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Q. If I have a medical condition(s), can I apply?
A. Yes. Complete the application truthfully and give all details about the medical condition(s) on the application. Your application will be reviewed by the Underwriting Department. If there are questions, you will be contacted.
Q. When I apply is payment required?
A. Yes. Payment is required at the time you apply for coverage. Your payment will be applied to your first month payment. If your application is declined, your payment will be promptly returned.
Q. How do I make my payments?
A. The Company allows various forms of payment methods. You can choose to pay monthly, quarterly, semi-annual (6 months) or annually (12 months). Payment can be sent to the Company through credit/debit card, electronic transfer/bank wire.
Q. How do I use Cash App to make my payment?
A. You can make your payment by using Cash App. Make sure you have your ID number available so you will be credited with your timely payment. The ID number must be noted in the Memo Section of the Cash App for immediate credit. Please refer to the payment/billing section.
Q. When is payment due? Will I be sent an invoice?
A. Yes. The Company will send an email invoice to you, usually by the first of the current month. Your payment is due on or before the first of the next month. If your payment is not received by the fifth day of the month, your Policy will be terminated for non-payment. It is your responsibility to make sure your payment is made whether you receive an email invoice or not.
Q. When does my insurance Policy become effective?
A. All effective dates begin on the first of the month. In most cases you will become eligible to start the plan in 30 days, (depending on the date your application was submitted) but no longer than 60 days at which time the Company will notify you via email of your effective date. In some cases, the Company will notify you that clarification is needed and your application is pending. Once the issue has been resolved, you will once again be notified promptly via email.
Q. How am I notified that I have insurance?
A. Once you have been approved, the Company will notify you by email. You will be sent a welcome letter, and attachments consisting of a Policy Cover Letter, Policy and Identification (I.D.) card(s).
Q. Can I choose my own doctor?
A. Yes. The Company wants you to use your own doctor when possible.
Q. What is a deductible waiver?
A. The Company will waive your $500 yearly deductible if you ask your doctor to become an in-network healthcare provider with the Company. Once your doctor enrolls (it only takes a few minutes via the website), your $500 deductible will NO LONGER be required (waived), or balance owed.
Q. If my deductible is waived, will I have a new deductible next year?
A. No, so long as you use the same in-network doctor. If you change doctors to a new non-network provider, you will have a new $500 yearly deductible. If your new doctor becomes in-network, then your deductible will be waived.
Q. If my doctor is in-network, will the doctor be responsible for filing a claim?
A. Yes. All in-network providers are responsible for filing claims, verifying eligibility and accessing the Company’s website regarding payments.
Q. How is a claim paid?
A. If your doctor is in-network, the Company will pay the doctor directly. If your doctor is a non-network (out-of-network) provider, you, the insured, is responsible for filing a claim timely and the payment to the doctor.
Q. How do I file a claim?
A. If our doctor is not an in-network provider with the Company, and you need to file a claim, you are required to go to the Company’s web page and click on the “Claim” button/bar. Then follow the simple instructions and complete the form. Proof of payment is required when a claim is submitted as an attachment.
Q. How do I know if my claim has been paid?
A. You can check the Company’s website by clicking on the “Claim” button/bar and go to the “Paid Claims.” There you will find a listing of the claims submitted, pending, under review and paid. If your claim is denied, you, the insurer is responsible for payment. (See Appeal Procedure)
Q. Can I appeal a denied claim?
A. Yes. If you feel your claim was unfairly denied, you may file a Request to Appeal. The time to file an appeal must be made within 60 days from the Notice of Denial. The appeal must include the reason(s) you feel the denial was improperly or unfairly made and why the benefit should have been paid. Submit all supporting documentation. The appeal will be reviewed within 45 days.
Q. Can I change plans after I am enrolled?
A. Yes. However, your request to change plans is subject to the Company’s approval. You will be required to complete a “Request for Change of Plan” form and could be subject to underwriting review and a possible exclusion of certain medical conditions.
Q. Can I be terminated?
A. Yes. The most common form of plan termination is failure to pay on time. All payments are due by the 28th before the first of the month the premium is due, i.e., Due date January 1, payment due December 28th. Other forms of plan termination are made by the Company for fraud, non-eligible members, or any other issue/act deemed inappropriate or in violation of the Policy or the Company’s standards, procedures or guidelines.
Q. Can a Specialist become an in-network provider?
A. Yes. If your doctor refers you to a specialist, you can ask him to participate as an in-network provider. Your Specialist can do so in minutes by accessing the Company’s webpage at www.transpacificdirect.com
Q. What is the difference between in-network and out-of-network providers?
A. An out-of-network (non-network) provider is any health care provider that you can visit and is not a provider who participates directly with the Company. Out-of-network providers are subject to lower approved payments as set forth in your Policy. In-network providers are approved by the Company and the Company pays the in-network provider directly at a higher approved payment schedule as set forth in your Policy. In-network providers bill the company directly. Out-of-network providers seek payment from you, the insured, as being the responsible party. You are solely responsible to make sure the claim forms are submitted properly and timely.
Q. How long do I have to file a claim?
A. All claims in-network or out-of-network must be filed within 90 days from the date of service.
Q. What is Pre-Authorization and Pre-Certification?
A. Pre-Authorization and Pre-Certification are Policy requirements which notification is required to the Company for various types of treatment, procedures, surgeries and hospitalization. (See Policy for specifics) Through this process the Company is better able to assist you in making sure you receive the proper course of treatment and your claim is processed timely.
Q. What is the difference between a deductible and a co-payment (co-pay)?
A. A deductible is the plan participant’s (insured’s) amount to be paid for services received before the Plan (the Company) pays per the Policy provisions. A co-payment (co-pay) is the portion (amount) due at the time of service to be paid by the plan participant (insured). Co-payments are not applied to the deductible and are paid directly to the provider, usually at the time of service.
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