A) Out-of-network liability and balance billing

Except for emergency services, you should always try to see providers that are in our network. But if you need to see an 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 out of network provider before you get non-emergency or non-urgent treatment.

If we approve your appointment with an out-of-network 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.

If you seek services from a non-network provider you may be responsible for the difference between the provider’s charge for a service and the eligible expense, this is called balance billing. Network providers may not balance bill you for covered service expenses. A health care provider performing anesthesiology, radiology, emergency medicine, or pathology services shall not balance bill you for fees or amounts other than copayments, deductibles, or coinsurance, if the service is performed in a hospital or ambulatory surgical center that is in Ambetter’s network.

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

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. Written notice of claim must be given to the insurer within 20 days after the occurrence or commencement of any loss covered by the contract, or as soon thereafter as is 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 NH Healthy Families
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 15 days for clean claims filed electronically, or 30 days for clean claims filed on paper.

We will notify you, in writing, that we have either accepted, pended or rejected your claim for processing within 15 days. 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 45 days after all information regarding the claim has been received. 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 30 days after receipt of a clean non-electronic claim or 15 calendar days upon receipt of a clean electronic claim.

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

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 advanced premium tax credits on behalf of the member from the Department of the Treasury, and will return the advanced 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.

If you don’t receive a subsidy payment

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 60 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 contract 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 health carrier to retroactively collect payments already made to a health care provider with respect to a claim by requiring repayment of such payments, 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 certain instances where claims may be denied retroactively. The health carrier has to provide the reason for the retroactive denial in writing to the health care provider. In addition, retroactive denial of a previously paid claim may be permitted beyond 12 months from the date of payment only for the following reasons:

• The claim was submitted fraudulently;
• The claim payment was incorrect because the provider or the insured was already paid for the health care services identified in the claim;
• The health care services identified in the claim were not delivered by the physician/provider;
• The claim payment was for services covered by Title XVIII, Title XIX or Title XXI of the Social Security Act;
• The claim payment is the subject of an adjustment with a different insurer, administrator or payor and such adjustment is not affected by a contractual relationship, association or affiliation involving claims payment, processing or pricing; or
• The claim payment is the subject of legal action.

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 the 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 eCashiering, Interactive voice response (IVR) system, 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) Prior Authorization

Prior Authorization means a decision to approve specialty or other medically necessity care for a member by the member’s PCP or provider group prior to the member receiving the services. Services are only covered if they are medically necessary. Medically necessary services are those that prevent, stabilize, diagnose or treat a member's illness, or injury which:

1. Is consistent with the symptoms or diagnosis;
2. Is provided according to generally accepted medical practice standards;
3. Is not solely for the convenience of the physician or the member;
4. Is not experimental or investigational; and
5. 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.

Charges incurred for treatment not medically necessary are not eligible 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 expenses for which you must obtain the prior authorization.

For services or supplies that require prior authorization you must obtain authorization from us before you or your dependent member:

1. Receives a service or supply from a non-network provider;
2. Are 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 member were referred by a non-network provider.

Prior Authorization must be obtained for the following services, except for Urgent Care or Emergency Services. This list is not exhaustive, to confirm if a specific service requires Prior Authorization, please contact Member Services.

1. Non-Emergency Health Care Services provided by Non-Network Providers;
2. Reconstructive procedures;
3. Diagnostic Tests such as specialized labs, procedures and high technology imaging;
4. Injectable drugs and medications;
5. Inpatient Health Care Services;
6. Specific surgical procedures;
7. Nutritional supplements;
8. Pain management services; and
9. Transplant services

Prior Authorization requests must be received by telephone, efax, or 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 48 hours of any inpatient admissions, including emergent inpatient admissions, or as reasonably practicable.
5. At least 5 days prior to the start of home healthcare except for 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 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 pre-service reviews, within 72 hours from date of receipt of request.
4. For non-urgent pre-service reviews within 5 days but no longer than 15 days of receipt of the request.
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.

How to Obtain Prior Authorization

To obtain prior authorization or to confirm that a network provider has obtained prior authorization, contact us by telephone at the telephone number listed on your health insurance identification card before the service or supply is provided to the member

Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements will result in benefits being reduced. A reduction in benefits will be not more than 50% of the benefit that would have otherwise been payable or $1,000.00, whichever is less. Services rendered that fail to comply with prior authorization are subject to medical necessity review.

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 benefits shall maintain an expeditious exception process, not to exceed 48 hours, by which members may obtain coverage for a medically necessary non-formulary prescription drug. The exception process shall begin when the prescribing provider has submitted a request with a clinical rationale for the exception to Ambetter from NH Healthy Families. A prescription that requires an exception for coverage shall be considered approved if the exception process exceeds 48 hours.

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 expedited exception request be granted, we will provide coverage of the non-formulary drug for the duration of the exigency.

Exception for drugs available on the formulary during previous 12 months

For any non-formulary drug that was available as a formulary product during the previous 12 months, you have the right to request a formulary exception. To request a formulary exception please call our vendor Envolve Pharmacy Solutions at 1-866-399-0928. You or your provider can also request a formulary exception by faxing the request to 1-866-399-0929.

Emergency prescription supply

For non-formulary drugs removed from the formulary during the previous 90 days, you have the right to request an emergency 72-hour prescription supply. To request a 72-hour emergency prescription supply please call the customer service number on the back of your ID card.

Notification of formulary changes

We will notify you of any formulary changes at least 45 days in advance of such changes. We will provide you with instructions on how to request a formulary exception for non-formulary drugs and an emergency supply.

Non-Formulary Prescription Drugs

Under the Affordable Care Act, you have the right to request coverage of prescription drugs that are not listed on the plan formulary (otherwise known as “non-formulary drugs”). To exercise this right, please get in touch with your medical practitioner. Your medical practitioner can utilize the usual prior authorization request process.

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 1-844-265-1278.

I) Coordination of Benefits

Insurance with Other Insurers

If there is other valid coverage, not with us, providing benefits for the same loss on a provision of service basis or an expense incurred basis, payment shall not be prorated or reduced. If such is the case, the member shall be entitled to payment from both insurers. Provided, however, that the provisions of this subparagraph shall not prohibit the issuance of a benefits deductible. Benefits deductible, as used herein, means the value of any benefits provided on an expense incurred basis which are provided with respect to covered medical expenses by any other hospital, surgical or medical insurance contract or hospital or medical service subscriber contract or medical practice or other prepayment plan, or any other plan or program whether on an insured or uninsured basis. Provided, however, that the term benefits deductible shall not mean the value of benefits provided with respect to medical or liability insurance offered under either a general liability insurance contract or an auto insurance contract.