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Frequently Asked Questions

1.

How Long Does It Take To Process Each Submitted Claim?

 

All valid and eligible drug and dental claims are processed and paid within 48 business hours. Members are notified within 24 hours for any claims that did not pass the adjudication process due, but not limited, to the absence of original receipt, ineligibility of the medical/dental service or lack of supporting documents.

 

 

2.

Does the Card Expire When It Reaches Zero Balance?

 

Transactions may not be processed if the card does not have available funds. However, this does not deactivate the card. The member can still use the card as soon as funds are replenished.

 

 

3.

Does It Support Coordination of Benefits?

 

ESORSE supports Coordination of Benefits for both public and privately administered plans. ESORSE can be a primary or a secondary payor. We used the birthday rule for members who have spousal coverage. In such case, the parent whose birthday comes in earlier in the calendar year is considered the primary payor.

 

 

4.

What Will Happen To Submitted Claims Exceeding The Existing Balance of The Member’s Account?

 

Similar to a banking concept, maximum withdrawal/reimbursement that can be made is equivalent to the Account’s Available Balance (net of applicable taxes and fees). Any outstanding balances can be paid as soon as the plan sponsor remits its periodic contribution.

 

 

5.

How can the members update their profiles?

 

The best way to update their profiles is to use Esorse’s secured portal. Alternatively, they can call 416-483-3265 or send an email to info@esorse.com for any changes.

 

 

6.

How will the members be kept abreast of their balances, claim history and payment status?

 

Members who provided their email addresses will be receiving an automated Statement of Benefits. They also have 24/7 access to our secured portal where they can view the status of their claims.

 

 

7.

How would Plan Sponsors know the best solution for their workplace?

 

Not all Plans are designed equally. What is good for one company may not be suitable for another. To help you decide on the best solution for you and your employees, the matrix below may be a good starting point. Our valued network of third party administrators and insurance agents/brokers can even take you a step further and help you design a viable and practical solution that is specifically customized to your unique needs.

 

 

8.

For health spending accounts, can unused contributions be carried forward?

 

Unused funds at the end of the initial plan year are not lost, but carry forward to the next plan year and are used first to cover new claims in that year. Any funds remaining from year one at the end of year two are forfeited back to the contributing employer at the start of plan year three per CRA rules regarding HSA's.

 

 

9.

Is there a grace period in submission of claims?

 

The Esorse system is very flexible in defining the grace period for claims. It can be based from the date the service is rendered or it is also possible to set a deadline for previous year’s claims.

 

 

10.

Are cosmetic procedures covered under Health Spending Account?

 

Budget 2010 announced that all expenses incurred for expenses incurred for purely cosmetic reasons are no longer considered eligible. As such, HSA coverage was revised so that all Drugs, surgical/non-surgical procedures, travel and other related services whose sole purpose is to enhance one's appearance will not be paid. Some of these procedures include but are not limited to liposuction, hair replacement procedure, laser hair removal, botulinium toxin injections, dental veneers & teeth whitening. However, the plan will continue to adjudicate and pay for claims similar to the ones mentioned above, if they are required for medical or reconstructive purposes such as surgery to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease. Eligible Expenses are based on Income Tax Folio: S1-F1-C1, Medical Expense Tax Credit, Income Tax Folio: S1-F1-C3, Form T2201, Disability Tax Credit Certificate; Guide RC4064, Medical and Disability-related Information

 

 

11.

Will it be possible to impose a waiting period before members are allowed to reimburse claims?

 

Members may be required to complete a waiting period before reimbursing claims. The system automatically detects the waiting period based on the effectivity date of the benefit coverage. Waiting period may also vary among the different claim categories (ie drugs, dental, paramedical services, etc)

 

 

12.

What are the eligible paramedical services covered by Health Spending Account?

 

Eligible Expenses are based on Income Tax Folio: S1-F1-C1, Medical Expense Tax Credit, Income Tax Folio: S1-F1-C3, Form T2201, Disability Tax Credit Certificate; Guide RC4064, Medical and Disability-related Information

 

 

13.

If the available balance in Health Spending Account is insufficient to pay for a claim, will the system reject the claim?

 

For claims that are payable to the members, it is possible to configure the system to defer payment and accept claims regardless of the available balance. Payment will be made as soon as contributions are deposited to the health spending account.

 

 

14.

What are the eligible drugs that may be reimbursed under Health Spending Account?

 

Drugs with corresponding Drug Identification Numbers from Health Canada that are prescribed by doctors and dispensed by licensed pharmacist are considered eligible expenses under a Health Spending Account.

 

 

15.

In the unfortunate event of member’s demise, is it possible to extend the benefits to the surviving family?

 

Yes, surviving members of the family may continue to reimburse claims up to a specific duration defined in the plan design.

 

 

16.

Can a group of drugs be set up to require special authorization prior to reimbursement?

 

Drug plans can be customized in such a way that specific drug groups may require prior approval. In such a case, the prescribing doctor may have to fill out a form for this purpose before claims are paid. Approvals are granted, in accordance to agreed criteria with Plan Sponsors or their Benefit Consultants. These may be given based on a specific time period, days-supply, quantity or an aggregate amount. Electronic and manual claims will be seamlessly adjudicated based on the approved parameters.

 

 

17.

Does the Esorse system have provisions to cap branded drugs to their generic price?

 

To reduce drug costs, therapeutic equivalents of branded drugs are sometimes recommended. However, members may still opt to purchase branded drugs. Plan sponsors, on the other hand, may design the plan in such a way where it will only pay for the price of the brand’s generic equivalent and any difference in price will have to be shouldered by the member.

 

 

18.

How does the system monitor the overage dependants?

 

The system has the capability to monitor Age restrictions. It can also auto terminate members as soon as they reach the age defined in the benefit coverage.

 

 

19.

Can reimbursements be deposited directly to the members’ account?

 

Just send a copy of your void cheque to Esorse Corporation. Your account will be enrolled under direct deposit as soon as we receive your void cheque. Alternatively, you may register your bank id, transit number and account number using our secured on-line portal.

 

Have a question you don’t see answered here? Please contact us today and we’ll be pleased help!

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