A) Out-of-network liability and balance billing

Except for emergency medical services, we do not normally cover services received from non-network providers. If a situation arises where a covered service cannot be obtained from a network provider located within a reasonable distance, we may provide a prior authorization for you to obtain the service from a non-network provider at no greater cost to you than if you went to a network provider. If covered services are not available from a network provider, you or your primary care provider must request prior authorization from us before you receive services from a non-network provider. Otherwise, you will be responsible for all charges incurred. 

When receiving care at an Ambetter participating hospital it is possible that some hospital-based providers (for example, anesthesiologists, radiologists, pathologists) may not be under contract with Ambetter as participating providers. These providers may bill you for the difference between Ambetter’s allowed amount and the providers 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 Ambetter.

Although healthcare services may be or have been provided to you at a healthcare facility that is a member of the provider network used by Ambetter, other professional services may be or have been provided at or through the facility by physicians and other medical practitioners who are not members of that network. You may be responsible for payment of all or part of the fees for those professional services that are not paid or covered by Ambetter.

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

We must receive notice of claim within 20 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 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. Send this to us at the following address:

Ambetter from Home State Health
Attn: Claims Department – Member Reimbursement
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 30 days or less.

We will notify you, in writing, that we have either accepted or rejected your claim for processing within 30 business days as well. If we are unable to come to a decision about your claim within 30 business days, we will let you know and explain why we need additional time.

We will accept or reject your claim no later than 30 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 29 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 (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 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: 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.

If you believe the denial is in error, you are encouraged to contact Member Services Department by calling the number on your ID card.

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.

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. In general, network providers must obtain authorization from us prior to providing a service or supply to a member. However, 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:

1. Receive a service or supply from a non-network provider;
2. Are admitted into a network facility by a non-network provider; or
3. Receive a service or supply from a network provider to which you were referred by a non-network provider.

The following services or supplies require prior authorization:

• Non-Emergency Health Care Services provided by Non-Network Providers;
• Reconstructive procedures;
• Diagnostic tests such as specialized labs, procedures and high technology imaging;
• Injectable drugs and medications;
• Inpatient health care services;
• Specific surgical procedures;
• Nutritional supplements;
• Pain management services; and
• Transplant services.

Prior Authorization requests can be submitted by telephone, eFax, or provider web portal. Although not required, submitting requests within the recommended timeframes below will allow for timely review of prior authorization requests:

1. At least 5 days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, or hospice facility.
2. At least 30 days prior to the initial evaluation for organ transplant services.
3. At least 30 days prior to receiving clinical trial services.
4. Within 24 hours of any inpatient admission, including emergent inpatient admissions.
5. At least 5 days prior to the start of home healthcare except those members needing home health care after hospital discharge.

After prior authorization has been requested and all necessary information, including the results of any face-to-face clinical evaluation or second opinion that may be required has been submitted, we will notify you and your provider if the request has been approved as follows: 

1. For immediate request situations, within 1 business day, when the lack of treatment may result in an emergency room visit or emergency admission.
2. For urgent concurrent reviews, within 24 hours of receipt of the request.
3. For urgent pre-service reviews, within 72 hours from date of receipt of request.
4. For non-urgent pre-service reviews, determination within 36 hours, which shall include one working day, or up to 14 days, if necessary, to receive all pertinent clinical information
5. For post-service or retrospective reviews, within 30 calendar days of receipt of the request.

Except for medical emergencies, prior authorization must be obtained before services are rendered or expenses are incurred.

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. 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.

G) Drug Exceptions Timeframes and Enrollee Responsibilities

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 or a protocol exception for step therapy. 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 or step therapy protocol exception request be granted, we will provide coverage of the non-formulary drug for the duration of the prescription, including refills, or of the drug that is the subject of the protocol exception.

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 standard exception or step therapy protocol exception request be granted, we will provide coverage of the non-formulary drug or the drug that is the subject of the protocol exception 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 designee or the member’s prescribing physician may request that the original exception request and subsequent denial of such request be reviewed by an external 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 or step therapy protocol exception request, we will provide coverage of the non-formulary drug or the drug that is the subject of the protocol exception 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 or the drug that is the subject of the protocol exception 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 1-855-650-3789 (TDD/TTY Relay 711).

I) Coordination of Benefits

Appendix B

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.

Due to Missouri Law, Ambetter does not coordinate benefits with other commercial plans. However, coordination with Medicare may be required to avoid duplication of benefits when Ambetter members who become eligible for and enroll in Medicare. In that instance, Medicare is considered to be the primary payer, with Ambetter paying secondary up to Medicare’s allowable amount, subject to our benefits. It is important to note that dually enrolled members may not qualify for any government premium subsidies they once qualified for prior to Medicare becoming effective. If a member has any questions or concerns regarding being dually enrolled with Medicare and Ambetter, please contact the Health Insurance Marketplace for more information on the best course of action.

Ambetter complies with federal and state laws and 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 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.

“Allowable expense” is the necessary, reasonable, and customary item of expense for health care, when the item is covered at least in part under any of the plans involved, except where a statute requires a different definition. When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered as both an allowable expense and a benefit paid.