for amounts that should have been paid by Evergreen. MEMBER FAQ:54When should I submit a POC form?Members should submit a POC form on or before the July 31, 2018 claim filing deadline if they are owed a reimbursement for a medical service that should have been paid by EHI. However, members are still responsible for deductible, coinsurance and co‐pay amounts due under their policies and no claim should be submitted for those payments. 55If I have received a bill from a provider that has not been paid do I need to submit a claim?No. Members should only submit claims for bills that they have paid. The providers are responsible for filing their own claims.56A Provider is trying to collect payment from me. Can they do that?Maryland law prohibits medical providers from billing patients for amounts that should have been paid by Evergreen. The provider can only bill you for your cost-share amount(s), such as co-payments, co-insurance and amounts that were applied to your deductible. EVERGREEN EMPLOYEE FAQ: 57Who is going to review my claim? Will my privacy be protected?The employee proof of claim forms will include an envelope identifying their claim as an employee claim. It is important that the proof of claim and any supporting documentation be returned in this envelope or in an envelope specifically noting an employee claim on the outside. The employee claims will be reviewed by the Receiver’s staff.58What if I receive a proof of claim form as a member and an employee?All claims belonging to an employee need to be included in the provided envelope or using the address provided and noting EMPLOYEE CLAIM on the outside of the envelope submitting your claim.59What is the priority of payment of employee claims, and how is it determined?Maryland Statute 9-227(d) determines the priority of employee claims in an insurance receivership when there are potential claims by the Federal Government. Employee claims are fourth in the priority of claims:(4) the first $500 of compensation or wages owed to an officer or employee of an insurer for services rendered within 3 months before the commencement of a delinquency proceeding against the insurer, which shall be instead of any other similar priority that may be authorized by law as to wages or compensation.60How do I get information about my claim, such as how much PTO I had remaining when the company was ordered into receivership?You can send a request for this information to EvergreenPOC@. ................
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