OSF HealthPlans (OSFHP), like other health plans and insurance companies, researches claims that may be work or accident related to determine responsibility for payment. This process is called "subrogation". Subrogation is coordinating payment between the health insurer and other third-party payers such as property/casualty workers' compensations, homeowners, etc.

In order to assist OSFHP in determining payment liability, we have entered into an agreement with Advana, Inc. effective January 1, 2002. Advana researches, on behalf of OSFHP, certain types of claims to determine if the injuries may be work-related or caused by an accident.

Prior to OSFHP paying a potential workers' compensation or accident-related claim, Advana will research the situation. Advana will call you to ask questions to determine if another insurance company is responsible. The Advana representative will identify him/herself and explain the relationship with OSFHP. All information provided to Advana is held in the strictest confidence and used solely to determine payment liability.

Questions and Answers About:

A. Members are not suing their neighbors or relatives. They are merely collecting under the insurance contract (Medical Payments portion) written specifically for that type of loss.

A. Most homeowners' insurance policies contain a Medical Payments portion designed to pay claims occurring on one's property without regard to fault or negligence. The policyholder has paid a premium for the Medical Payments Coverage. A claim submitted under the Medical Payment portion generally does not have an effect on the homeowner's premium.

A. Auto insurance is primary coverage written specifically for auto-related injuries. For example, Auto Medical Payments typically covers injuries sustained while riding in a car (or getting into or out of a car). The Member pays for this coverage under their auto insurance policy.

A. As with the Homeowners policy, most Auto policies contain a Medical Payments portion designed to pay claims without regard to fault or negligence. The policyholder has paid a premium for the medical payments coverage. A claim submitted under the medical payments portion generally does not have an affect on the auto premium.

A. Medical Payments Coverage reimbursement is available, but more difficult to obtain once the claim has been paid (voluntary payor).

A. Advana will advise OSFHP to begin processing the additional claims according to the terms and provisions of your policy. Advana will then pursue reimbursement or recovery from a responsible third party for amounts paid in excess of the Medical Payments Coverage, if possible.

A. Advana will aggressively pursue and protect OSF HealthPlans' rights. The contract excludes coverage for benefits "provided or payable" under any Worker's Compensation Act or when workers compensation coverage was "available" regardless of whether "such coverage was actually applied for".

A. It depends on the case. Work Comp carriers routinely deny claims when there is medical coverage in hopes that the health plan will simply pay the claim. Advana will investigate and obtain the facts to determine whether the injury or sickness is compensable under the Work Comp carrier.