A) Out-of-network liability and balance billing

Except for emergency services, when receiving care at one of our in-network hospitals, it is possible that some hospital-based providers (for example, anesthesiologists, radiologists, pathologists) may not be under contract with us as in-network providers. These providers may bill you for the difference between our allowed amount and the provider’s billed charge — this is known as “balance billing.” We encourage you to inquire about the providers who will be treating you before you begin your treatment, so you can understand their participation status with us.

B) Enrollee Claim Submission

Providers will typically submit claims on your behalf, but sometimes you may be financially responsible for covered services. This usually happens if:

• Your provider is not contracted with us
• You have an out-of-area emergency

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.

To request reimbursement for a covered service, you need a copy of the detailed claim or bill from the provider in English or English Translation must be provided. You also need to submit the Member Reimbursement Claim Form along with required documents listed on the form that is posted on the health plan website under “Member Materials and Forms”.  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 30^th 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 three-month 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. We will also notify the U.S. Department of Health and Human Services (HHS) that you haven’t paid your premium.

If you don’t receive a subsidy payment

After you pay your first bill, you have a grace period of one month. 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.

If you believe the denial is in error, you are encouraged to contact member’s services department by calling the number on your ID card.

E) 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 the member:

1. Receives a service or supply from a non-network provider;
2. Is admitted into a network facility by a non-network provider; or
3. Receives 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/efax/Provider portal as follows:

1. 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.
2. At least 30 days prior to the initial evaluation for organ transplant services or as soon as reasonably possible.
3. At least 30 days prior to receiving clinical trial services or as soon as reasonably possible.
4. Within 24 hours of any inpatient admission, including emergent inpatient admissions.
5. At least 5 days prior to the start 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:

1. For urgent care services, within 48 hours of receipt of the request.
2. For urgent concurrent review within 24 hours of receipt of the request.
3. For non-urgent pre-service requests within 10 days, of receipt of the request.
4. 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

1.  Standard exception request

A member, a member’s designee or a member’s prescribing physician may request a standard review of a decision that a drug is not covered by the plan. The request can be made in writing or via telephone. Within 72 hours of the request being received, we will provide the member, the member’s designee 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.

2. Expedited exception request

A member, a member’s designee 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 designee 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.

3. External exception request review

If we deny a request for a standard exception or for an expedited exception, the member, the member’s designee 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.