Ascend to Wholeness:
This is the NAD HCAP’s new activity-based, lifestyle and wellness program, that is available beginning January 2018. It focuses on whole-person health and invests in you through valuable new services. Ascend to Wholeness provides comprehensive care coordination, biometrics screening, wellness assessment, free personalized health coaching, a wellness portal and many educational opportunities. For more information visit:
Biometrics screening:
These tests measure total cholesterol and HDL cholesterol, glucose, blood pressure, height and weight, and BMI (body mass index). Participants may choose optional screenings for LDL cholesterol and triglycerides (requiring an 8 to 12 hour fast) and body composition/percent body fat. The confidential screening (free to health plan members) and wellness assessment are part of the NAD’s commitment to supporting employees and their families in achieving optimal physical, mental and spiritual health.
Care coordination:
Your new plans include care coordination, integrated wellness and confidential health coaching for all plan members provided in partnership with Adventist Health. Accelerate Plan members who are at risk for serious health issues must participate in free care coordination, education and support through one-on-one health coaching. They will learn how to reduce risk, identify resources, overcome barriers and set goals to make lifestyle changes to improve overall health. Many of these enhanced benefits are also available to those enrolled in the Access Plan.
A payment request to the health plan for covered services provided to a member enrolled in the health plan. A claim can be submitted by the patient, the patient’s representative or by the healthcare professional who provided the service. Further information about the 2018 NAD HCAP claim submission process will be available online at:
The monthly amount you pay for health plan coverage.
Covered Service:
A service or supply that is covered by the Plan.
The specified amount of money you must pay for covered services before the health plan will pay a claim.
The pre-determined amount you pay for covered services each time you visit a provider or facility. Your co-pay applies to your deductible and accrues to your out-of-pocket maximum.
The percentage you must pay for care after you’ve met your deductible.
Explanation of Benefits (EOB):
When a healthcare provider sends out bills for services rendered, the patient receives what is commonly called an Explanation of Benefits (EOB). An EOB resembles a bill. It contains the date of service, the code used to bill a particular service to an insurance company, the fee charged by the healthcare provider, the allowed amount under the third-party payers’ contractual fee schedule, the patient’s responsibility under the terms of their coverage, the payment made by the payer, and the contractual write-off. An entry usually the titled, “what you owe” or “your responsibility” is why some health plan members confuse an EOB with a medical bill.
Health coaching:
This is a telephone-based, lifestyle improvement program available at no cost to all NAD health plan members beginning in January 2018. Your personal health coach partners with you to help you with healthy lifestyle changes. Your coach doesn’t tell you what to do, but helps you explore ways to address your health concerns.
HealthSCOPE is a full-service claims administration and health management firm which partners with NAD HCAP to help manage your claims process. You will continue to go to the HealthSCOPE website to view your explanation of benefits (EOB) and other information: Your doctor/provider should submit all claims to HealthSCOPE, via the information on your identification card. Do NOT call or submit anything to AETNA.
This acronym stands for the Health Insurance Portability and Accountability Act. As your health plan administrator, ARM, and its partners adhere to all HIPAA privacy regulations. No personally-identifiable information will be shared with your employer (including Human Resources, your manager or supervisor). NAD employers receive only aggregated data stripped of personally-identifiable information.
An acronym for the North American Division Healthcare Assistance Plan. It is important to note that this is a self-funded plan meaning that your employer pays the actual cost of your healthcare.
Open enrollment:
Once each year, a period of time is designated by your employer when you can sign up for health insurance or are allowed to make changes to your coverage. (An exception to this is if you experience “a qualifying event” such as marriage, divorce, a birth, etc.) Your employer should provide you with written materials that explain your benefits so that you can select the plan that is the best fit for you and your family.
Out-of-network Services: These are services from a provider that are not part of the plan’s preferred provider organization (PPO). Beginning January 2018, non-emergency, out-of-network services are not covered by the plan. It is your responsibility to confirm your doctor/provider is part of the plan’s PPO.
Out-of-network Service Request:
If a health plan member believes there is no in-network physician or services available, this form needs to be submitted for pre-certification (and can be done by the member and/or by provider.)
Out-of-pocket maximum (OOP):
The absolute maximum you’ll pay annually for healthcare services. Once you meet the OOP maximum, the health plan pays 100 percent of covered services with in-network providers and facilities.
Preferred provider organization (PPO):
A preferred provider organization (PPO) is a network of doctors, hospitals, clinics, specialists, labs and pharmacies. This arrangement allows health plan members to choose the providers they want to visit from among those who participate in the health insurance plan’s network called “preferred providers.”
Pre-authorization or pre-certification:
A health plan requirement in which you or your primary care physician must notify NAD HCAP in advance about certain medical procedures and medications in order for those procedures to be considered a covered expense. Examples would be cancer therapy or back surgeries. Your plan document outlines further examples of services that require pre-authorization/certification. The 2018 plan will be available at
It is your responsibility to make sure the needed pre-authorization/certification is received in advance of any service. If there is any doubt, please have your provider call the number on the back of your identification card.
Wellness assessment:
This easy, secure online personal health questionnaire helps to identify risk factors for conditions such as diabetes, heart disease and hypertension which are often preventable with lifestyle change. The assessment is an easy, secure online personal health questionnaire that should take about 15 minutes to complete. You will receive an actionable wellness plan based on your responses.