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RATING AND BILLING PROCEDURES

DEMOGRAPHIC RATINGDemographic FactorsFive demographic factors are used to determinerates for small groups in associations/pools.

• Size categories…demographic rating applies togroups with 1 to 50 contracts. Groups with 51 ormore employees are master-rated.

• Industry…based on SIC code, groups arecategorized into one of three SIC code industrybands. The SIC code is required when the groupis submitted. The industry classification for aparticular group is based on the overalldescription of the company’s business and noton the individual duties of its employees.Accurate SIC assignment is provided in the Dun& Bradstreet industry classification manual.

• Geographic location…refers to the physicallocation of the company.

• Average age…is based on the number ofemployees enrolling across all Highmark andKeystone Health Plan West products, includingthose enrolling in the out-of-area programs thegroup offers to its employees. When calculatingaverage age, include only those employeesenrolling. Because average age can change daily,the following rules are applied:

A. New Groups…Average age is calculated asof the requested effective date for the newcoverage.

B. Replacement Groups…Average age is basedon the “renewal demographics” which arecalculated approximately 6-9 months prior tothe group’s renewal.

C. Dual Option Groups…Average age is basedon the “renewal demographics” which arecalculated approximately 6-9 months prior tothe group’s renewal.

• Gender

Adjustments for incorrect or changeddemographics• Any initial rate quoted based on incorrect

demographic information will be revised toreflect the correct data upon enrollment of thegroup.

• When a group’s demographic characteristicschange, its rates will be adjusted at the newrenewal.

SUBMISSION OF NEW TO BLUEGROUPS OR PRODUCT CHANGESWhat to submit:

HHIC Small Group Business Application (ENR-120)

HHIC Enrollment Forms (ENR -130)

Tax Documentation

Copy of Illustrative Rate Quote

Producer Checklist (this can be found on theproducer portal)

When just changing products, you only need theSmall Group Business Application.

Once completed you can submit by:

Email: HHICGroupAppl@highmark.com

Fax: 1-888-567-5685

U.S. Mail: Highmark Blue Cross Blue ShieldPO Box 890172Camp Hill, Pennsylvania 17089-0172

Overnight Delivery:Highmark Blue ShieldAttention Incoming Mail1800 Center StreetCamp Hill, PA 17011

Phone number to include for FedEx 717-302-3784

NOTE: When emailing or faxing any groups pleasemake sure you use the Fax Sheet for HHIC SGBA, FaxSheet for Enrollment Apps and Fax Sheet forSupporting Documents. You do not have to send

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6separate emails/faxes for each. Just make sure thateach sheet is before the paperwork.

Acceptance Process Assigned Underwriter will email the Group

Acceptance Form to the Producer.

Producer has three days to obtain the Client’ssignature on the Group Acceptance Form.

Producer returns the signed Group AcceptanceForm to the assigned Underwriter via email.

Producer mails the original Group AcceptanceForm and the binder check to Highmark HealthInsurance Company, PO Box 535184, Pittsburgh,PA 15253.

MEMBERSHIP AND BILLINGYou should contact Membership and Billing forassistance with:

Changes in employee information and coverage

Requests for duplicate identification (ID) cards

Adding or terminating employees and/ordependents

Explanation of billing activity

Requesting forms

Resolution of outstanding premiums

Request for a duplicate invoice

Please contact your Membership and BillingAdministrator between the hours of 7:30 AM and4:30 PM at the appropriate number or email addresslisted below:

Phone: 1-866-763-9469Email: WRSCSmall@highmark.comFax : 412-544-8196

Enrollment

Enrolling Employees and DependentsNew employees are effective based on the date youprovide, as long as they fall within Highmark’sretroactivity policy. Current employees and theireligible dependents become eligible on the samedate your group’s coverage becomes effective.

New EmployeesAll employees enrolling for new coverage mustcomplete an Enrollment Application Form ENR-130(enrollment/waiver application and change form).

Employees Returning to WorkTo keep both your and our records current,employees returning to work after a layoff or leaveof absence must always complete an EnrollmentApplication (ENR-130). Even though the employeebeing rehired may have been previously enrolled inyour group’s program, they must reapply forcoverage. You must include the new effective dateon the enrollment forms.

Disabled DependentsWhen you request coverage for an overage disableddependent, please contact your Membership andBilling Administrator. We will mail the employee aDisabled Dependent Certification form to becompleted by the employee, employer and thefamily physician then returned to Highmark forreview and approval. We will notify the employee ofour decision. If the disabled dependent qualifies forcoverage, they will automatically be added to theemployee’s policy.

Terminated EmployeesUpon termination of employer provided coverage,Highmark will provide the terminated employee withinformation about direct pay coverage. If theterminated employee does not enroll in a Highmarkdirect pay product within the conversion timeframe,they will lose any conversion advantages.

If an employee or an enrolled dependent is receivinghospitalization for benefits on the date coveragewould otherwise terminate, those benefits willcontinue to be provided until the end of theparticular hospital stay, or until benefits areexhausted, whichever occurs first.

A cancelled spouse and/or dependent child will begiven the opportunity to apply for their ownHighmark direct pay coverage. If the spouse and/ordependent are employed where a Highmarkprogram is in effect, he or she may be eligible toenroll in the group’s health plan.

Changes to Enrollment

Change in Family StatusAn employee’s benefit selection, including waiver ofcoverage, will remain in effect for the contract yearunless he or she experiences what the InternalRevenue Service (IRS) defines as a “change in family

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7status.” If an employee has a change in family status,they can change certain benefit selections withouthaving to wait until the next annual enrollment.

A change in family status occurs when:

The employee gets married, divorced or legallyseparated

The employee has a child or adopts a child

A spouse or child dies

A child is no longer eligible for dependentcoverage

A spouse loses coverage under another benefitplan, or that coverage is significantly changed(For example, a spouse is laid off or changesfrom full-time to part-time employment)

The employee loses coverage by transferring toan ineligible employment status. (For example,the employee goes from full-time to part-timeand works less than 20 hours per week.)

In addition, if an employee waives health carecoverage for themselves and their dependentsbecause they have other health care coverage andthey lose that coverage during the year, they may beable to enroll with Highmark prior to the next annualenrollment.

An employee may be eligible for this specialenrollment if one of the following occurs:

The employee and/or dependents are no longereligible for their other health care coverage forreasons other than non-payment of premiums

An employee’s COBRA coverage ends—forreasons other than non-payment of premiums

A spouse’s employer-provided coveragebecomes fully contributory

NOTE: Employees and dependents will not beoffered conversion privileges if your companycancels its Highmark coverages.

Reporting your Group’s EnrollmentIf you submit your enrollment via paper, you mustcomplete an Enrollment/Waiver Application andChange Form (ENR-130).

If you are an ePlatform client, you must submit yourenrollment electronically.

(We have electronic enrollment alternatives. If youare not currently submitting your enrollmentelectronically, please contact your SalesRepresentative for more information.)

Whether you report your enrollment electronicallyor via paper, we encourage you to submit yourupdates as changes, occur throughout the month.

NOTE: Do not send enrollment forms orcorrespondence with your invoices. Send them toWRSCSmall@highmark.com or 412-544-8196.

Termination of Your GroupAll requests to terminate your group’s coveragemust be made in writing by an authorizedrepresentative of your group. This request must beforwarded to your Sales Executive or Producer.Cancellation requests are subject to limitations andrequirements as stated in your contract.

Billing Information

Billing PolicyPlease pay the Total Amount Due on your invoice bythe due date indicated. We cannot accept partialpayments of premium.

Past Due PaymentsWe will aggressively pursue past due premiums. Youjeopardize your employee’s benefits with non-payment of the total premium amount due.According to the terms outlined in your contract,your group is responsible for any accrued premiumsin the case of utilization of services by an employee.

In the event of non-payment of premium, you canexpect to receive a Past Due Notice advising you thatwe have not received your scheduled premiumpayment. If we do not receive payment shortlythereafter, you will receive a Cancellation ofCoverage Notice. This is the final warning you willreceive prior to the actual cancellation of your groupcoverage for non-payment of premium.

We recognize that occasionally situations arise thatmay result in a late payment. When a situationarises, please contact your Membership and BillingAdministrator immediately.

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8e-BillAfter you receive your first invoice, you can sign upfor e-Bill, a secure way to view your billselectronically. You can also pay your bills throughAutomatic Clearinghouse (ACH) from the first timeyou make a connection. Electronic paymentseliminate mailing delays and ensure prompt postingto your account.

With e-Bill you receive your bills as they areproduced—no mail delays and no paper copies tofile. Download or print any reports or informationyou want to keep on file.

Important Payment Instructions: If you are an e-Billcustomer and you submit payment by check, youmust send your payment and copy of the invoiceremittance stub to the “remit to address.” Sendingyour payment to any other address or not includingthe remittance stub will delay processing yourpayment.

The address to send invoice payments to is:

Highmark Blue ShieldPO Box 382069Pittsburgh, PA 15251-8069

Invoices

PremiumYour premium invoice is typically generated 20 daysprior to your payment due date. Highmark mustreceive payment on or before the due date.

If you are an ePlatform client, you must receive yourinvoice via e-Bill.