Updates'25

An office or facility may be in-network, but not all providers within that location are in-network.

Important Reminder

• Provider directories are for reference only.

• Information may change and may not always be current.
  
  

What to Advise Members
Before seeking care, members must call the office or facility directly to confirm that:

• The specific provider they will see is contracted with the network, and

• The provider is in-network at that location.
  
  

Action Required

• Do not guarantee network status based on directory listing alone.

• Always advise members to verify directly with the provider’s office.

All appeals will be responded to within 30 days from the date received.

What to Say:

• “Once the appeal is received, a response will be provided within 30 days.”

• “The appeal response timeframe is within 30 days from the receipt date.”
  
  

Action Required:

• Always communicate the 30-day timeframe to members.

• Do not promise responses outside this period.

When providers ask why their Explanation of Benefits (EOB) shows Careington, please note:

Careington is the umbrella company of Connection Dental and Dentemax, so it will always appear on the EOB even if the member’s network is listed under those partners.

Use this as your standard response when addressing similar questions.

When an individual member or a key contact for Seniors Choice Group asks why their premium increased, follow this process:

1. Check the member’s age first.
   Premium adjustments apply in the month the member turns 66, 67, 68, 69, 70, 75, 80, or 85.

2. If the increase is not age-related, advise one of the approved explanations below:

   • “The increase is mainly driven by the rising cost of medical care itself—hospital services, doctor fees, and especially expensive new medications—which we are required to cover.”

   • “The increase in rates this year is a result of several unavoidable, rising costs across the entire healthcare industry, not just our plan. The primary factors include the rising cost of medical services and the increased use of care.”

Keep this handy and apply consistently during all Seniors Choice premium-related calls.

In cases where a broker contacts the center requesting to speak with the Commission Department to obtain account numbers or routing information for deposit purposes, agents must inform the caller that the Commission Department does not exist.

Agents are encouraged to refrain from escalating or transferring such calls to Team Leads or Support. Instead, they should direct the caller to send their inquiry via email to accountservices@mbaadmin.com, which serves as the sole point of contact for Account Services.

If further escalation is necessary, agents may escalate the details to Level 3 (L3) using the following format:

• Broker Name:

• Company:

• Contact Number:

• Email:

This protocol ensures accurate communication, prevents unnecessary escalations, and reduces the likelihood of supervisory involvement.

          The reinstatement process for MBA-Multiflex Dental, VSP and Senior's Choice is to restore an account or service that has been deactivated or suspended.

Standard Reinstatement Process:

(1) Payment Collection Timing

● If a member is quoted an amount due but does not make the payment on thesame day, representatives must contact Level 3 (L3) again to quote the current amount due, if the member calls back later to pay. The balance may have changed, and it is essential to verify and collect the updated amount (the amount may have changed, and if more than 90 days have passed, reinstatement may no longer be allowed)

(2) Collect Payment

● Obtain payment for the quoted amount from L3. The amount includes the total account balance plus an advance payment for 2 months.

● Set up auto-pay for the member and update L3 when payment and enrollment are finalized

(3) Reinstatement Forms

● Following payment completion, L3 will dispatch the reinstatement form and conduct the necessary follow-up

*How do we know if an account is eligible for reinstatement? Is there an allowable reinstatement window?

 > MFD and VSP policies are eligible for a one-time reinstatement only, with no prior reinstatements allowed. The policy must have been terminated for less than 90 days.

> For Seniors Choice, the policy must be terminated for less than 30 days to qualify for reinstatement. If it's been more than 30 days, L3 will refer the case to Account Services.

Approval from Humana is then required, and they will determine if reinstatement is allowed and provide the effective date.

          The W9 form must be submitted to the network in order to update the provider’s information. Once processed, the updated information—such as the provider’s address—will be reflected in Xeos. Advise providers to contact the network directly to request the W9 form. 

 If providers call regarding claims denied for Telemedicine coverage, do not offer the Telemedicine phone number. This number is intended solely for members who wish to schedule a virtual appointment. 

The SC Group Address Change Form is used when there is a need to update the address of a group or company. For individual members or employees who wish to update their address, the SC Member Address Change Form should be used. 

     NOTE: If the member is retired and still paying premiums while the SC group plan has not yet transitioned to an individual plan, submit a request to Level 2 for a Group-to-Individual Change Form. 

   For vaccine coverage and determining what's considered preventive, we follow the plan’s Breakdown of Benefits (BOB) age limit should refer to the BOB as     well. While CDC guidelines may provide general recommendations, coverage is ultimately based on what is outlined in the BOB.

Medical records are needed to determine pre-existing condition. Submit medical records through email, or fax then adv caller to reference the denied claim number.

Email: medicalrecords@mbaadmin.com

Fax: 480-776-5054

NOTE:   Mail is no longer an option for Medical Submission. In case the provider insists, you can send a request to L3 but no guarantee.