2021 Aviso sobre la transparencia

A) Out-of-network liability and balance billing

Except for emergency services, you should always access healthcare services through preferred providers that are in our network. If you need to see a non-preferred/out-of-network provider, you will need to arrange care with your PCP and get approval from us. We have to approve an appointment with any non-preferred/non-participating provider before you get non-emergency or non-urgent treatment.

If we approve your appointment with a non-preferred/non-participating 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 a network hospital or other facility, it is possible that some hospital-based providers (for example, anesthesiologists, emergency room providers, radiologists, pathologists) may not be under contract with Ambetter as network providers. These providers cannot bill you for the difference between Ambetter’s eligible service expense and the provider’s billed charge - this is known as “balance billing.”, unless a notice and disclosure statement was signed ten days prior to receiving care. We encourage you to inquire about the providers who will be treating you before you begin your treatment, so you can understand their network status with Ambetter.

Ambetter Plan Description (PDF)

Ambetter Plan Description - Off Exchange (PDF)

Annual HBP DIR (PDF)

Annual OON HBP (PDF)

B) Enrollee Claim Submission

Providers will typically submit claims on your behalf, but sometimes you may have to pay for a covered service and file a claim for reimbursement. This may happen if your provider is not contracted with us or 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, less any deductible, copayment or cost sharing that is your financial responsibility. We must receive notice of claim within 30 days of the date the loss began or as soon as reasonably possible. We must receive a request for reimbursement through receipt of a claim within 90 days of the date of service.

To request reimbursement for a covered service, you need a copy of the detailed claim or bill from the provider. You also need to submit an explanation of why you paid for the covered services. You also need to submit the Member Reimbursement Claim Form along with any required documents listed on the form. Send this to us at the following address:

Ambetter from Superior HealthPlan
Attn: Claims Department – Member Reimbursement
P.O. Box 5010
Farmington, MO 63640-3800

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 after receiving all items necessary to resolve your claim. If we accept your claim, we will make payment within 5 business days after notifying you of the payment of your claim. If we reject your claim, we will give you the reason your claim is rejected. 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, and will make our decision to accept or reject your claim no later than the 45th day after our notice about the delay for paper claims or no later than the 30th day after our notice about the delay for electronic claims.

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 —payment of your claims. If your premium is not brought current by the end of your grace period, you may be held responsible for services provided to you during that time.

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 premiums on time!

If you receive a subsidy payment

After you pay your first bill, you have a 90 day grace period. During the first and second months of your grace period, we will keep paying claims for covered services you receive. If you continue to receive services during the third month of your grace period, we may hold these claims. If your coverage is in the 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 30 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 retroactive attempt by a carrier 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, or 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 termination 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) 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.

Some covered services require prior authorization. However, there are some covered services 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 enrollee:

  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 enrollee were referred by a non-network provider.

Prior Authorization requests must be received by phone/efax/Provider portal as follows:

  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 scheduled start of home health services, except those enrollees needing home health services 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 services that require prior authorization, within 3 business days of receipt.
  2. For concurrent review, within 24 hours of receipt of the request.
  3. For post-stabilization treatment or life-threatening condition, within the timeframe appropriate to the circumstances and condition of the enrollee, but not to exceed one hour of receipt of the request.
  4. For post-service requests, 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 or not covered.  

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

Prescription Drug Exception Process

Standard exception request

An enrollee, an enrollee’s designee or an enrollee’s prescribing provider 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 by telephone. Within 72 hours of the request being received, we will provide the enrollee, the enrollee’s designee or the enrollee’s prescribing provider with our coverage determination. If we do not deny a standard exception request within 72 hours, the request is considered granted. Should the standard exception request be granted, we will provide coverage of the non-formulary drug for the duration of the prescription, including refills.

Expedited exception request

An enrollee, an enrollee’s designee or an enrollee’s prescribing provider may request an expedited review based on exigent circumstances. Exigent circumstances exist when an enrollee 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 enrollee, the enrollee’s designee or the enrollee’s prescribing provider with our coverage determination. If we do not deny an expedited exception request within 24 hours, the request is considered granted. Should the expedited 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 enrollee or the enrollee’s designee may request that the denial of such request be reviewed by an external review organization. The external review organization will make the determination on the denied exception request and notify the enrollee or the enrollee’s designee of the 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 or the external review organization grants an exception for a standard or 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 enrollees to explain what medical treatments and/ or services we paid for on behalf of an enrollee. 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 an enrollee after we receive and adjudicate a claim on your behalf from a provider. If you need assistance interpreting your EOB, please contact Member Services at 1-877-687-1196.

I) Coordination of Benefits

The Coordination of Benefits (COB) provision applies when a person has healthcare coverage under more than one plan. Plan is defined below.

The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits in accord with its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. The secondary plan may reduce the benefits it pays so that payments from all plans equal 100 percent of the total allowable expense.