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2021 Transparency Notice
A) Out-of-network liability and balance billing
Except for emergency services, you should always try to see providers that are in our network. If you need to see a nonparticipating provider, you will need to arrange care with your PCP and get approval from us. We have to approve an appointment with any nonparticipating provider before you get non-emergency or non-urgent treatment.
If we approve your appointment with a nonparticipating 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.
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.
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 from your 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.WesternSkyCommunityCare.com under “Member Resources.” Send all the documentation to us at the following address:
Ambetter from Western Sky Community Care
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. Benefits will be processed immediately for clean claims.
We will notify you, in writing, that we have either accepted or rejected your claim for processing within 20 days. If we are unable to come to a decision about your claim within 20 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 fifth business day after the notice has been made.
C) Grace Periods and Claims Pending
Each premium is to be paid on or before its due date. The initial premium must be paid prior to the coverage effective date, although an extension may be provided during the annual Open Enrollment period.
If you do not pay premium on time, you will receive a grace period. A grace period is a time period when your plan will not terminate even though you did not pay your premium. Claims submitted for you during that grace period will be pended. A pended claim is a claim missing information necessary to make a coverage decision. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full.
When a member is receiving a premium subsidy:
After the first premium is paid, a grace period of 3 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 advance premium tax credits are received.
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. We will notify HHS of the non-payment of premiums, the member, as well as providers of the possibility of denied claims when the member is in the second and third month of the grace period. We will continue to collect advance premium tax credits on behalf of the member from the Department of the Treasury, and will return the advance premium tax credits on behalf of the member for the second and third month of the grace period if the member exhausts their grace period as described above. A member is not eligible to re-enroll once terminated, unless a member has a special enrollment circumstance, such as a marriage or birth in the family or during annual open enrollment periods.
When a member is not receiving a premium subsidy:
Premium payments are due in advance, on a calendar month basis. Monthly payments are due on or before the first day of each month for coverage effective during such month. There is a ten (10) day grace period. 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 policy will stay in force; however, claims may pend for covered services rendered to the member during the grace period. We will notify 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 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 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 our 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, 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
Prior Authorization Required
Some covered service expenses require prior authorization. In general, participating 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 Summary of Benefits and Coverage (SBC), you must obtain authorization from us before you or your dependent member:
- Receive a service or supply from a nonparticipating provider; or
- Receive a service or supply from a participating provider to which you or your dependent member were referred to by a nonparticipating provider.
Prior Authorization requests must be received by phone/efax/ Provider portal as follows:
- At least 7 days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, or hospice facility.
- At least 7 days prior to the initial evaluation for organ transplant services.
- At least 7 days prior to receiving clinical trial services.
- Within 24 hours of an admission for inpatient mental health or substance abuse treatment.
- At least 7 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 reviews within 24 hours of receipt of the request.
- For urgent pre-service reviews, within 72 hours from date of receipt of request.
- For non-urgent pre-service reviews within 5 days, but no longer than 15 days, of receipt of the request.
- For post-service or retrospective reviews, within 30 calendar days of receipt of the request.
Failure to Obtain Prior Authorization
Failure to comply with the prior authorization requirements may result in denial of payment.
Participating 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 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.
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 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.
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 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 1-833-945-2029 or TDD/TTY: 711.
I) Coordination of Benefits
Ambetter 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 policies. Ambetter 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 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.