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2023 Aviso sobre la transparencia
A) Out-of-network liability and balance billing
The Ambetter network is the group of providers, including but not limited to physicians, hospitals, pharmacies, other facilities and health care professionals, we contract with to provide care for you. If a provider is in our network, services are covered by your health insurance plan. Network providers may not bill you for covered expenses beyond your applicable cost sharing amounts (e.g., copayment, coinsurance, and/or a deductible).
If you receive services from a nonnetwork provider, you may have to pay more for services you receive. Non-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual maximum out-of-pocket limit.
When receiving care at a network facility, it is possible that some hospital-based providers (for example, assistant surgeons, hospitalists, and intensivists) may not be under contract with us as network providers. We encourage you to inquire about the providers who will be treating you before you begin your treatment, so that you can understand their network participation status with us.
As a member, non-network providers should not bill you for covered services for any amount greater than your applicable in-network cost sharing responsibilities when:
- You receive a covered emergency service or air ambulance service from a non-network provider. This includes services you may get after you are in stable condition, unless the non-network provider obtains your written consent.
- You receive non-emergency ancillary services (emergency medicine, anesthesiology, pathology, radiology, and neonatology, as well as diagnostic services (including radiology and laboratory services)) from a non-network provider at a network hospital or network ambulatory surgical facility.
- You receive other non-emergency services from a non-network provider at a network hospital or network ambulatory surgical facility, unless the non-network provider obtains your written consent.
B) Enrollee Claim Submission
Providers will typically submit claims on your behalf, but sometimes you may need to submit claims yourself for covered services. This usually happens if:
- Your provider is not contracted with us
- You have an out-of-area emergency
We must receive written proof of loss within 90 days of the loss or as soon as is reasonably possible. Proof of loss furnished more than one year late will not be accepted, unless you or your covered dependent member had no legal capacity to submit such proof during that year.
If you have paid for services we agreed to cover, you can request reimbursement for the amount you paid. We can adjust your deductible, copayment or cost sharing to reimburse you. We must receive notice of claim within 30 days after the occurrence or commencement of any loss or as soon as reasonably possible.
To request reimbursement for a covered service, you need a copy of the detailed claim or bill from the provider. You also need to submit an explanation of why you paid for the covered services along with the Member Reimbursement Claim Form (PDF) posted at Ambetter.BuckeyeHealthPlan.com under “For Members-Forms and Materials”. Send this to us at the following address:
Ambetter from Buckeye Health Plan
Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-5010
Benefits will be paid within 30 business days after receipt of proof of loss. Should we determine that additional supporting documentation is required to establish responsibility of payment, we shall pay benefits within 45 business days after receipt of proof of loss. If we do not pay within such period, we shall pay interest at the rate of 18 percent per annum from the 30th day after receipt of such proof of loss to the date of late payment.
C) Grace Periods and Claims Pending
If you don’t pay your premium by its due date, you’ll enter a grace period. This is the extra time we give you to pay (we understand that stuff happens sometimes).
During your grace period, you will still have coverage. However, if you don’t pay before a grace period ends, you run the risk of losing your coverage. During a grace period, we may hold — or pend — your claim payment.
If your coverage is terminated for not paying your premium, you won’t be eligible to enroll with us again until Open Enrollment or a Special Enrollment period. So make sure you pay your bills on time!
If you receive a subsidy payment
After you pay your first bill, you have a 90 day grace period. During the first month of your grace period, we will keep paying claims for covered services you receive. If you continue to receive services during the second and third months of your grace period, we may hold these claims. If your coverage is in the second or third month of a grace period, we will notify you and your healthcare providers about the possibility of denied claims.
If you don’t receive a subsidy payment
After you pay your first bill, you have a grace period of 60 days. During this time, we will continue to cover your care, but we may hold your claims. We will notify you, your providers and the HHS about this non-payment and the possibility of denied claims.
D) Retroactive Denials
"Retroactive denial of a previously paid claim" or "retroactive denial of payment" means any attempt by a carrier retroactively to collect payments already made to a provider with respect to a claim by reducing other payments currently owed to the provider, by withholding or setting off against future payments, or in any other manner reducing or affecting the future claim payments to the provider.
There are instances where claims may be denied retroactively if you received services from a provider or facility that is not in our network, terminate coverage with Ambetter, provide late notification of other coverage due to new coverage, or have a change in circumstance, such as divorce or marriage. This causes Ambetter from Buckeye Health Plan to request recoupment of payment from the Provider.
Retroactive denials can be avoided by paying your premiums on time and in full, and making sure you talk to your provider about whether the service performed is a covered benefit. You can also avoid retroactive denials by obtaining your medical services from an in-network provider.
If you believe the denial is in error, you are encouraged to contact Member Services by calling the number on your ID card.
E) Recoupment of Overpayments
Members may call in to request a refund of overpaid premium. Refunds are processed by two methods, electronically or by a manual check. The type of refund that is issued is dependent on the method of payment. Payments made with a debit/credit card via e-Cashiering, IVR, auto pay, member portal as well as credit card payments sent to our lockbox vendor will be refunded via e-Cashiering. Payments made via e-Check will also be refunded electronically. Payments made by check to our lockbox vendor and payments that were processed in-house at our Little Rock location must be refunded manually via live check.
F) Medical Necessity and Prior Authorization
Services are only covered if they are medically necessary. Medically necessary services are those that:
- Are the most appropriate level of service for the member considering potential benefits and harm.
- Are known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes.
Some covered service expenses require prior authorization. There are some network eligible service expenses for which you must obtain the prior authorization.
For services or supplies that require prior authorization, as shown on the Schedule of Benefits, you must obtain authorization from us before you:
- Receive a service or supply from a non-network provider;
- Are admitted into a network facility by a non-network provider; or
- Receive a service or supply from a network provider to which the member was referred by a non-network provider.
Prior Authorization requests must be received by phone/e-fax/Provider portal as follows:
- At least 5 days prior to an elective or scheduled admission as an inpatient in a hospital, extended care or rehabilitation facility, or hospice facility or as soon as reasonably possible.
- At least 30 days prior to the initial evaluation for organ transplant services or as soon as reasonably possible.
- At least 30 days prior to receiving clinical trial services or as soon as reasonably possible.
- Within 24 hours (or as soon as reasonably possible) of any inpatient admission, including emergent inpatient admissions.
- At least 5 days prior to the start (or as soon as reasonably possible) of home health care except those members needing home health care after hospital discharge.
After prior authorization has been requested, we will notify you and your provider if the request has been approved or denied as follows:
- For urgent care services, within 72 hours (3 calendar days) of receipt of the request.
- For urgent concurrent review within 24 hours (1 calendar day )of receipt of the request.
- For non-urgent pre-service requests within 10 calendar days, of receipt of the request.
- For post-service requests, within 30 calendar days of receipt of the request.
Failure to Obtain Prior Authorization
Failure to comply with the prior authorization requirements will result in benefits being denied.
In cases of emergency, benefits will not be reduced for failure to comply with prior authorization requirements. However, you must contact us as soon as reasonably possible after the emergency occurs.
Network providers cannot bill you for services for which they fail to obtain prior authorization as required.
G) Drug Exceptions Timeframes and Enrollee Responsibilities
Sometimes members need access to drugs that are not listed on the formulary. Members or provider can submit a drug exception request to us by contacting Member Services at 1-877-687-1189 (TTY/TDD 1-877-941-9236) or by sending a written request to the following address:
Ambetter from Buckeye Health Plan
Attn: Member Services
4349 Easton Way
Columbus, OH 43219
Standard exception request
A member, a member’s authorized representative or a member’s prescribing physician may request a standard review of a decision that a drug is not covered by the plan. Within 72 hours of the request being received, we will provide the member, the member’s authorized representative or the member’s prescribing physician with our coverage determination. Should the standard exception request be granted, we will provide coverage of the non-formulary drug for the duration of the prescription, including refills.
Expedited exception request
A member, a member’s authorized representative or a member’s prescribing physician may request an expedited review based on exigent circumstances. Exigent circumstances exist when a member is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug. Within 24 hours of the request being received, we will provide the member, the member’s authorized representative or the member’s prescribing physician with our coverage determination. Should the expedited exception request be granted, we will provide coverage of the non-formulary drug for the duration of the exigency.
External exception request review
If we deny a request for a standard exception or for an expedited exception, the member, the member’s authorized representative or the member’s prescribing physician may request that the original exception request and subsequent denial of such request be reviewed by an independent review organization (IRO).
H) Information on Explanations of Benefits
An Explanation of Benefits (EOB) is a statement that we send to members to explain what medical treatments and/ or services we paid for on behalf of a member. This shows the amount billed by the provider, the issuer’s payment, and the enrollee’s financial responsibility pursuant to the terms of the policy. We will send an EOB to a member after we receive and adjudicate a claim on your behalf from a provider. If you need assistance interpreting your Explanation of Benefits, please contact Member Services at 1-877-687-1189 (TTY/TDD 1-877-941-9236).
I) Coordination of Benefits
The Coordination of Benefits (COB) provision applies when you have healthcare coverage under more than one Plan. Plan is defined below.
The order of benefit determination rules govern the order which each Plan will pay a claim for benefits. The Plan that pays first is called the Primary Plan. The Primary Plan must pay benefits according to its policy terms without regard to the possibility that another Plan may cover some expenses. The Plan that pays after the Primary Plan is the Secondary Plan. The Secondary Plan may reduce the benefits it pays so that payments from all Plans do not exceed 100 percent of the total Allowable Expense.