2024 Transparency Notice (HMO) for Ambetter from Sunshine Health

A) Non-network liability and balance billing

If you receive services from a non-network 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 we agreed to pay and the full billed amount for a service. This is known as balance billing. This amount is likely more than network costs for the same service and might not count toward your annual maximum out-of-pocket amount limit. However, you will not be balance billed when balance billing protections apply to covered services.

As a member, non-network providers should not bill you for covered services for any amount greater than your applicable in-network cost responsibilities when balance billing protections apply to covered services that are:

1. Emergency services provided to a member, as well as services provided after the member is stabilized unless the member gave notice and consent to be balance billed for the post-stabilization services;
2. Non-emergency health care services provided to a member at a network hospital or at a network ambulatory surgical center unless if member gave notice and consent pursuant to the federal No Surprises Act to be balance billed by the non-network provider; or
3. Air ambulance services provided to a member by a non-network provider.

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 may happen if your provider is not contracted with us.

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 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 had no legal capacity to submit such proof during that year.

To request reimbursement for a covered service, you need a copy of the detailed claim from your provider.  You will also need to submit a copy of the member reimbursement claim form (PDF) posted at ambetter.sunshinehealth.com under “Forms and Materials”. Send all the documentation to us at the following address:

Ambetter from Sunshine Health
Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-5010

After getting your claim, we will let you know we have received it, begin an investigation and request all items necessary to resolve the claim. We will do this in 45 days or less.

We will notify you, in writing, that we have either accepted or rejected your claim for processing within 15 business days after our receipt of all requested information. If we are unable to come to a decision about your claim within 15 business days, we will let you know and explain why we need additional time.

We will accept or reject your claim no later than 120 days after we receive it. If we reject your claim, the notice will state the reason why. If we agree to pay all or part of your claim, we will pay it no later than 14 business days after the notice has been made.

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.

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. We will continue to pay all appropriate claims for covered services rendered to the member during the first month of the grace period and may pend claims for covered services rendered to the member in the second and third month of the grace period.

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. 

If you receive a subsidy payment

After the first premium is paid, a grace period of three months from the premium due date is given for the payment of premium. Coverage will remain in force during the grace period. If full payment of premium is not received within the grace period, coverage will be terminated as of the last day of the first month during the grace period, if advanced premium tax credits are received.

If you don’t receive a subsidy payment

Premium payments are due in advance, on a calendar month basis. Monthly payments are due on or before the first day of each month  or coverage effective during such month. There is a 30-day grace period. If your payment is not received by day 30, your account will move into suspended status. Please ensure your payment is posted at least 10 days prior to due date to ensure timely processing and payment posting. This provision means that if any required premium is not paid on or before the date it is due, it may be paid during the grace period. During the grace period, the contract will stay in force. We will notify Health and Human Services (HHS), as necessary, of the non-payment of premiums, the member, as well as providers of the possibility of denied claims when the member is in the grace period.

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: receive 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 to request recoupment of payment from the provider.

You can avoid retroactive denials 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 the Member Services

Department 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, interactive voice response (IVR) system, auto pay, or 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 paper check.

F) Medical Necessity and Prior Authorization

Services are only covered if they are medically necessary.  Medically necessary services are those that:

1. Are the most appropriate level of service for the member considering potential benefits and harm
2. Are known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes

Prior Authorization Required

Some medical and behavioral health covered service expenses require prior authorization. Network providers must obtain authorization from us prior to providing a service or supply to a member. However, there are some network eligible expenses for which you must obtain the prior authorization.

For services or supplies that require prior authorization, as shown on your Schedule of Benefits, you must obtain authorization from us before you or your dependent 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 you or your dependent member were referred by a non-network provider.

Pursuant to the federal No Surprises Act, emergency services received from a non-network provider are covered services without prior authorization.

Prior Authorization requests must be received by phone/e-fax/Provider portal as follows:

1. At least five calendar days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, hospice facility, or residential treatment facility.
2. At least 30 calendar days prior to the initial evaluation for organ transplant services.
3. At least 30 calendar days prior to receiving clinical trial services.
4. Within one business day of any inpatient admission, including emergent inpatient admissions.
5. At least five calendar 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 and all required or applicable documentation has been submitted, we will notify you and your provider if the request has been approved as follows:

1. For urgent concurrent reviews, within one calendar of receipt of the request.
2. For urgent pre-service reviews, within three calendar from date of receipt of request.
3. For non-urgent pre-service reviews, within 15 calendar days of receipt of the request.
4. For post-service or retrospective reviews, within 30 calendar days of receipt of the request

You do not need to obtain prior authorization from us or from any other person (including your PCP) in order to obtain access to obstetrical or gynecological care from a medical practitioner in our network who specializes in obstetrics or gynecology. The medical practitioner, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan or procedures for making referrals. For a list of participating medical practitioners who specialize in obstetrics or gynecology, contact Member Services.

Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements will result in benefits being reduced. 

Network providers cannot bill you for services for which they fail to obtain prior authorization as required.

In cases of emergency, benefits will not be reduced for failure to comply with prior authorization requirements prior to receiving emergency services. However, you must contact us as soon as reasonably possible after you receive the emergency services.

G) Drug Exceptions Timeframes and Enrollee Responsibilities

Prescription drug exception process is applicable when:

1. The drug is not covered based on our formulary.
2. We are discontinuing coverage of the drug.
3. The prescription drug alternatives required to be used in accordance with a step therapy requirement:
   • has been ineffective in the treatment; or
   • has caused an adverse reaction or harm to a member.

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. 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 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 requested drug for the duration of the prescription, including refills not to exceed the standard duration of treatment as established by clinical guidelines and criteria. Please see the Grievance and Complaints Procedures provision for appeals information.

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 requested 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. We will make our determination on the external exception request and notify the member, the member’s authorized representative or the member’s prescribing physician of our coverage determination no later than 72 hours following receipt of the request, if the original request was a standard exception, and no later than 24 hours following receipt of the request, if the original request was an expedited exception.

If we grant an external exception review of a standard exception request, we will provide coverage of the non-formulary drug for the duration of the prescription. If we grant an external exception review of an expedited exception request, we will provide coverage of the non-formulary drug for the duration of the exigency.

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 you 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.

I) Coordination of Benefits

We coordinate benefits with other payers when a member is covered by two or more group health benefit plans. Coordination of Benefits (COB) is the industry standard practice used to share the cost of care between two or more carriers when a member is covered by more than one health benefit plan.

It is a contractual provision of a majority of health benefit contracts. Ambetter from Sunshine Health complies with Federal and state regulations for COB and follows COB guidelines published by National Association of Insurance Commissioners (NAIC).

Under COB, the benefits of one plan are determined to be primary and are first applied to the cost of care. After considering what has been covered by the primary plan, the secondary plan may cover the cost of care up to the fully allowed expense according to the plan’s payment guidelines. Ambetter from Sunshine Health Claims COB and Recovery Unit procedures are designed to avoid payment in excess of allowable expense while also making sure claims are processed both accurately and timely.