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2019 Transparency Notice

A) Out-of-network liability and balance billing

Services from Non-Network Providers

Except for emergency medical services, unless covered services are not available from network providers within a reasonable proximity such services will not be covered. If required medically necessary services are not available from network providers you or the network provider must request prior authorization from us before you may receive services from non-network providers. Otherwise you will be responsible for all charges incurred.

Coverage received from non-network providers will be covered in the following limited situations:

  1. When a covered service is received from a non-network provider, as a result of an emergency;
  2. When a covered service is received from a non-network provider, not as a result of an emergency, but has been approved or authorized by us; and
  3. When a covered service is received from a non-network provider because the service or supply is not available from a network provider in the member’s service area, but is not an emergency.

In these limited situations, you will be entitled to the covered services as described under this policy and you will only be responsible for the amount that you would have been charged if you received the covered services from a network provider.

Hospital Based Providers

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. 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 health care services may be or have been provided to you at a health care 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 health care practitioners who are not members of that network.

In the event our network is unable to reasonably meet the member’s needs, the member may seek out-of-network prior authorized covered services, and the member will be entitled to full reimbursement. Additionally, if a member goes to an in-network facility and the hospital based providers are not participating providers, this is not the member’s fault. The member cannot be balance billed because they did not choose these providers. If you are balance billed for the covered services please contact Member 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.

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 of North Carolina Inc.
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 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

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.

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 eCashiering. 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:

  • Provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease; and except as allowed for clinical trials under G.S. 58-3-255, not for experimental, investigational, or cosmetic purposes;
  • Necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms;
  • Within generally accepted standards of medical care in the community; and
  • Not solely for the convenience of the member, the member’s family, or the provider.

For medically necessary services, nothing in this definition precludes us from comparing the cost-effectiveness of alternative services or supplies when determining which of the services or supplies will be covered.

Charges incurred for treatment not medically necessary are not eligible service expenses.

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 or your dependent member:

  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 or your dependent member were referred to 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, skilled nursing 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 health care, except those 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:

  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 review within 24 hours of receipt of the request.
  3. For urgent prospective, within 72 hours from date of receipt of request.
  4. For non-urgent prospective requests within 3 business days of receipt of all necessary clinical information.
  5. For post-service requests, with in 30 calendar days of receipt of the request.
  6. Except in cases of fraud or material misrepresentation, we will be bound by our initial approval of medically necessary services or supplies.

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

Prescription Drug Exception Process

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 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 1-833-863-1310 Relay 711.

I) Coordination of Benefits

Due to North Carolina 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.

This provision describes how we coordinate and pay benefits when a member is also enrolled in Medicare and duplication of Coverage occurs. If a member is not enrolled in Medicare or receiving benefits, there is no duplication of Coverage and we do not have to coordinate with Medicare.

The benefits under this Policy are not intended to duplicate any benefits to which members are entitled under Medicare.

Medicare primary/secondary payer guidelines and regulations will determine primary/secondary payer status, and will be adjudicated by us as set forth in this section.  In cases where Medicare or another government program has primary responsibility, Medicare benefits will be taken into account for any member who is enrolled for Medicare. This will be done before the benefits under this health plan are calculated.  When Medicare, Part A and Part B or Part C is primary, Medicare's allowable amount is the highest allowable expense.

When a person is eligible for Medicare benefits and Medicare is deemed to be the primary payer under Medicare secondary payer guidelines and regulations, we will reduce our payment by the Medicare primary payment and pay as secondary up to the Medicare allowable amount. However, under no circumstances will this plan pay more than it would have paid if it had been the primary plan. 

Charges for services used to satisfy a member’s Medicare Part B deductible will be applied in the order received by us. Two or more expenses for services received at the same time will be applied starting with the largest first.

This provision will apply to the maximum extent permitted by federal or state law. We will not reduce the benefits due any member because of a member's eligibility for Medicare where federal law requires that we determine its benefits for that member without regard to the benefits available under Medicare.

Members may no longer be eligible to receive a premium subsidy for the Health Insurance Marketplace plan once Medicare coverage becomes effective.