Kimber Health WellAway Plans: Member Getting Started Guide – Support | Kimber Health

Get Started

This guide helps you understand how to use your plan for medical, pharmacy, vision, dental, and wellness services. It’s a summary and does not replace your official Policy Terms & Conditions.

Your WellAway ID Card

Your ID card is required for providers to submit claims.
One card is issued for each covered member.
Check your card for accuracy—if anything is incorrect, contact a ConciergeCare counselor.
View or download your card anytime at: portal.wellaway.com/login
Example cards in this guide may differ based on your coverage zone. Refer to your Policy Terms for specifics.

Understanding the different sections of your card

Zone 1 WellAway ID cards:

WellAway’s ConciergeCare US Phone number: +1 855 7737810
For Verification of Benefits and Pre-Authorization: Providers can verify eligibility and claim status electronically via Change Healthcare using Payer ID: 27048 (c/o PayerFusion). To verify by phone, providers may call PayerFusion at +1-855-773-7810.
Member ID. This member ID number is unique to you and your dependents.
Dependents Covered persons under your plan are listed here.
Pharmacy Information. This section includes the necessary information to access your pharmacy benefits via our pharmacy benefits manager, EHIM.
Provider Network. In the U.S. the provider network is UnitedHealthcare and your preferred lab is Quest Diagnostics.
Pre-authorization. Using your ID card to access your benefits allows your provider to verify coverage for you and your dependents.
WellAway's Pharmacy Network in the U.S.- EHIM. If you purchased coverage in the United States which includes pharmacy coverage, you have access to the EHIM Pharmacy Network. This is also the number that your pharmacist can call for pricing and coverage information. Your pharmacist mus call the number below to verify pricing and coverage.

EHIM Pharmacy Network: +1800 3113446
WellAway's Dental Provider Network in the U.S.UnitedHealthcare Dental Benefit Providers. If you purchased the optional dental and vision plan, you have access to UnitedHealthcare Dental benefit Providers.
Information for Providers. Be sure that providers call the PayerFusion phone number listed here to confirm benefits and coverage. Instructions to submit a claim are also provided.

Zone 2 WellAway ID cards:

WellAway’s ConciergeCare US Phone number: +1 855 7737810; Outside the US: +1 786 4534008
Member ID. This member ID number is unique to you and your dependents.
Contact information. Your ID card lists necessary numbers for ConciergeCare. These numbers can be used by both members and providers.
Pre-authorization. Using your ID card to access your benefits allows your provider to verify coverage for you and your dependents
Information for Providers. Your provider should contact PayerFusion for further information

Frequently Asked Questions (FAQs)

What is a Deductible?

A deductible is the amount you must pay for covered health services before your plan starts to pay. For example, if your deductible is $1,000, you pay that amount out-of-pocket before your insurance kicks in.

Do I have to pay the deductible all at once?

Not necessarily. Your provider will check how much of your deductible has been met. If you still owe part of it, they may ask for payment at the time of service.

What’s the difference between an individual and family deductible?

Individual Deductible: Applies if you're the only person on the plan.

Family Deductible: If you have dependents on your plan, the deductible can be met by one or more members. If your plan has an embedded deductible, each person only needs to meet their individual amount before the plan begins to pay for them.

What is Coinsurance?

Coinsurance is your share of costs (e.g., 20%) after you’ve met your deductible. Your plan pays the rest.

When do I pay coinsurance?

You pay coinsurance after meeting your deductible. It applies to most covered services unless otherwise stated.

What is a Copayment?

A copayment (copay) is a fixed amount (e.g., $15) you pay for certain services like doctor visits or prescriptions.

When do I pay copayments?

Copays are usually due at the time of your appointment or when receiving a covered service.

What are Out-of-Pocket Costs?

These include deductibles, copays, and coinsurance—any expenses not reimbursed by your insurance.

What’s my Out-of-Pocket Maximum?

This is the most you’ll pay in a year for covered services. Once you hit that limit, your plan covers 100% of eligible costs. Refer to your Policy Terms for exact amounts.

What does "Usual, Reasonable and Customary Charge" mean?

This is the standard charge for a service based on what most providers in your area typically charge. WellAway uses this to determine the amount they will reimburse for out-of-network care.

What is Pre-authorization?

Pre-authorization is written approval required for certain services or treatments before you receive care. Not getting pre-authorization when required may result in reduced coverage or denial of claims. Refer to your Policy Terms for a full list of services that require it.

What is PayerFusion?

PayerFusion is a third-party administrator based in Coral Gables, Florida. WellAway partners with PayerFusion to handle claims and provide support services for members.

Introducing ConciergeCare

As a WellAway member, you have access to ConciergeCare, your dedicated support service for health plan questions and coordination.

How to Contact ConciergeCare:

U.S.: +1-855-773-7810
International (collect): +1-786-453-4008
Email: conciergecare@payerfusion.com
Portal: wellaway.com

ConciergeCare Services Include:

24/7 multilingual support
Emergency coordination with providers
Help finding and booking in-network appointments
Claims status updates
Answers to questions about your benefits, coverage, and policy

Pre-authorization Explained

Pre-authorization is a process by which you must obtain written approval for certain medical procedures or treatments, prior to the commencement of the proposed medical treatment or procedure. Certain medical procedures will require the pre-authorization process to be followed for the service to be covered and to maximize your benefits.

For some services or drugs, the provider/pharmacy may need to get pre-authorization before your plan will cover them. This helps ensure coverage from your plan, guides you to trusted care and helps to save you money.

Please note that if your provider does not obtain pre-authorization for a required benefit, there may be a penalty.

For full details on which benefits require pre-authorization, please refer to your Policy Terms and Conditions. Your Summary of Benefits lists the services that require pre-authorization with an asterisk *.

If you need further assistance or guidance, please contact ConciergeCare U.S. +1-855-773-7810 ConciergeCare International: +1-786-453-4008 (collect) or by logging in to your Member Portal online at wellaway.com. You can also send an email to Conciergecare@payerfusion.com

Guarantee of Payment Explained

A Guarantee of Payment (GOP) assures payment directly to a health care professional outside the U.S. for covered services. This helps prevent you from having to pay for services that would normally be covered under your plan. Please refer to your Policy Terms and Conditions if you are unsure how your plan settles costs outside of the U.S. Some of our plans settle claims outside the U.S. via reimbursement only.

Why is a GOP important?

Using a guarantee of payment increases access to care around the world.
Reduces out-of-pocket expenses at those health care professionals who do not, per normal practice, directly bill WellAway (Please note: you are responsible for any applicable coinsurance, deductible or copayments per your plan).
Enables the hospital to bill us directly.
Allows WellAway to consult on the services being rendered, providing you the best care possible.

Who is responsible for requesting a GOP?

If a health care professional requests payment upfront, always ask them to contact WellAway per the normal process that they use to verify benefits and confirm payment by WellAway for urgent/emergency services on your behalf.

If you are requesting a GOP for urgent/emergency Service, call the toll-free number on the back of your ID card. WellAway will verify benefits and confirm payment.

If you are requesting a GOP for a service/procedure planned in the future through consultation with your health care professional, they should contact us per the normal process that they use to verify benefits and confirm payment by WellAway for any services on your behalf.

Within 48 hours of an emergency which requires an inpatient procedure, or if an inpatient procedure is planned or you require outpatient surgery, you must contact a ConciergeCare Counselor before services are rendered. This is essential so that we may provide the necessary information to guarantee the costs or to pay the provider and/or hospital. This includes conducting a medical review of the invoices to make sure that they are Usual, Reasonable and Customary Charges.

What Information is needed for a GOP?

We require the following information prior to placing a guarantee of payment to the provider and/or hospitals outside the United States:

Medical reports from your Physician stating the Diagnosis, date of occurrence, beginning of the Symptoms, Treatments previously received for the same condition, evolution, complications, and current medical/Surgical Procedures recommended.
Results of lab tests, x-rays, and all medical tests performed in relation to the specific condition.
Copy of past medical history.
Cost Estimate for Services Incurred outside the United States. This is to include complete cost Estimate including Hospital fees, surgeon’s fees, anesthesiologist fees and/or assistant fees if one is required.

Upon receipt of this information, our medical advisors will evaluate all pertinent information and make a determination based on medical necessity. We will review the cost estimate and advise if the same is within the Usual, Reasonable and Customary Charges. Upon final determination by our medical advisors, the ConciergeCare Counselor will inform the you of the cost as determined to be Usual, Reasonable and Customary Charges. We will proceed to send verification of benefits to the Hospital and Providers if they agree to accept direct settlement. If you do not provide the required information as outlined above, provide advance notice, request a guarantee of payment, or receive a PreAuthorization from the Plan Administrator in writing, you will be required to pay and then submit eligible invoices for reimbursement. Failure to request a Pre-Authorization for services in advance may result in the application of a penalty as indicated in your policy.

We will always attempt to settle the costs directly with the Hospital and/or Provider; however, it is in the Hospital’s and/or Provider’s discretion to accept payment from us. In the event a direct settlement is not accepted, you will be required to settle the invoices in full directly with the Hospital and/or Provider. Thereafter, you may submit the invoices for reimbursement; provided, however, reimbursement will be in the amount of the Usual, Reasonable and Customary Charges for such services.

For information on the Providers, Physicians and Hospitals in our network, you may log into your member portal at www.wellaway.com or contact your ConciergeCare Counselor by calling collect +1-786-453-4008.

You may request a GOP at any time. Coverage will depend on WellAway reviewing the services for medical necessity, and your benefits and eligibility at the time of treatment. Once the information is received, we ask that you allow up to at least five business days for confirmation, unless urgent service(s) is required for your GOP letter to be completed.

Finding a Provider

ConciergeCare counselors can recommend a variety of health care provider options and help you choose based on past performance with other members, as well as several other factors including efficiency, quality of care, treatment protocols and fair pricing. Please give us a ConciergeCare U.S. +1-855-773-7810 ConciergeCare International: +1-786-453-4008 (collect) or email Conciergecare@payerfusion.com; we would be happy to help you find a provider that is best suited for you and fairly priced.

Our online provider search can be found on our website, www.wellaway.com/en/providers/.

Finding a Provider in the U.S

In the United States, if the provider you are seeking is outside of your plan’s network, your

ConciergeCare counselor or a UnitedHealthcare Global representative can suggest an in-network provider that offers the same services. Staying within your policy’s network of providers will control your medical expenses while living in the U.S.

The UnitedHealthcare Global network is available under your coverage. In order to maximize your benefits and pay the least out of pocket, we urge our members to use UnitedHealthcare’s Premium Care Physicians and In-network facilities. Please read the UnitedHealthcare Member Guide. ConciergeCare U.S. +1-855-773-7810 or Conciergecare@payerfusion.com.

Finding a Dentist in the U.S.

If you purchased the optional dental and vision package, WellAway has an open network. You may seek care from the provider of your choice and then submit a U.S. Dental form with official codes (this form is provided by your dentist). You must also include the WellAway U.S. claim form and proof of payment (credit card statement, check, etc.). Be sure to review your Policy and your Summary of Benefits to understand what is covered or may require pre-authorization.

If your existing dental provider is able to bill us directly with the proper procedure codes, we are happy to process the claims. Benefits allowable are payable based on the customary charge of the geographic area where your dentist is in by zip code and reimbursed at the level and benefits outlined by your Dental Policy Rider Terms and Conditions. We encourage you to ask your Dentist to present a preestimate prior to any dental work being performed to present to them what payment amount is to be expected reimbursed by your insurance and the reimbursement amount will be made to you within 14 days of the claim received. Reimbursements are made based on the National Dental Advisory Service. Please contact ConciergeCare U.S. +1-855-773-7810 or Conciergecare@payerfusion.com for assistance finding a provider.

Vision Coverage in the U.S.

If you purchased the optional dental and vision package, you have coverage for vision services. Please contact ConciergeCare U.S. +1-855-773-7810 or Conciergecare@payerfusion.com for assistance finding a provider.

Teladoc Available in the U.S.

If you have purchased coverage in U.S., you have access to Teladoc medical services within the U.S. You should have received a member package from Teladoc, in the mail. Your benefits with Teladoc are specified in your Summary of Benefits within your Policy Terms and Conditions. Teladoc representatives also know your benefits and can give you these details when you are seeking care. Within your member portal, you can also find instructions on how to set up your Teladoc account. You can also just call 1-800-TELADOC (835-2362)

With Teladoc, you can:

Talk to a doctor anytime, when you are in the USA.
Receive quality care via phone, video or mobile app.
Prompt treatment. Talk to your doctor in minutes.
A network of doctors that can treat every member of the family.
Prescriptions sent to pharmacy of choice if medically necessary.
Teladoc is less expensive than the ER or urgent care.

Teladoc doctors can treat many medical conditions, including:

Cold & flu symptoms
Allergies
Pink Eye
Respiratory infection
Sinus problems
Skin problems

Finding a Provider Outside of the U.S.

Outside of the United States, WellAway has an open network. You may seek care from the provider of your choice and then submit an international claim form and supporting required documents, such as the medical invoice, medical records and a receipt. Be sure to review your Policy and your Summary of Benefits to understand what is covered or may require pre-authorization.

Dental and Vision Coverage Outside of the U.S.

If you purchased the optional dental and vision package, you have coverage for dental and vision services. The same process applies-. You may seek care from the provider of your choice and then submit an international claim form and supporting required documents, such as the medical invoice, medical records and a receipt.

Please note that claims must be submitted within the time frame from the date of service
stipulated in your Policy Terms and Conditions in order to be considered eligible for
processing. We will return your incomplete claims with an explanation on what is missing
to help us expedite processing your claim.

Please refer to the “How to File a Claim” section on page 15
If you need further assistance or guidance, Please contact ConciergeCare International: +1-786-453-4008 (collect) or email us Conciergecare@payerfusion.com

Pharmacy Benefit

Your WellAway plan may include a pharmacy benefit. Please be sure to check your Policy Terms and

Conditions and Pharmacy Formulary (when applicable) for full details about your pharmacy coverage.

You can also contact ConciergeCare for more information.

Pharmacy Benefit- Within the U.S.

Within the U.S., your prescription benefits manager is EHIM. You may notice the EHIM logo on your WellAway ID card. Each of WellAway’s products has a different pharmacy formulary and different levels of coverage for pharmacy, so please refer to Policy Terms and Conditions and Medication Guide for full details on your coverage for prescription medication. Also note that coverage for some prescription medication may also require a pre-authorization.

Important things to note:

If you are due a reimbursement, WellAway will reimburse you for medications your plan should pay based on the policy coverage and pharmacy formulary.
Over the counter medications are not reimbursable.
Prescriptions being filled exceeding a 30-day supply require pre-authorization.
Search for in-network pharmacies at: https://www.ehimrx.com/pharmacylocator.php
Contact EHIM by phone for questions: +1-800-311-3446

Pharmacy benefit- Outside of the U.S.

Outside of the United States, WellAway has an open network. Once you have purchased your prescribed medication upfront at the pharmacy you must submit a claim for reimbursement. We recommend contacting us as soon as you know that you have a prescription to fill so that we can assess if the medication is covered and what the cost will be.

Important things to note:

Give us a call as soon as you know that you will be filling a prescription- we can help clarify what your costs will be.
WellAway will reimburse you for medications your plan should pay based on the policy coverage and pharmacy formulary.
Over the counter medications are not reimbursable.
Prescriptions being filled exceeding a 30-day supply require pre-authorization.

How to File a Claim

A claim is a request for payment for medical services. Whether you are filing a claim for services rendered in the US or elsewhere, you may need to file your claim directly with us, after receiving medical treatment from a provider. Claim forms can be found in the Resources section of this guide and on your member portal at wellaway.com.

Please note that claims must be submitted within the time frame from the date of service
stipulated in your Policy Terms and Conditions in order to be considered eligible for
processing. We will return your incomplete claims with an explanation on what is missing
to help us expedite processing your claim.

Completed claims, along with the required supporting documentation, must be submitted via your member portal or via e-mail to corpclaims@payerfusion.com.

Filing a Claim- Within the U.S.

Your health care provider will need your WellAway ID card in order to submit all claims (including pharmacy claims) to WellAway Limited on your behalf. If you need to submit a claim, the best way is by completing the WellAway U.S. claim form located in the Resources section of this guide as well as on your member portal at wellaway.com. You may also request a claim form by contacting a ConciergeCare counselor. Completed claims, along with the required supporting documentation, must be submitted via your member portal. We will process your claim as soon as we receive it. We will let you know if any additional fees are due to the provider and make sure everything was billed correctly. You will receive a notice explaining the payment of your claim and if certain costs were not covered. Please note that claims must be submitted within the time frame from the date of service stipulated in your Policy Terms and Condition in order to be considered eligible for processing.

Filing a Claim- Outside of the U.S.

You must fill out and send us a completed WellAway International Claim Form. The International Claim Form can be found in the Resources section of this guide as well as on your member portal at: wellaway.com. Additionally, please provide the local claim form used in the country where the service was rendered. The form must state all diagnoses which clearly identify the services received. The doctor’s signature must be evident, as well as the reason for the visit. Medical services rendered outside of the U.S. are payable based on the reasonable fees (URC). The excess amount above the URC fee schedule will be the member’s responsibility.

Important things to note:

If you are due a reimbursement, WellAway will reimburse you for medications your plan should pay based on the policy coverage and pharmacy formulary.
Over the counter medications are not reimbursable.
Prescriptions being filled exceeding a 30-day supply require pre-authorization.
Any medical, dental or vision services are subject to the limitations outlined in your policy terms and conditions. The same limitations and exclusions apply regardless of where the services are rendered. This is also applicable to exclusion riders.
Members of the CFE may also receive reimbursement for covered services.

About Member Reimbursements

There are times when you may be required to pay your medical bill and then submit the invoice to us for reimbursement. The most common cause for reimbursement delays is unclear or missing information. For a covered expense to be considered for reimbursement, either within or outside of the U.S., all the required documents must be complete and submitted within the filing period stated in your policy terms and conditions (check your policy for a list of the documents required).

Completed claims, along with the required supporting documentation, must be submitted via your member portal or via e-mail to corpclaims@payerfusion.com. Please note that we will return your incomplete claims with an explanation on what is missing to help us expedite your reimbursement.

Once your claim has been processed and your reimbursement has been prepared to be paid by our third party administrator, PayerFusion, you will receive an invitation from corpaccounting@payerfusion.com to register for an account with our quick and safe payment partner, Tipalti. Once you input your information and preferred method of payment, your reimbursement will be sent to specified account. Please note that failure to enroll in the Tipalti system will result in the inability to receive your Reimbursement.

Reimbursement Within the U.S.

Always carry and present your ID card at all doctors’ appointments or if you go to the hospital this way, the provider can submit the claim directly to us and we send payment to the provider for the charges your plan covers.
Dental claims must be submitted with a U.S. Dental form with official codes (this form is

provided by your dentist). You must also include the WellAway U.S. claim form and proof of

payment (credit card statement, check, etc.).

Vision claims require a detailed receipt from the provider along with the WellAway U.S. claim

form and proof of payment (credit card statement, check, etc.).

Use your ID card at the pharmacy to access your pharmacy network, EHIM.
CFE members submitting claims for CFE reimbursement must indicate this on the claim form.
Whether your claim is for medical services received in or outside the U.S., reimbursements are payable in the same currency you have paid your premium.

Reimbursement Outside of the U.S.

You must fill out and send us a completed WellAway International Claim Form. Additionally, please provide the local claim form used in the country where the service was rendered. The form must state all diagnoses which clearly identify the services received. The doctor’s signature must be evident, as well as the reason for the visit.
We will reimburse you for medications your plan should pay based on the policy coverage and pharmacy formulary.

o A WellAway International Claim Form is also required to be submitted.

o Over the counter medications are not reimbursable.

o Prescriptions being filled exceeding a 30-day supply require pre-authorization.

Any medical, dental or vision services are subject to the limitations outlined in your policy terms and conditions. The same limitations and exclusions apply regardless of where the services are rendered. This is also applicable to exclusion riders.
Medical services rendered outside of the U.S. are payable based on the reasonable fees (URC). The excess amount above the URC fee schedule will be the member’s responsibility. CFE members may also receive a CFE reimbursement for covered services.

Claims are managed by PayerFusion

PayerFusion Holdings LLC

2121 Ponce de Leon Boulevard

Suite 820 Coral Gables, FL 33134

USA: +1-855-773-7810

Outside USA: +1-786-453-4008 (Call Collect)

Member Portal Highlights

Your member portal is a secure place where you may review your plan benefits, download your policy documents, update your payment information and contact a ConciergeCare Counselor. Please review our Member Portal Guide for more information. When your policy became active, you received an email inviting you to “create a Member Portal Account”. Click on this link and follow the instructions. Please note that you must use the email address to which this email was sent, to set up the account.

How to Log-in to your account

Step 1: Visit our website, www.wellaway.com

Step 2: Click on Login at the top righthand corner of the page

Step 3: Enter your account email address and password

*Our site is mobile friendly! Access your portal on the go!

What’s in the Member Portal?

View your basic account information
View your policy documents as well as retrieve a copy of your ID card and certificate of coverage as well as any forms you may need
View your claims, your out of pocket costs, deductibles and download your Explanations of
Benefits (EOB)
Review transactions and know when your next payment is due. You can also update your credit card on file, and make a payment instantly- directly on our secure portal
Search for a nearby provider or pharmacy
Send us a message directly through the portal

Read our Member Portal Guide for more information about using the member portal.

If you require assistance with the portal, please contact ConciergeCare at:

ConciergeCare U.S. +1-855-773-7810

ConciergeCare International: +1-786-453-4008 (collect)

Email: conciergecare@payerfusion.com

How to Add Our Portal to Your Mobile Device

iPad or iPhone

1. Launch “Safari” app. This does not work from the “Chrome” app.

2. Enter into the address field https://portal.wellaway.com/login. Tap “Go.”

3. Tap the icon featuring a right-pointing arrow coming out of a box along the top of the Safari window to open a drop-down menu.

4. Tap “Add to Home Screen.” The Add to Home dialog box will appear, with the icon that will ben used for this website on the left side of the dialog box.

5. Enter the name for the shortcut using the on-screen keyboard and tap “Add.” Safari will close automatically and you will be taken to where the icon is located on your iPad’s desktop.

Android

1. Launch “Chrome” app.

2. Open https://portal.wellaway.com/login.

3. Tap the menu icon (3 dots in upper right-hand corner) and tap Add to homescreen.

4. You’ll be able to enter a name for the shortcut and then Chrome will add it to your home screen.

You may reach a ConciergeCare counselor at any time by calling +1-855-773-7810 in the U.S. or if

you are outside of the U.S., you may call us collect at +1-786-453-4008 or email ConciergeCare at

conciergecare@payerfusion.com.

Caisse des Francais de l’Etranger CFE Complémentaire

If you are a French National living abroad, you may have coverage with Caisse des Francais de l’Etranger (CFE). The CFE program assists in covering items such as Cost Share amounts, pharmaceuticals, pharmacy network products or other medical care not covered by insurance coverage in the United States and worldwide. It also allows you to return to France or your country of origin for certain critical illnesses that arise. The CFE alone may not provide enough coverage for you in the United States and may not be compliant with the Affordable Care Act requirements for individuals living in the United States.

Your CFE coverage will begin once your application has been approved by the CFE and your first CFE premium has been paid. The CFE effective date will be on the first day of the following month from when the CFE application was approved. As the policyholder, you will be responsible for any cost share amounts for claims incurred prior to the effective date of the CFE coverage or in the event of non-payment of the CFE premiums.

CFE Affiliation Certificate – Please go to www.cfe.fr to download your CFE Affiliate Certificate. The CFE is your primary insurance. Please keep this Certificate together with your WellAway ID card and present it at every physician/hospital/pharmacy visit.

Your contributions towards the CFE are not included in your WellAway Premium and must be paid separately as they become due directly to the CFE.

If you have coverage through the CFE, all payments made by the CFE shall constitute a contribution to the cost of claims and will be applied towards claims for covered services, as primary insurance. WellAway will determine subrogation.

To determine the primary policy, the following guidelines will be used:

If an insured person has local coverage in the Country of Residence, the local coverage would be primary for the services incurred locally over this policy. This policy would be secondary, and our liability would only be the amount not covered by the primary insurer, subject to the satisfaction of any cost share amounts as stated in your Summary of Benefits.
If the insured person has two international policies, the policy which has been in effect with the longest effective date would be primary.
If no other international policy is available and the insured person travels outside the country of residence, this policy would be primary.
If two policies cover the insured person as an individual, the policy that has covered him/her for the longer period of time is the primary policy.

If you are due a reimbursement, WellAway works directly with the CFE so that payments are issued electronically to you- there is no need for you to submit any claims to the CFE.

How to Appeal a Denial

General Tips

If we deny a claim or a request from your provider for prior authorization of services and you do not agree, you can ask for a review. This is called an appeal. You will find the complete process outlined in the section of your policy titled Claims Appeal Procedures.

Please refer to your Policy Terms and Conditions located within your member portal for more information on how to appeal a denied claim.

You must submit your request in writing along with the Member Appeal Form. You may send your appeal via email to conciergecare@payerfusion.com or postal service to our Plan

Administrator:

PayerFusion Holdings, LLC

2121 Ponce de Leon Boulevard

Suite 820 Coral Gables, FL 33134

You may appeal on your own or you may authorize someone to appeal for you. This is called an authorized representative. Please complete the Appeal Patient Consent Form.

How long do I have to ask for an appeal?

The amount of time you have to file for an appeal varies from product to product. Each of our policies specifies the number of days from when you receive the notice of the denied claim or the denial of the request for prior authorization to submit your appeal.

What should the request include?

In your appeal, you should explain the reasons for your appeal and include all information to support your request. You should also include (if applicable):
Your policy number
Your name (and the name of the member you are appealing for if it is not you)
Your member ID number located on your member ID card
The provider’s name
The date of service
The type of service
The Explanation of Benefits (you can obtain your EOB from your member portal or contact
ConciergeCare on the phone number listed on your member ID card. We will send it to you free of charge.)
Any other documents, records or other information you would like us to consider.

Please note that any costs for medical records or other documentation in support of your appeal will be at your sole expense. It is the member’s responsibility to provide all information in support of the appeal. We will not be able to begin our review until we receive all of your information. If we do not receive the information requested for your appeal, the appeal will be closed until the required information is provided to us. If we do not receive the required information within the number of days specified in your Policy, from the date of the denial of your claim or pre-authorization, the decision will stand (with non-payment or no prior authorization approval) and the appeal file will be closed.

How long will it be before WellAway makes a decision?

The number of days varies among our products. Please refer to your Policy. We are always available to answer any questions.

Phone: ConciergeCare U.S. +1-855-773-7810

ConciergeCare International: +1-786-453-4008 (collect)

Email: conciergecare@payerfusion.com

Filing a complaint

We aim to keep our members satisfied; however, we understand that there are instances whereby we may not be able to meet your expectations.

For a formal complaint, please contact us by post, telephone or e-mail.

WellAway Limited

Victoria Place

31 Victoria Street, 5th Floor PO Box HM 1624

Hamilton, HM GX, Bermuda