My 1st Appeal, Insights, Thoughts on Prevention

Aug 1, 2015

  1. yorkriver1

    yorkriver1 Guru

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    1. The nice guy answering the special appeal phone line was quick to tell me, in essence, don't worry why the income info sent in didn't work, it was probably an error to reject it. Not sure if I should be reassured by that. No one at Marketplace seems to have much of a clue about any records regarding the difference between an actual rejection of documents/removal of subsidy and one done in error.

    2. His advice, get names of reps on every call, use certified mail (or take a screen shot of an upload) send documents to cure "inconsistencies" asap, keep calling if no letter is sent verifying the doc(s) were accepted.

    3. The process for this one, an expedited appeal went quickly. I needed to say that the clients had prescriptions in need of filling and medical appointments coming up soon, for the chronic illnesses outlined on the appeal form. What may not be so fast is the time between the less than 5 minutes with them by phone and the actual reinstatement of original benefits. May take at least another 30 days.

    4. I am considering a form to give to clients when they sign up or any time they have a new document submission deadline, giving them details of how to be diligent in submitting forms and following up. If they don't know to look for a letter confirming the receipt of the forms, they won't know to contact me and/or the Marketplace.

    5. In addition, considering a letter that goes out about 45 days from new business, with same info. One consideration, E&O carriers tell agents that if they get "between" the client and cancellation by calling on late pays, etc, the client can come to rely on the agent instead of the mail from insurer. Could be bad if dispute arises. I don't know right now, if I don't do some of the up front, I wind up getting involved in the time consuming mess later.
  2. Sherota1

    Sherota1 Super Genius

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    I feel it's important to only help with things I can control. Making sure document get processed properly is not one of them. Many of my clients do not have Internet access but regardless of whether they do or not I send each of them a letter letting them know what their responsibilities are such as contacting the company to get their application status, making their first payment etc. On the FFM I send them a copy of the first few pages of their eligibility letter along with the barcode page if they need to send in verification documents. I instruct to send their documents and to do so by certified mail. I also let them know if they want to they could they could fax me a copy and I could add it to their account. I do not mention that I will upload it to their account. I give them instructions on how to do this if they have Internet access and sufficient computer skills. Overall I think it is a bad idea to give the impression that I will take on the responsibility of submitting documents since there is no guarantee that the Marketplace will process them properly. If you do take on that responsibility and there is a problem they could possibly blame you for any errors leading to the cancellation of their subsidy and or policy.

    It's best to let them know up front that you as the agent no longer are responsible for submitting their application to the insurance company. Let them know the Marketplace has now taken over this responsibility and it is their responsibility to make sure that all applications reach the carriers in good order and error free.
    Second let them know it is their responsibility to make sure that they submit their documents to the Marketplace or risk losing their benefits.

    As for accounts in danger of lapsing an email or text reminder is sufficient. I never call. If they get cancelled oh well that's life. My creditors don't call me each month to remind me to pay my bills. This is just another bill. I have several who lost coverage due to negligence. They are waiting for OEP. Keep in contact with them but don't play mom and dad.


    This will not work since it has been verified that CSR's on the FFM use aliases and have no representative number to identify themselves. You can never speak to the same person twice. Tell the client to save all USPS receipts and a copy of all documents that they sent it.
    Last edited: Aug 2, 2015
  3. kgmom219

    kgmom219 What's Next?

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    Every agent does it differently. And it totally depends on your market. I do this through the backdoor, then I know it was submitted. Yes, I still had about 5% that were uploaded and I had to rewrite, then resubmit the same docs. Clients were told that if they received a request (which we new almost immediately on the Sherp) that those were sent to me and I would upload. If they sent them in, it was their problem. Also, all clients are defaulted to "mail" communication and told if something arrives, they better read it.
  4. AllenChicago

    AllenChicago Guru

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    I read somewhere that for 2016 Open Enrollment, CMS is setting up a dedicated line for agents to work directly with the Marketplace for client service matters. Anyone else read or hear this?