Claims FAQs for Plan Members

As a Plan Member you have questions. We have answers

We know group insurance benefits can be confusing. We are here to help and have detailed some of the more frequently asked questions and subsequent answers. If you require additional assistance, please do not hesitate to contact RWAM directly.

Please note these frequently asked questions contain general information only, are subject to change, and may not apply to your specific situation. Your Employee Benefits Booklet outlines the specific coverages associated with your group plan as well as any requirements and exclusions specific to your plan.

How can I speed up claim payments?

To avoid unnecessary delays, register for Plan Member Services, submit your claims electronically, and have your claims deposited directly into your bank account. 

Can I submit my claims electronically instead of mailing them in?

It's easy to submit a claim using either the RWAM Mobile App or the Plan Member Services website. Choose the 'Submit a Claim' option, answer a few questions regarding your claim, attach an electronic copy** of your receipt and submit.

To submit claims on the Mobile App you must:

  • Already be enrolled for Plan Member Services, having a User ID and password,
  • Set up direct deposit of your claim payments by providing your banking information on Plan Member Services, and
  • Provide your email address on Plan Member Services for email notification of your Explanation of Benefits.

 

**Photos and scanned images of receipts must be legible. Files may contain multiple pages, but must be less than 4MB in total size. Acceptable file types are gif, jpg, png, pdf, and tif. Be sure any transaction slip (debit/credit card receipt) does not cover pertinent information (e.g. names, dates of service, etc.) on your provider receipt when scanned. RWAM has the right to ask for original receipts at any time, so please retain your receipts for 12 months.

Can my Provider submit claims on my behalf?

Healthcare Providers are able to submit Plan Member claims directly to RWAM for immediate adjudication. For more information on Provider submission of claims visit our Provider eServices page.

How do I download the RWAM Mobile App?

Download the free RWAM Mobile App to your smartphone or tablet from your device's app store (search 'rwam') and follow the simple enrolment steps.  You must be enrolled on the RWAM Plan Member Services site, and have a User ID and password in order to use the RWAM Mobile App. 

Download the RWAM Mobile App from your device's app store now

Apple App Store Google Play 

How do I know what exactly I am covered for?

Your Employee Benefits Booklet outlines the coverage provided by your group plan. If you don't have your Employee Benefits Booklet, you can always download a current copy from RWAM Plan Member Services, or ask your Plan Administrator for a copy. 

Refer to the fact sheet "Extended Health Care Benefits. What's Covered?" for helpful hints on confirming whether your Group Health Benefit Plan includes coverage for a particular service or Provider.

Contact your Plan Administrator or RWAM directly to obtain answers to any additional questions you may have. 

What paramedical benefits require a doctor's referral in advance?

Most plans do not require a doctor's referral for services rendered by a Chiropractor, Naturopath, Osteopath, Podiatrist, Chiropodist, clinical Psychologist, licensed Physiotherapist, Speech Therapist or Acupuncturist. However, some plans require a doctor's written referral for registered Massage Therapy to be sent in with the claim. If you are unsure of your group's requirements, you should review your Employee Benefits Booklet first for coverage and any claim requirements specific to your plan.

What if my claim will exceed $500?

RWAM suggests that you obtain a detailed treatment plan from your Provider and submit it to RWAM prior to starting any treatment that is expected to exceed $500. We will then advise you of the amount for which you are eligible to be reimbursed.

What if my claim will exceed $500?

In order for orthotics to be eligible:

  • They must be custom made for the individual from raw materials and a 3 dimensional cast of the foot to address an existing medical problem/condition,
  • They must be prescribed by a medical doctor, chiropodist, or podiatrist (off-the-shelf products are not covered), and
  • If the plan doesn't have an annual maximum, a reasonable and customary limit is applied based on usual and customary charges for custom made orthotics.

I understand charges and amounts covered for dental work are based on a fee guide. What is a fee guide?

Dental fee guides are established and published by provincial dental associations - for example the Ontario Dental Association. Fee guides serve as a reference for dental practitioners to develop fee structures that are fair and reasonable for the patient and the practitioner. Insurers use these guides to provide consistent benefits within provinces and in the management of their dental plans. 

What factors can impact how much of my claim is eligible for reimbursement?

Coverage under most plans is subject to certain rules, limits, and maximums which govern how much of your claim is eligible for reimbursement. Every benefit plan can be different – so always refer to your Employee Benefits Booklet for the details specific to your plan. If you don't have an Employee Benefits Booklet, you can download a current copy from RWAM Plan Member Services, or ask your employer's Group Plan Administrator for a copy.

Review the "Understanding Your Group Insurance Benefits" fact sheet to learn more about the rules, limits, and maximums that are applied to your claim.

Contact your Plan Administrator or RWAM directly for any additional questions you may have. 

Can my claim payments be deposited directly to my bank account?

Yes. Approved Extended Health Care, Dental, Short and Long Term Disability claim payments can be deposited directly to your bank account, and your Explanation of Benefits (EOB) statement will be sent electronically to your personal email address.

Sign up for direct deposit by entering your banking information and email address on the Plan Member Services website. You may update your banking and personal information at any time using RWAM Plan Member Services.

You may also download an 'Application for Direct Deposit of Group Benefit Payments' form and send to RWAM, or contact your Plan Administrator or RWAM Group Administration to enroll in direct deposit or change your banking information or email address.

How do I obtain replacement Explanation of Benefits (EOB) statements?

You may want to reproduce your Explanation of Benefits (EOB) for income tax or Coordination of Benefits (COB) purposes. You can print a replacement copy of your EOB statements directly from your RWAM Plan Member Services account. RWAM does not reproduce these. 

How do I obtain replacement Explanation of Benefits (EOB) statements?

RWAM is committed to ensuring that your group benefit plan operates within the guidelines of your contract and according to industry parameters. Fraud can present itself in numerous ways. The following are some of the measures used to protect your plan:

  • Conduct Provider and patient audits to confirm services being claimed have actually been rendered as billed by the Provider indicated on the receipts, and received and paid for by the Insured.
  • Investigate suspicious claims or patterns (e.g. over-utilization or unusual claims frequency) and followup requesting additional information to support the claim or validate the pattern.
  • Check credentials of paramedical Providers to ensure they are active, current members with the appropriate regulatory authority and/or association, and are billing appropriately.

 

 

Fraud can lead to higher insurance premiums and/or reduced coverage for you. As a plan member, you can play a role in helping to prevent fraud by:

  • Safeguarding your benefits information and RWAM OneCard to prevent unauthorized use.
  • Understanding what claims a Health Care Provider is submitting on your behalf.
  • Ensuring that the services you received reconcile with those billed (e.g. date, Provider, duration and type of service) and that the Claim Statement/Explanation of Benefits reflects the same.
  • Contacting RWAM if you have any reason to suspect insurance fraud is taking place by either a Health Care Provider or a co-worker.