User Manual
Contents
1. Fields are not mandatory if you do not have Life Insurance Member Eligibility Medical Plan Selecta Group Plan From Date j Group s established waiting period will be verified to confirm effective date Other Information Beneficiary Beneficiary Relationship Anyone Eligible and Covered By MEDICARE Yes No If YES who Does member have Other Coverage Yes No Fields will be mandatory to determine if there is any coordination of benefits needed If YES will member continue coverage yes No Do dependents have other coverage yes No Who If YES will they continue Yes No Does member or any dependents qualify for pre existing limitation credit If YES how many months Name of previous carrier Continue to Dependent Section Cancel yes No mitedvag United Agricultural Benefit Trust User Manual Enrollment Change Enrollment Add Change Start a New Form If employee was previously enrolled onto your policy the employee s information will populate in the data field below Member Signed In Welcome back Security 315 Change Password lt 2 Home a Forms Enrollment 4 Coverage Verification fia Reports Additional Services SSN Prefix First Name Last Name Suffix Address City Phone Gender Employment Date Employee Demographics2. 5 nitedA The UABT Online Portal Home a Forms S Enrollment 4 Coverage Verification ml Reports Additional Services Member Signed In Print Temporary ID Card Weicome back Security 315 Member Number Verify Member Number Change Password aaa i Your Privacy Is Our Top Priority This is a password protected site As supporters of the Verisign Secure Site Program this is a secure site that keeps you and your family s health care information strictly confidential Privacy amp Security Policy Disclaimer 20 initedwag United Agricultural Benefit Trust User Manual Print Temporary ID Card Below is a copy of the temporary ID card TT amp Home 853 Forms Enrollment im Claim 4 Coverage a Reports Additional Member Center Verification Services Signed In Print Temporary ID Card Welcome back Security 315 Click here to Print Card Your Privacy Is Our Top Priority This is a password protected site As supporters of the Verisign Secure Site Change Password Program this is a secure site that keeps you and your family s health care information strictly confidential Privacy amp Security Policy Disclaimer 21 initedwag United Agricultural Benefit Trust User Manual Temporary ID Card Sample Below is a sample of the temporary ID card Temporary ID Card UA B T Err it ID Dhl y Hot Pro g Eligibility Unwed gar thor el Hara Tea SSlo Pars Prdertificars
3. DOB mm dd yyyy DOB mm dd yyyy DOB mm dd yyyy DOB mm dd yyyy 05 05 11980 11 1107 1976 11 1103 j 2003 Plan FRR REVOLUTION PLAN Member DOB 5 05 1980 Spouse DOB 11 07 1976 Child 1 DOB 11 03 2003 Child 2 DOB Child 3 DOB Member Spouse Child 1 Child 2 Child 3 TOTALS If more than 3 children enter the 3 oldest Member Effective Date Spouse Effective Date Child 1 Effective Date Effectiv Effectiv Effectiv Effectiv Effectiv Calculate 1 01 2014 1 01 2014 1701 2014 Child 2 Effective Date Child 3 Effective Date Med 385 74 398 62 204 46 Den 14 Date 01 01 2014 ate 01 01 2014 ate 01 01 2014 Admin Zip Code Zip Code Zip Code Zip Code Zip Code Your monthly contribution amount initedwag United Agricultural Benefit Trust User Manual V Coverage Verification To view employee s coverage date Enter the employee s ID or Social Security Number to view coverage verification on that specific employee The UABT Online Portal amp Home a Forms Enrollment 4 Coverage Verification ia Reports Additional Services r g Member Signed In Coverage Verification Weicome back Security 315 Member Number oo Retr
4. unitedwag United Agricultural Benefit Trust Access UnitedAg Online Portal The UABT Online Portal User Manual UABT gives you the tools and resources you need to manage your health benefits Get instant access to our secure website for these services whether you are a provider employer or member April 2014 initedwag United Agricultural Benefit Trust User Manual Table of Contents l LOON SP AOS rera T vapor an E awe Glatae EAE 2 LOZIN WAS CEUCTION orrendi E T E EEE 2 FOS To Derri E E ERE 3 TIPES Or FOE a A E E EE E N 3 IH Enrollment Add Change ccccccccssseeeeeeeeeeeseveveveeeeeeeeenenenenenens 4 Slat a NEWN TOT eeri rE A aontaiedoa ts iuneaiodemtansvqindacainasetgineiamamiudeainans 4 Eroin ge 0 0 Ieee EE E E ne ee ee eee ee ee 4 EA OMI IG CAINS E serian n TEETE ETEA TEE NEETA EEE 6 Adding a dependent ssrirareisicreriine akiki nn ER R ER EE AE aa eiai enie iieii 7 Enrollment Confirmation Page seeesesesssseserrenessrrerereressrrerererrersrreesrerersrseesreerossrreesrerersreeesrene 10 Ie aain E OV r E A E A E E A EE E E 11 Submit Multiple Termina tioN ticctccteessannsacedinasnstanesnecasossanstousenateanenesasnnoasasaceas seoeeererseansasncenes 12 PENCE NTON I eien i A E E E A E EEN 13 RC MNOU e A E E E E 14 Ve CEI ONTO orerar rN EEA EEE 14 Group Cam CEN E sonaria aee Error Bookmark not defined V Coverage Verification ssssssssrssrsnrrnrrnrrrnrnnrrnrrnrrnrrnrrrnrrrrrnerns 15 To view emp
5. 22 4530 Fax 343 264 1335 Aue Shield of Coliforms an independent member of the Aue Shield erod ati on provides n wg k access only ard mo ret work wows is aval able From H us Q ose B ue Shield plans outside of Calif ania s service area Hus Shield oF California provides mo claim payment service and dots mob sume any Financia risk or obi gation wth respect bo clai me 22 unitedwag User Manual Make Contribution Payments Under Additional Services you will need to click on Make Contribution Payment A new window will pop up If this is your first time you will need to register by selecting Contribution Payment You will need your UABT Group number Enter the number without the preceding zeros 1234 000 You will need your Billing Zip Code The site will lead you into registering and you will then be able to make a payment If you have already registered proceed with your payment i T I TORC SONNIG ONS DE sticali and miernatonaly Please be advised that all payments received after 4 30 PM PST M F will be processed on the following business day Indicates required field Log In Register Username Bill Type Contribution Payment Password 3 Group Number Login p Zip Code forgot your username ES forgot your password Submit 23 mitedvag United Agricultural Benefit Trust User Manual Contact Us From the Additional Services tab you can cli
6. Enrollment Form ENROLLMENT ACTION G New 23456789 enter no dashes a a a a Modifying Employee I nfo SMITH m 54 CORPORATE PARK IRVINE State cA Zip 92606 9495551234 numerics only no dashes or parenthesis Male Female Birth Date 07 fia 11948 07 07 2009 Status Active Member Eligibility Medical Plan Selecta Group Plan From Date 01 or 2012 E al Group s established waiting period will be verified to confirm effective date Other Information Beneficiary SAMANTHASMITH gt gt Beneficiary Relationship WEE Anyone Eligible and Covered By MEDICARE Yes No IfYES who S Does member have Other Coverage Yes No If YES will member continue coverage Yes No Do dependents have other coverage C yes No wo SS If YES will they continue Yes No Does member or any dependents qualify for pre existing limitation credit If YES how many months Name of previous carrier Yes No Cancel mitedvag United Agricultural Benefit Trust User Manual Adding a dependent Enrollment Add Change Adding a dependent Once a member has been added or modified the option to add dependent s will follow You will need to click on Add Dependent If there are no dependent s to be added for this employee click on Submit this Enrollment Home a3 Forms amp amp Enrollment 4 Co
7. supporters ofthe Verisign Secure Site Program this is a secure site that keeps you and your familys health care information strictly confidential Privacy amp Security Policy Disclaimer Register Now Forgot ID Password mitedvag United Agricultural Benefit Trust User Manual Il Forms Tab Types of Forms Once you are logged in the first tab is the Forms tab which provides you the following UABT forms Domestic Partnership Affidavit Domestic Partnership Termination Employee Enrollment Application Employee Change Form Statement of Health Form Upload a File The Upload a file feature allows you to submit any secured file to UABT such as Eligibility Listing Response to Missing Pending Information A Accarinitedan The UABT Online Portal Se Lay N SP Enrollment 4 Coverage Verification lia Reports Additional Services Signed In Welcome back We E oa security 315 Employers Logout d oe peysur he Get instant access to our secure website where you can Change Password D Enroll amp Change Members KEN Terminate Members d Print Temporary ID Card Make Contribution Payment You are able tO Stier change the privacy amp Securty Posy Disclaimer password that was given to you mitedvag United Agricultural Benefit Trust User Manual Lil Enrollment Add Change Start a New Form Allows you to enroll a new employee onto your policy or
8. 315 SAMANTHA SMITH WIFE JOHN SMITH Member 123 45 6739 54 CORPORATE PARK IRVINE CA 92606 Male 7 14 1948 SAMANTHA Spouse Female 5 05 1974 DEPENDENT EFFECTIVE DATE 1 01 2012 Electronically Signed by security315 on 3 28 2012 10 at Print This Page Please Print in Landscape Mod initedwag United Agricultural Benefit Trust User Manual Termination This option will allow you to terminate a single employee off your policy or do multiple terminations Please Note You will only be able to terminate one month at a time grat amp Home 83 Forms SS Enrollment 4 Coverage Verification fa Reports Additional Services Member Signed In Multiple Termination Welcome back Terminate Security 315 Employer Select an Employer Last Coverage Date Retroactive termination of coverage will be reviewed and must be approved Please Note Retro active termination is prohibited by the No Rescission Rule which is mandated by the Patient Protection and Affordable Care Act PPACA Submit Cancel Change Password Your Privacy Is Our Top Priority This is a password protected site As supporters of the Verisign Secure Site ni Program this is a secure site that keeps you and your familys health care information strictly confidential Privacy amp Security Policy Disclaimer 11 mitedvag United Agricultural Benefit Trust User Manual Submit Multiple Termination Termi
9. Address a State City a Zip Gender Male Female Birth Date Dependent Disablilty Disabled Yes No Medicare Disabled Yes No if yes a note of disability from the primary physician is required annually Other Information J Status Change Date COBRA Reason Please Choose X Please Choose X Comments Add this Dependent Cancel initedwag United Agricultural Benefit Trust User Manual Enrollment Add Change Adding a dependent At this point you may repeat the process to add additional dependent s or you can click on Submit this Enrollment to complete the enrollment process on this employee Se a amp Home aj Forms Enrollment 4 Coverage Verification fe Reports Additional Services Member Signed In Dependent Enrollment Welcome back Member Info Security 315 123 485 6789 gt JOHN SMITH Previous 20 Add Dependent Next 20 Logout Action Relationship Dependent Name SSN Sex Birth Date Status Change P Member JOHN SMITH 123 45 6789 M 07 14 1948 DEPENDENT EFFECTIVE Change Password P Spouse SAMANTHA 000 00 0000 F 05 05 1974 E DATE 01 01 2012 Previous 20 Add Dependent Next 20 Submitthis Enrollment Delete this Enrollment Cancel Your Privacy Is Our Top Priority This is a password protected site As supporters of the Verisign Secure Site F Program this is a secure site that keeps you and your familys
10. Finalized FE 315 000 6600 70 7838 JOHN DOME 2012 03 27 Finalized a 315 000 123 45 6789 JOHN SMITH 2012 03 28 Submitted Your Privacy Is Our Top Priority This is a password protected site As supporters of the Verisign Secure Site Program this is a secure site that keeps you and your familys health care information strictly confidential Privacy amp Security Policy Disclaimer 13 nitedwa United Agricultural Benefit Trust Rate Inquiry 5 User Manual This feature will allow you to calculate the contribution rate for new and existing employees on your benefit plan a Follow the instruction on the Rate Inquiry screen based on your group size b Once all the required information is entered click on Calculate Default Eff Member DOB mm dd yyyy Spouse Child 1 Child 2 Child 3 Instructions Must enter all family member enrolled to get appropriate monthly contribution Small Groups calculation must use the member s effective date a If member s effective date is prior to January 1 2014 please enter 01 01 2014 Rate Inquiry b Otherwise please use effective of eligibility c If dependent s eligibility start after the members please enter dependent s effective date of eligibility Rehires must use effective date of eligibility Large Group calculation must use effective date of eligibility Date mm dd yyyy o 01 2014 FRR REVOLUTION PLAN y Base Plan
11. bution Amount B View Archived Data The location of all reports you ve ordered in chronological order Please allow a minute for the report to be generated and placed in this location You will receive an email notification once the report has been created 18 mitedvag United Agricultural Benefit Trust User Manual VII Additional Services Requesting for Member ID Card Under Additional Services you will need to click on Request for a member ID card A new window will pop up with the following fields All the fields are required Note It will be faster if you give the Enrollment amp Billing Department a call if you are trying to order an ID Card for more than 5 employees Or email a list to us at enrollment unitedag org UABT ID Card Request Form First Name PO Last Name Member ID fo Email PO Mailing Address PO City PO State zip poo Name of Employer PO Phone Number XXX XXX XXXX Number of Cards Requested 19 mitedvag United Agricultural Benefit Trust User Manual Print Temporary ID Card Under Additional Services you will need to click on Print Temporary ID card Enter the employee s ID or Social Security Number to view coverage verification on that specific employee Note This feature will only be available to existing and active employees New enrollees that have not been approved and contributions have not been posted will not have access to a temporary card
12. ck on Contact Us for contact information WE iay Contact Us Please fill out this form for more information United Agricultural Benefit Trust Mailing Address 54 Corporate Park Irvine CA 92606 5105 Phone Number 800 223 4590 Please contact the following departments for questions regarding L claims and Benefits Customer Service customersenvice uabtorg C Enrollment and Eligibility Billing Department uabtbilling uabtorg O Reports Client Services mevanson uabtorg Comments Submit Reset Form 24
13. ck to Member Selection Back to Main Page Your Privacy Is Our Top Priority This is a password protected site As supporters of the Verisign Secure Site x Program this is a secure site that keeps you and your family s health care information strictly confidential Privacy amp Security Policy Disclaimer 16 unitedwag User Manual Plan Summary a Below is a sample of the Plan Summary UABT Schedule of Dental Expense Benefits Dental Plan lf you or an eligible dependent incur Covered Expense for dental services while the patient is eligible for benefits under the Plan you will be reimbursed in accordance with the following schedule Type Services Examinations X rays prophylaxis and fluoride treatment 0 cece cece eeee eee ees 100 of usual amp customary charges Type Il Services Fillings restorative crowns root canal therapy extractions and inlays 00 80 of usual amp customary charges Type Ill Services Removable or fixed bridges pontics abutment crowns and partial or complete dentures 60 of usual and customary charges Type IV Services OnHgdonia TOF BAY FEARON aa O AD not covered expense 17 mitedvag United Agricultural Benefit Trust User Manual VI Reports A Eligibility List The Eligibility list will provide you with the current day roster of employees by group and plan You will be able to view ID Name Date of Birth and Contri
14. e Mo es Procbs de Bi gq bil i ded hembra John Doe Beemer O Mumie er 11142777 Enel wer AMEC Company rec Erel oya Buimber 1700 000 Bedi cal Copy 2 Fe Gop S10 S20 S30 bidi col Wetwork A ovi ded by Hue Shield Galiforni amp Gow amp 512161 PA ht 603256 Fe AC 01470000 Issue Dt e Oh 13 2012 This tenporary O Cadis valid 30 days From issue date Abuse Shield CA Aig Authorization 200 541 BBS Prequiries Higi H lity Benefits Osim amp all Services cut of Calif aria G00 223 4550 Locate a H ue Shiel d Provider w bl ueshi el d com na wor KPA Catalyst Px Hath Fe Prog am G00 207 2565 First Health MEt vork oksi de of Cal iforni zg BO 247 2555 C alps Fee iF co pap reads 100 patient will pay a contracted discount pri ce Patients with a co pay may still be responsi ble For percet ag d covered experce F co pm reads H A patient my be responsi ble For payment of a deductibl ard percentage of covered expense Prior A ho ization Allo inpatient adm ssions require prio authorization Emergency admissions require hour mobioce Failure to notify my result in bert it reduction IF IO Ca d reads Bexican Panel Coy mo ber its are pwal For treatmert in the US Providers Fila all Californias medi col claim wth Bue Ehield Caolifeorn a F O Bex 200 CH co OA 327 2540 Abense File all d sime outzi d Californias vell ss Wision snd Dertal claim with LEBT 24 Gor porate Fark Irvine GY 3260 s00
15. health care information strictly confidential Privacy amp Security Policy Disclaimer initedwag United Agricultural Benefit Trust Enrollment Confirmation Page Enrollment Add Change Adding a dependent User Manual A Confirmation page will pop up for you to print for your file See sample below On Line Enrollment Form Employee Demographics Form Status SSN Name Address Phone Employment Date Enrolling User Other Information Beneficiary Beneficiary Relationship Anyone Eligible and Covered by MEDICARE If YES who Does member have Other Coverage If YES will member continue coverage Do dependents have other coverage Who If YES will they continue Does member or any dependents qualify for pre existing limitation credit If YES how many months Name of previous carrier Dependent Number 1 Information Dependent Name Relationship Dependent SSN Dependent Address Gender Date of Birth Disabled Medicare Disabled Status Change Status Change Date COBRA Reason Comments Dependent Number 2 Information Dependent Name Relationship Dependent SSN Dependent Address Gender Date of Birth Disabled Medicare Disabled Status Change Status Change Date COBRA Reason Comments Submitted 123 45 67389 JOHN SMITH 54 CORPORATE PARK IRVINE CA 92606 949 555 1234 1 01 2009 Employment Status Active security
16. ieve Member Number Change Password Your Privacy Ils Our Top Priority This is a password protected site As supporters of the Verisign Secure Site Program this is a secure site that keeps you and your family s health care information strictly confidential Privacy amp Security Policy Disclaimer 15 unitedwag United Agricultural Benefit Trust User Manual Display Plan Summary Enter the employee s ID or Social Security Number to view coverage verification on that specific employee You can click on Display Plan Summary to get a detailed description of the associated plan listed to the left of the link AT amp Home s Forms 2 Enrollment 4 Coverage Verification fia Reports Additional Services The UABT Online Portal Member Signed In Coverage Verification Welcome back Security 315 Member ID 846L44846 Name ADAMS TRACY L Address 570 DAHLIA PLACE Change Password State CA Zip Code 93455 0000 Enroll Date 2 01 2004 DEPENDENTS Name Birthdate Plan Type Plan Description Effective Eligible Bian Summary Date Through DENTAL S F DCPTX 2 01 2004 3 31 2014 TEIXEIRA COMP SELF 10 000 LIFE L10 3 NEFITS 2 01 2004 3 31 2012 ae SELF FUNDED Vision RTXVP 2 01 2004 3 31 2012 Display Plan Summary VISION TEIXEIRA Prescription Drugs RX663 RX 663 2 01 2004 3 31 2012 _Display Plan Summary TEIXEIRA FARMS Medical TX15 2 01 2004 3 31 2012 Display Plan Summary PLAN S F Ba
17. loyee s coverage date eeesessssssssssssssssssssrrrrrrrereereeesssssssessserererrerrrreeeeesssses 15 DISHI Plan SUMAT y ansiasisaisierirecie ein e a a a a 16 Vie REDON aree E A d Aa 18 Vil Adarna AVIC O irer E A EA E ni 19 Requesting for Member ID Card sicisiucvonsseacStoncsatwaasdncsdedeiesdonesacoaniniesasseneddsacesboaiinisadsaearadaans 19 Pune TEMPO y ID Sr co a E 20 Make Contribution PAVING AES sesicicasntaneessncaciiceabodincueviscsteiasacesledtediaanavadeneatdacanatsarseayenineteioladeeeens 23 CONT T S aa E detent bnen E E E E E E S E 24 mitedvag United Agricultural Benefit Trust User Manual Login Page Login Instruction Employers login must be set with United Agricultural Benefit Trust A HIPAA Release of Information form must be on file prior to receiving your login information Please contact UABT Enrollment Department for access Phone 800 223 4590 Email enrollment unitedag org UnitedA The UABT Online Portal Gr Home Welcome to u UABT Online Portal UABT gives you the tools and resources you need to manage your health benefits Get instant access to our secure website for these Password services whether you are a provider employer or member At a glance M Providers Processed Claims Members eView Health Benefits ePrint Explanation of Benefits Employers Enroll change amp Terminate Members Your Privacy Is Our Top Priority This is a password protected site As
18. modify an existing employee s demographics i e address date of birth dependent info i This feature will also allow you to add additional qualified dependents Change an Existing Form Listed Below allows you to modify forms that was created through AccessUnitedAg before it gets approved by UABT gt Access UnitedAg Online Portal We ay bay f amp Home a Forms Enrollment 4 Goverage Verification fe Reports Additional Services Member Signed In Member Enrollment List e New Enrollment Numerics only No dashes Must be 9 digits lead with zeros if necessary Welcome back Change Password initedwag United Agricultural Benefit Trust User Manual Enrollment Add Enrollment Add Change Start a New Form Once you enter the employee s Social Security Number i If employee is brand new you will get a blank form as Shown below 8 me f amp Home aj Forms Enrollment A Coverage Verification fas Reports Additional Services Member Signed In Enrollment Form Welcome back ENROLLMENT ACTION Security 315 New Employee Demographics SSN 123456789 enter no dashes Prefix First Name i ti CCSY M I Change Password Last Name Suffix Address City State Zip Phone numerics only no dashes or parenthesis Gender Male Female Birth Date Employment i sa Status SelectEmployment Status e sis
19. nation Once you select the account the terminated employee is enrolled under you will need click on the check mark next to their name and click on the Submit Multiple Termination button Please note All termination is subject to review Retro active termination will be prohibited Sy aa re i Gy Home aj Forms amp Enrollment 4 Coverage Verification ia Reports Additional Services Member Signed In Multiple Termination Welcome back Select for Termination Date 03 31 2012 Security 315 Mbr ID Name Empir ID Employer Plan Plan Description Check All Uncheck All me 2 Submit Multiple Termination Cancel Change Password Your Privacy Is Our Top Priority This is a password protected site As supporters of the Verisign Secure Site x Program this is a secure site that keeps you and your familys health care information strictly confidential Privacy amp Security Policy Disclaimer 12 lnitedwa United Agricultural Benefit Trust User Man ual Print Enrollment This option will allow you to print a copy of the enrollment that was processed through this online portal Member amp Home a4 Forms S Enrollment 4 Coverage Verification Hl Reports Additional Services Signed In Print Enrollment List Welcome back Security 315 Print a Form Search Member Last Name Goto Previous 20 Next 20 Group Action SSN Name Form Date Status Number Change Password m a 315 000 600 700 7838 JOHN DOME 2012 03 27
20. verage Verification lm Reports Additional Services Member Signed In Dependent Enroliment Member Info 123 45 6789 JOHN SMITH Welcome back Security 315 Previous 20 Add Dependent Next 20 Logout Action Relationship Dependent Name SSN Sex Birth Date Status Change 2 Member JOHN SMITH 123 45 6789 M 07 14 1948 Previous 20 Add Dependent Next 20 Submit this Enrollment Cancel Change Password this Enrollment Your Privacy Is Our Top Priority This is a password protected site As supporters of the Verisign Secure Site 4 Program this is a secure site that keeps you and your familys health care information strictly confidential Privacy amp Security Policy Disclaimer unitedwag User Manual United Agricultural Benefit Trust Enrollment Add Change Adding a dependent Once you complete the employee s enrollment section see Part III Section a you will be instructed to enter the appropriate information on the dependent in the fields provided When you are done click on Add this Dependent Additional Services amp Home Ss Forms Enrollment 4 Coverage Verification ia Reports Member Signed In Enrollment Form Welcome back Member Info Security 315 123 45 6789 JOHN SMITH Dependent Demographics Add Delete Relationship Add Delete Please select a relationship CE er First Name Mis Last Name Chango Password Suffix SSN 000 00 0000 enter no dashes
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