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2023 Aviso sobre la transparencia
A) Out-Of-Network Liability and Balance Billing
The Ambetter network is the group of providers, including but not limited to physicians, hospitals, pharmacies, other facilities and health care professionals, we contract with to provide care for you. If a provider is in our network, services are covered by your health insurance plan. Network providers may not bill you for covered expenses beyond your applicable cost sharing amounts (e.g., copayment, coinsurance, and/or a deductible).
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 your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual maximum out-of-pocket limit.
When receiving care at an Ambetter network facility, it is possible that some hospital-based providers (for example, assistant surgeons, hospitalists, and intensivists) may not be under contract with Ambetter as network providers. We encourage you to inquire about the providers who will be treating you before you begin your treatment, so that you can understand their network participation status with Ambetter.
As a member of Ambetter, non-network providers should not bill you for covered services for any amount greater than your applicable network cost sharing responsibilities when:
- You receive a covered emergency service or air ambulance service from a non-network provider. This includes services you may get after you are in stable condition, unless the non-network provider obtains your written consent.
- You receive non-emergency ancillary services (emergency medicine, anesthesiology, pathology, radiology, and neonatology, as well as diagnostic services (including radiology and laboratory services)) from a non-network provider at a network hospital or network ambulatory surgical facility.
- You receive other non-emergency services from a non-network provider at a network hospital or network ambulatory surgical facility, unless the non-network provider obtains your written consent.
Please refer to your Schedule of Benefits for an overview of your costs for out-of-network services.
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
Be sure to show your member identification card at the time of service to ensure that the provider bills us for your care.
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 of the date the loss began or as soon as reasonably possible.
To request reimbursement for a covered service, you need to provide a copy of the detailed claim from the provider. You will also need to submit a copy of the Member Reimbursement Claim Form (PDF) posted at Ambetter.ARHealthWellness.com under “For Members – Forms and Materials. Send all the documentation to us at the following address:
Ambetter from Arkansas Health & Wellness
Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-5010
C) Grace Periods and Claims Pending
*NOTE: The following information applies to those who have a premium payment associated with their health coverage. If you do not have a premium associated with your coverage, please disregard this section.
If you have a premium payment, and 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 will not 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
Premium payments are due in advance, on a calendar month basis. Monthly payments are due before the first day of each month for coverage effective during such month. After the first premium is paid, a grace period of 3 months from the premium due date is given for the payment of premium. 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. 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.
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 Health & Human Services of the non-payment of premiums, 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.
If you don’t receive a subsidy payment
Premium payments are due in advance, on a calendar month basis. Monthly payments are due before the first day of each month for coverage effective during such month. After the first premium is paid, a 60 day grace period starting from the premium due date is given for the payment of premium. 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. Coverage will remain in force during the grace period; however, claims may pend for covered services rendered to the member during the grace period. We will notify the member of the non-payment of premiums, 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 from Arkansas Health and Wellness to request recoupment of payment from the Provider.
Retroactive denials can be avoided 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 Member Services 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 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 any medical services, items, supplies or treatment authorized by a provider to diagnose and treat a member’s illness or injury:
- Is consistent with the symptoms or diagnosis;
- Is provided according to generally accepted standards of medical practice;
- Is not custodial care;
- Is not solely for the convenience of the provider or the member;
- Is not experimental or investigational;
- Is provided in the most cost effective care facility or setting;
- Does not exceed the scope, duration, or intensity of that level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment; and
- When specifically applied to a hospital confinement, it means that the diagnosis and treatment of your medical symptoms or conditions cannot be safely provided as an outpatient.
Charges incurred for treatment not medically necessary are not eligible expenses.
Prior Authorization Required
Some medical and behavioral health covered expenses require prior authorization. In general, network providers must obtain authorization from us prior to providing a service or supply to a covered person. 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 the Schedule of Benefits, you must obtain authorization from us before you or your dependent:
- Receives a service or supply; or
- Are admitted into a facility.
Prior authorization (medical and behavioral health) 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, hospice facility, or residential treatment facility.
- At least 30 days prior to the initial evaluation for organ transplant services.
- At least 30 days prior to receiving clinical trial services.
- Within 24 hours of an inpatient admission, including emergent inpatient admissions.
- At least 5 days prior to the start of home healthcare except 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:
- For urgent concurrent review within 24 hours of receipt of the request.
- For urgent pre-service reviews, within 1 business day of receipt of all information.
- For non-urgent pre-service reviews, within two business days of receipt of all information,.
- 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 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. However, you must contact us as soon as reasonably possible after the emergency occurs.
G) Drug Exceptions Timeframes and Enrollee Responsibilities
Sometimes members need access to drugs that are not listed on the formulary. Members or provider can submit a drug exception request to us by contacting Member Services at 1-877-617-0390 (TTY/TDD 1-877-617-0392) or by sending a written request to the following address:
Ambetter from Arkansas Health & Wellness
Attn: Member Services
P.O. Box 25538
Little Rock, AR 72221
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 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 authorized representative 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.
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 member's life, health, or ability to regain maximum function or when an member is undergoing a current course of treatment using a non-formulary drug. The request can be made in writing or via telephone. 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 step therapy protocol exception request be granted, we will provide coverage of the non-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 its receipt of the request, if the original request was an expedited exception.
If we grant an external exception or step therapy protocol exception review of a standard 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 1-877-617-0390.
I) Coordination of Benefits
We coordinate benefits with other payers when a member is covered by two or more 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. We comply with Federal and state regulations for COB and follows COB guidelines published by the 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. Our 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”, as used in this section, is the necessary, reasonable, and customary item of expense for healthcare, when the item is covered at least in part under any of the plans involved, except where a statute requires a different definition. “Plan”, as used in this section, is a form of coverage written on an expense-incurred basis with which coordination is allowed. 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. When Medicare is the primary plan, Medicare’s allowable expense is the allowable expense when we are paying claims as the secondary plan.