FMU STUDENT HEALTH BENEFITS

Plans  │ Waiving Coverage │ Enrollment  │ Plan Documents & Forms  │ Providers │ Coordination of Benefits │ Claims Procedures │ Student Provider Search

ABOUT THE PLANS

FMU Student Health Benefits Brochure Here

 

SUPPLEMENTAL HEALTH PLAN

Includes the cost of the University Health Fee and all services rendered at the University’s designated Health Care Provider; includes a modest outpatient medical and pharmacy benefit for those students on high deductible health plans, out of state, HMO or other plans with an insufficient local area physician and hospital network.

Click here to see the schedule of benefits

 

COMPREHENSIVE HEALTH PLAN

Includes the cost of the University Health Fee and all services rendered at the University’s designated Health Care Provider. This plan is intended for students who have no other health insurance coverage, meets the minimum essential coverage requirements set forth under the Affordable Care Act, and the J1 and F1 Visa requirements, as set forth by the U.S. Department of State.

Click here to see the schedule of benefits

PayerFusion has arranged for you to access a network of local and state-wide providers. To confirm your physician or provider is part of the network you may call 866.752.8881 or please visit our student provider search.

The payment of any co-pays, deductibles, the balance above any coinsurance amount, and any medical expenses not covered are the responsibility of the insured person. To maximize your savings and reduce out-of pocket expenses, choose the Student Health Center (SHC) or Designated In-Network Provider. It is to your advantage to utilize an In-Network provider because significant savings can be achieved from the substantially lower rates these providers have agreed to accept as payment for their services. Out- of-Network care is subject to reasonable charge allowance maximums. Any charges in excess of the reasonable charge allowance are not covered under the Plan.

WAIVING COVERAGE

You may waive out of the Comprehensive Health Plan if you have other adequate health care coverage by completing and submitting the waiver form. The charge for the Comprehensive Health Plan will not be reversed unless an approved waiver is granted by Florida Memorial University.

With an approved waiver, a credit for fall and for spring/summer will be applied to your student account. An approved waiver is valid for the full academic year. Without an approved waiver, you will automatically be enrolled in the Comprehensive Health Plan for the full academic year. If you have an approved waiver you will be enrolled in the Supplemental Health Plan to help defray the deductible and coinsurance from your primary plan and cover the FMU Student Health Center at 100%. You may not waive out of the Supplemental Plan.

Please download and complete the waiver form with valid and current information regarding yourself and your private health insurance plan. This application must be completed in its entirety for consideration. Your plan must meet the current academic year’s waiver criteria. If your plan does not meet the required criteria, you are not permitted to waive enrollment in the Florida Memorial University Student Health Benefit Plan. Please consult your plan representative if you require further assistance.

Required documents are:

• a copy of your ID card
• a summary of benefits
• full master policy

Waiver Form

Please email your complete waiver form and required documents to: waivers@payerfusion.com

ENROLLMENT FOR STUDENTS AND DEPENDENTS

All domestic full-time undergraduate students, international students on a J1 or F1 visa, and athletes participating in an intercollegiate sport while attending FMU are automatically enrolled in the Comprehensive Health Plan. The cost is included in your tuition and billed to your student account each semester. All Part-time students are automatically enrolled in the Supplemental Health Plan. The cost is included in your tuition and billed to your student account each semester. Eligible Part-time and graduate students may elect to purchase the Comprehensive Health Plan on a voluntary basis. All students who enroll may also purchase coverage for their eligible dependents. Eligible dependents are the spouse, and children to the age of 26. Dependent eligibility expires concurrently with that of the covered student. Newborn infant coverage and adopted child coverage: The student must (1) enroll the child within 31 days of birth; and (2) pay the appropriate premium. To voluntarily enroll: payerfusion.com/fmu & click the enrollment link to register!

 

SPECIAL ENROLLMENT RIGHTS

Students and their dependents are eligible to enroll outside the open enrollment period when a qualifying event occurs.  The Plan covers the below Special Enrollment events:

• Loss of health insurance or group health plan coverage
• Birth of a dependent child
• Marriage
• Adoption or placement for adoption

 

A request for enrollment must be made within 30 days after the student’s other coverage ends or from the date of birth, marriage, adoption or placement for adoption. If a dependent becomes eligible to enroll under Special Enrollment and the student is not currently enrolled, the student must enroll in order for the dependent to enroll. If Special Enrollment is permitted, coverage will become effective as of the first day of the first calendar month following the date the completed enrollment form is received and the premium is paid. To request Special Enrollment or obtain more detailed information, please contact PayerFusion.

PLAN DOCUMENTS AND FORMS

DOCUMENTS

Plan Document
Plan Guide
Brochure
Supplemental Summary of Benefits
Comprehensive Summary of Benefits

 

FORMS

PayerFusion Accident and Subrogation Questionnaire

PayerFusion Authorization Health Information Form

PayerFusion – University Claim Form

FMU Waiver Form

Electronic Payment – International

Electronic Payment – U.S.

PLAN DOCUMENTS AND FORMS

DOCUMENTS

Plan Document
Plan Guide
Brochure
Supplemental Summary of Benefits
Comprehensive Summary of Benefits

 

FORMS

PayerFusion Accident and Subrogation Questionnaire

PayerFusion Authorization Health Information Form

PayerFusion – University Claim Form

FMU Waiver Form

Electronic Payment – International

Electronic Payment – U.S.

PROVIDERS

Your Student Health Plan allows you to choose whether to receive care from a Network provider, or a provider outside the Network. Using a network provider saves you money and provides better coordinated care. The Student Health Center (SHC) serves as your Primary Care Provider (PCP). Please contact PayerFusion for a referral to any other provider.

To Find a Provider please visit our student provider search.

You may also call +1.866.752.8881 or email universityprograms@payerfusion.com.

 

NEED HELP FINDING A PROVIDER?

Step One
You’re not alone, call Customer Service, powered by PayerFusion.

We do the work for you. Reach out to our experienced customer support team. We are standing by to find the right provider who has been vetted to give you the care and service you deserve, while keeping your expenses low.

Step Two
Along with your Customer Service representative, choose your provider.

Your representative will lead you through your choices. There are pros and cons to every healthcare provider. There are many metrics involved in this decision.

Step Three
We set it, fill it, and complete it.

Customer Service will set the appointment and along with you, complete any required paperwork. For nonemergency appointments and sessions, most cases are completed, and a date is assigned within less than 72 hours. During this time, they are set to help you with the full scope of services offered by PayerFusion’s Customer Service.

 

To Find a Provider please visit our student provider search.

You may also call +1.866.752.8881 or email universityprograms@payerfusion.com.

 

PRE-CERTIFICATION REQUIREMENTS

This program is designed to help you receive quality, cost-effective medical care. If you do not secure a precertification for necessary services, your covered medical expenses will be subject to a penalty or not covered. Pre-certification is designed to help you receive quality, cost-effective medical care. Services must be certified in advance by contacting the Pre-certification at: +1.866.752.8881 and Press 2.

COORDINATION OF BENEFITS

A Coordination of Benefits (COB) provision applies to the Plan when you have medical and/or dental coverage under more than one Plan. Your other Plan will ALWAYS be the primary plan and must pay first. PayerFusion will only pay after the primary plan; and may reduce the benefits it pays; so that payments from all group plans do not exceed 100% of the total allowable expense. For more information about the Coordination of Benefits procedure, including the Order of Benefits Determination Rules, you may call the Member Services telephone number shown on your ID card. A complete description of the Coordination of Benefits procedure is contained in the Master Policy issued to your University, and may be viewed here.

CLAIMS PROCEDURES

Customer Service Representatives are available 9:00 a.m. to 6:00 p.m., Monday through Friday (EST) for any questions.

1. Bills must be submitted from the provider of service within 90 days from the date of treatment.
2. Payment for Covered Medical Expenses will be made directly to the hospital or Physician concerned.
3. Any itemized medical bills should include the student ID number, date of service, name of provider, CPT code, diagnosis code, and should be mailed promptly to the below address. In the event of a disagreement over the payment of a claim, a written request to review the claim must be mailed to PayerFusion within 60 days from the date appearing on the Explanation of Benefits.

 

SUBMISSION OF CLAIMS

In-network providers automatically submit your claim (bill) to PayerFusion. If you must use an out-of network provider, make sure to ask how your claim will be handled. If the provider will not submit the claim directly to PayerFusion, you may have to pay the provider immediately. In this case, you must send us the itemized bill and all other required documentation. Make sure to write your name and ID number on all the medical bills, and keep a copy for your own records.

 

PAYMENT

The expenses covered under your plan will be paid directly to the medical provider unless you send proof of payment that you paid the provider directly. If you request to be reimbursed, send the proof (receipt, etc.) to PayerFusion.

Electronic Payment Form – International

Electronic Payment Form – U.S.

 

REIMBURSEMENTS – Ways we pay back

• Electronic direct deposit.
• Check can be sent to member and provider where electronic payment is not possible.

Once a claim has been processed, an EOB will be mailed to you indicating payments to your medical provider. If you have an outstanding balance, your medical provider will send you a separate statement indicating any payment due.

 

TERMINATION OF BENEFITS

Benefits are payable under the Plan only for those Covered Medical Expenses incurred while the Plan is in effect as to the insured person. No benefits are payable for expenses incurred after the date the coverage terminates.

 

CLAIMS APPEALS PROCEDURES

Benefits are payable under the Plan only for those Covered Medical Expenses incurred while the Plan is in effect for the insured person. No benefits are payable for expenses incurred after the date the coverage terminates. If a claim is wholly or partially denied, a written notice will be sent to the Covered Person containing the reason for the denial. The notice will include a description of any additional information which might be necessary for reconsideration of the claim. The notice will also describe the right to appeal. A written appeal along with any additional information or comments may be sent within 6 months after notice of denial. In preparing the appeal, the Covered Person, or his/her representative, may review all documents related to the claim and submit written comments and issues related to the denial. The appeal must be in writing and include:

1. The claims information in question;
2. The statement of why the claimant feels the denial or reduced payment was not correct;
3. The name of the health care provider or hospital;
4. The date of service;
5. The place of service;
6. The description of the service; and
7. The charge incurred.

 

PLEASE SUBMIT ALL REQUESTS TO:

PayerFusion Holdings, LLC
Attn: Appeals Department
5200 Blue Lagoon Drive, Suite 100, Miami, FL 33126

 

CONTACT US

universityprograms@payerfusion.com

STUDENT PROVIDER SEARCH

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