2018 Coverage Information - Quick Tips
Below is information about your Ambetter coverage including claims information, prior authorization and more. For a full summary of your benefits and coverage, always refer to your Evidence of Coverage or Schedule of Benefits.
A) Out-of-network liability and balance billing
Except for emergency services, you should always try to see providers that are in our network. But if you need to see an out-of-network provider, you will need to arrange care with your primary care provider (PCP) and get approval from us. We have to approve an appointment with any out-of-network provider before you get non-emergency or non-urgent treatment.
If we approve your appointment with an out-of-network provider, your copayment and deductible will not change. We will let you know when the authorization is approved. If you don’t receive our prior authorization, we cannot provide any benefit, coverage or reimbursement. You will be financially responsible for any and all payments.
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 from the provider. You also need to submit an explanation of why you paid for the covered services. Send this 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 15 days or less.
We will notify you, in writing, that we have either accepted or rejected your claim for processing within 15 days as well. If we are unable to come to a decision about your claim within 15 days, we will let you know and explain why we need additional time.
We will accept or reject your claim no later than 45 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 the fifth business day 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 (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, late notification of other coverage due to new coverage, a change in circumstance, such as divorce or marriage. This causes AMBETTER to request recoupment of payment from the Provider.
If you believe the termination is in error, you are encouraged to contact member’s services department by calling the number on your ID card.
"Not Available in EOCs/ Handbooks."
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 eCashiering, IVR, auto pay, member portal as well as credit card payments sent to our lockbox vendor will be refunded via eCashering. Payments made via eCheck 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
Prior Authorization Required
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:
- Receives a service or supply from a non-network provider;
- Is admitted into a network facility by a non-network provider; or
- 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:
- At least 5 days prior to an elective admission as an inpatient in a Hospital, extended care or Rehabilitation facility, or Hospice facility.
- At least 30 days prior to the initial evaluation for organ transplant services.
- At least 30 days prior to receiving clinical trial services.
- At least 5 days prior to a scheduled inpatient behavioral health or Substance Abuse treatment admission.
- At least 5 days prior to the start of Home Health Care.
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:
- For immediate request situations, within 1 business day, when the lack of treatment may result in an emergency room visit or emergency admission.
- For urgent concurrent review within 24 hours of receipt of the request.
- For urgent pre-service, within 72 hours from date of receipt of request.
- For non-urgent pre-service requests within 5 days but no longer than 15 days of receipt of the request.
- For post-service requests, with in 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 reduced. Please see the contract Schedule of Benefits for specific details.
Network providers cannot bill you for services for which they fail to obtain prior authorization as required.
Benefits will not be reduced for failure to comply with prior authorization requirements prior to an emergency. However, you must contact us as soon as reasonably possible after the emergency occurs.
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. We will make our determination on the external exception request and notify the member, the member’s designee 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 its 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 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 1-877-687-1169.
I) Coordination of Benefits
Ambetter from Sunshine Health coordinates 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.