Claims Payment Policies and Practices

Qualified Health and Dental Plan Issuers have provided information to help you understand what is needed for a claim to be paid, or why a claim was denied.

Click the links below to see the information the issuers have provided.

• Anthem Blue Cross

Out-of-network liability, balance billing, and enrollee claim submission

A claim is a request to apply benefits for your health care coverage. Claims are submitted to Anthem Blue Cross for health care services, supplies, drugs, and/or equipment that are provided to you. In most cases, In Network Providers will send claims to Anthem Blue Cross for you. But if you received care from an Out of Network Provider that does not send the claim to Anthem Blue Cross on your behalf, it may be your responsibility to do so. If you are sending a claim to Anthem Blue Cross, we must receive the Claim Form within fifteen (15) months from the date of service in order for Anthem Blue Cross to determine benefits. Anthem Blue Cross will determine if benefits are due in a timely manner. This is typically within thirty (30) days of receiving the claim. You may obtain a copy of the Claim Form by contacting Anthem Blue Cross Customer Service at 855-634-3381 or at the links below.

Links to Claim Form	Medical	Pharmacy	Dental
The physical address to mail your Claim Form to is	Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007	IngenioRx Claims Department P.O. Box 52065 Phoenix, AZ 85072-2065	Anthem Blue Cross P.O. Box 1115 Minneapolis, MN 55440-1115
Maximum Filing Time Limit	180 Days	365 Days	365 Days

In Network Providers have an agreement with Anthem Blue Cross. Out of Network Providers do not have an agreement with Anthem Blue Cross. Your personal financial costs when using Out of Network Providers may be considerably higher than when you use In Network Providers. Services provided by Out of Network Providers for non-emergency, non-urgent, and/or non-authorized services are not a covered benefit. This means you will be responsible for all charges performed by an Out of Network Provider. For care obtained from an out of network provider that is an emergency, urgent, and/or authorized service, you are responsible for any deductible, coinsurance, or copayment responsibility that we determine you may owe. Covered Services performed at an In Network Facility at which, or as a result of which, you receive services provided by an Out of Network Provider, you will pay no more than the same cost sharing that you would pay for the same Covered Services received from an In Network Provider.

Anthem Blue Cross wants you to understand the benefits of your health care coverage so you can maximize your health care coverage with us. Anthem Blue Cross offers a variety of ways to assist and educate you to be a more informed consumer. For detailed information regarding the benefits of your plan, please refer to your Combined Evidence of Coverage and Disclosure Form. When logged in to www.anthem.com/ca you can also send messages to us electronically. Anthem Blue Cross is also available to answer any questions you have by contacting our Customer Service at 855-634-3381.

Grace periods and claims pending

If you are getting financial help from the government to pay for your health coverage, once you have paid at least one monthly payment, you can get a grace period of up to three months if you fall behind on payments.

We will continue to consider services you receive during the first month of this grace period according to plan benefits. If you receive services after the first month of this grace period, we will hold (also called "pend") claims — meaning, we won’t pay them yet, but we’ll keep them and will process them after receipt of your premium payments.

If you pay all the missed monthly payments before your grace period ends, we will then go back and consider any claims for coveredservices we were holding (also called “pending”) according to plan benefits.

Reminder: Not all grace periods are three months — you are entitled to three months if you are getting financial help from the government for your monthly payment.

If you don’t pay for all the missed monthly premiums, we have to deny any claims that we are holding or pending. And you will be responsible to pay all charges for those services.

It is best to pay your monthly payment on time every month, to avoid any chance of getting into your grace period.

Retroactive claim denials

Retroactive denial means going back and denying claims that were paid in the past. One way that could happen is if we paid a claim after we got your monthly payment; but then your bank says there is not enough money in your account and we never get a new payment from you. We will then go back and retroactively deny that claim, and we will need to get the money back that we paid for it.

If a claim was not paid yet, but we were just holding it (or pending it) as described in the previous section, Grace periods and claims pending — it can also be denied if you run out your grace period. But since we did not pay the claim yet, we wouldn’t call it a retroactive denial. It is just called a denial.

One way you can avoid having your claims denied is by always paying your monthly payment on time. If you are late, be sure to pay before your grace period runs out. Contact us at 855-634-3381 to ask us about setting up automatic payments if you think that can help you prevent you from missing your premium payment.

Getting money back if you pay us more than you owe

If you pay more than what you owe for your premium, we will either refund or credit the extra amount to you or your account. Hopefully, our processes will identify any overpayment automatically. But if you believe you have paid more than you needed to, please contact us at 855-634-3381 or log in to your online account at wwww.anthem.com/ca and send us a message. Some health plans will describe this by the official terms "recoupment of overpayments," which means the same thing — getting your money back if you have overpaid.

Medical necessity and prior authorization

Medical necessity is a standard that doctors and health plans use to determine if the care you are getting, or are looking to get, is right for you. It means, is the care reasonable and necessary to protect your life, prevent significant illness or significant disability — or to alleviate severe pain through treatment of diseases, illnesses, or injuries? What your plan covers depends on whether the care is medically necessary and right for the situation, and also the details of your plan.

Sometimes, in order to help us figure out ahead of time (before you get the care) if a health service or device is medically necessary and covered by your plan, you or your doctor may need to contact us. This is called getting "prior authorization (preservice review).”

When you go to a doctor or hospital in your plan, they will work with us to see if any of the care you are getting needs prior authorization. If you go to a doctor or hospital that is not in your plan, it's a good idea to check with us first — especially if it's more involved care, for example, surgery. If you are admitted to the hospital, contact us as soon as you can — ideally within 24 hours of admission. That's not necessary for childbirth admissions unless there's a complication and/or mother and baby are not discharged at the same time.

If you or your doctor do not get prior authorization for something that needs it, you could be responsible for more of the cost as stated in your Combined Evidence of Coverage and Disclosure Form.

We will review requests for prior authorization (preservice review) benefits according to the timeframes listed below.

Non-Urgent	Urgent
Five (5) business daysfrom the receipt of the request	Seventy-two (72) hours from the receipt of the request

When you need a prescription drug that’s not on your plan’s drug list

If you and your doctor feel you need a prescription drug that's not on your plan's drug list, please have your doctor or pharmacist get in touch with us. We will make a decision within 72 hours of getting the request. We will look at whether it is medically necessary and appropriate compared to the other drugs on our list.

If we deny coverage of the drug, you have the right to request an External Review by an Independent Review Organization (IRO). The IRO will make a coverage decision within 72 hours of receiving your request.

You or your doctor may also submit a request for a prescription drug that is not on your plan's drug list based on what's called "exigent circumstances". For example, if you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or if you are undergoing a current course of treatment using a drug not covered by your plan. In that case, we will make a decision within 24 hours of getting your request.

If we deny coverage for exigent circumstances, you can request an external review by an IRO, similar to above. But a decision will be made more quickly, within 24 hours of getting your request.

Explanation of Benefits (EOB)

After you get care and you or your doctor submits a claim to us for it, we'll send you an Explanation of Benefits (also called EOB for short). It's like recap of your claim. It explains what service you got, the amount the doctor charged, the amount we paid and why — and more. It also tells you how to appeal a claim. Information on how to read and understand an EOB is available in the document attached.

Health Care Summary

Coordination of Benefits

When you or anybody else on your plan, like your spouse or kids, is covered by two different health plans — both plans may need to know about it. If your plan has coordination of benefits, we will work together to make sure you are getting the right benefits. From time to time, you may get a notice asking if anybody is covered by another plan. Not getting this info back to us may delay claim payments. So, if you are asked for this information, be sure to let us know as soon as possible.

• Blue Shield of California

URL

https://www.blueshieldca.com/

Blue Shield does not currently have this information available on our website. Most of this information is included in the member’s Evidence of Coverage booklet that once registered can be accessed using the URL above.

Out-of-network liability and balance billing

On the Blue Shield PPO plan you can choose to seek services from a Non-Participating provider for most covered services.

Participating Providers have a contract with Blue Shield and agree to accept Blue Shield’s Allowable Amount as payment in full for Covered Services. As a result, your Cost Share is less when you receive Covered Services from a Participating Provider.

Except for Emergency Services and services received at a Participating Hospital under certain conditions, you will pay more for Covered Services from a Non-Participating Provider. Non-Participating Providers do not have a contract with Blue Shield to accept Blue Shield’s Allowable Amount as payment in full for Covered Services and can balance bill for the difference between the Allowable Amount and the Billed Charges. You will be responsible for any Plan deductibles, copayment and coinsurance amounts, non-covered items and the difference between the billed change and the allowed amount.

Enrollee Claim Submission

When you see a Participating Provider, your provider submits the claim to Blue Shield. When you see a Non-Participating Provider, you may have to submit the claim to Blue Shield or the Benefit Administrator. Claims must be submitted within one year of the service date.

How To Submit A Claim

Type Of Claim	What To Submit	Where To Submit It
Medical Services	Blue Shield claim form; and The itemized bill from your provider	Blue Shield of California P.O. Box 272540 Chico, CA 95927
Pharmacy Services	Prescription Drug claim form; and Related receipts or the pharmacy’s bill	Blue Shield of California P.O. Box 419019 Dep. 191 Kansas City, MO 64141
Mental Health and Substance Use Disorder Services from an MHSA Participating Provider	MHSA online claim form; and The itemized bill from your provider	Blue Shield of California Mental Health Service Administrator P.O. Box 719002 San Diego, CA 92171
Mental Health and Substance Use Disorder Services from an MHSA Non-Participating Provider	Blue Shield claim form; and The itemized bill from your provider	Blue Shield of California P.O. Box 272540 Chico, CA 95927

Grace Periods and Claims Pending

Premium grace period if you do not receive Advance Payments of Premium Tax Credits

The Subscriber has a 30-day grace period from the due date to pay all outstanding Premiums before coverage is canceled due to nonpayment of Premiums. Coverage will continue during the grace period. If the Subscriber does not pay all outstanding Premiums within the grace period, coverage will end 30 days after the last day of paid coverage. The Subscriber will be liable for all Premiums owed, even if coverage is canceled. This includes Premiums owed for coverage during the 30-day grace period.

Premium grace period if you receive Advance Payments of Premium Tax Credits

If the Subscriber previously paid Blue Shield at least one full month’s Premium during the benefit year and is late on a Premium payment, Blue Shield will notify the Subscriber and the Subscriber will have a federal grace period of three consecutive months from the due date to pay all outstanding Premiums. Blue Shield will pay claims for Covered Services during the first month (or first 30 days, whichever is greater) of the federal grace period. Coverage will be suspended for the second and third months of the federal grace period until the Subscriber pays all Premiums owed.

If the three-month federal grace period expires before the Subscriber pays all outstanding Premiums, Blue Shield will terminate coverage. The last day of coverage will be the last day of the first month of the three-month federal grace period (or 30 days from the first day of the first month, whichever is later).

Retroactive Denials

Whenever payment on a claim is made in error, Blue Shield has the right to recover such payment from the Subscriber or, if applicable, the provider or another health benefit plan, in accordance with applicable laws and regulations. With notice, Blue Shield reserves the right to deduct or offset any amounts paid in error from any pending or future claim extent permitted by law. Circumstances that might result in payment of a claim in error include, but are not limited to, payment of benefits in excess of the benefits provided by the health plan, payment of amounts that are the responsibility of the Subscriber (Cost Share or similar charges), payment of amounts that are the responsibility of another payor, payments made after termination of the Subscriber’s coverage, or payments made on fraudulent claims.

To Prevent Retroactive Denials:

• Make sure your providers have your current ID card;
• Know how you can access care;
• Know which services are covered under your plan;
• Know which services are not covered under your plan;
• Know how you must get prior authorization for certain services; and
• Pay your premiums on time

Recoupment of Premium Overpayments

If the Subscriber pays Premiums beyond the date coverage ends, those Premiums are unearned. Blue Shield will refund unearned Premiums to the Subscriber, minus any amount Blue Shield pays for Benefits received after the date coverage ends. Blue Shield will only issue a refund to the Subscriber if the amount the Subscriber paid in unearned Premiums is more than the amount Blue Shield pays for Benefits after coverage ends.

To obtain a refund of a Premium overpayment call the Shield Concierge (HMO) or Customer Service (PPO) phone number on the back of your ID card.

Medical Necessity and Prior Authorization Time Frames and Enrollee Responsibilities

Benefits are only available for services and supplies that are Medically Necessary. Blue Shield reserves the right to review all claims to determine if a service or supply is Medically Necessary. A Physician or other Health Care Provider’s decision to prescribe, order, recommend, or approve a service or supply does not, in itself, make it Medically Necessary.

Coverage for some Benefits requires pre-approval from Blue Shield. This process is called prior authorization. Prior authorization requests are reviewed for Medical Necessity, available plan Benefits, and clinically appropriate setting. The prior authorization process also identifies Benefits that are only covered from Participating Providers or in a specific clinical setting.

If you see a Participating Provider, your provider must obtain prior authorization when required. When prior authorization is required but not obtained, Blue Shield may deny payment to your provider. You are not responsible for Blue Shield’s portion of the Allowable Amount if this occurs, only your Cost Share.

If you see a Non-Participating Provider, you or your provider must obtain prior authorization when required. When prior authorization is required but not obtained, Blue Shield may deny payment and you will be responsible for all billed charges.

You do not need prior authorization for Emergency Services or emergency Hospital admissions at Participating or Non-Participating facilities. For non-emergency inpatient services, your provider should request prior authorization at least five business days before admission.

When a decision will be made about your prior authorization request

Prior authorization or exception request	Time for decision
Routine medical, mental health and substance use disorder, dental, and vision requests	Within five business days
Expedited medical, mental health and substance use disorder, dental, and vision requests	Within 72 hours
Routine prescription Drug requests	Within 72 hours
Expedited prescription Drug requests	Within 24 hours

Expedited requests include urgent medical and exigent pharmacy requests. Once the decision is made, your provider will be notified within 24 hours. Written notice will be sent to you and your provider within two business days.

Drug exception time frames and enrollee responsibilities (not required for SADPs)

Blue Shield’s Drug Formulary is a list of FDA-approved Generic and Brand Drugs. This list helps Physicians or Health Care Providers prescribe Medically Necessary and cost effective Drugs. Drugs not listed on the Formulary may be covered when approved by Blue Shield through the exception request process.

To request coverage for a non-Formulary Drug, you, your representative, your Physician, or your Health Care Provider may submit an exception request to Blue Shield. Once all required supporting information is received, Blue Shield will approve or deny the exception request, based on Medical Necessity, within 72 hours in routine circumstances or 24 hours in exigent circumstances.

To start the exception request process call the Shield Concierge (HMO) or Customer Service (PPO) phone number on the back of your ID card.

Explanation of Benefits (EOB)

Blue Shield or the Benefit Administrator will process your claim within 30 business days of receipt if it is not missing any required information. If your claim is missing any required information, you or your provider will be notified and asked to submit the missing information. Blue Shield cannot process your claim until we receive the missing information.

Once the claim is processed, you may receive an Explanation of Benefits (EOB). The EOB will include valuable information including the provider and date of each service, a description of each service, patient responsibility, deductible status (if applicable) and the amount paid.

Coordination of Benefits

NOT APPLICABLE – Individual and Family Plans do not coordinate with other Individual or Group Health Plans

• BSC-QHP

Qualified Health Plans

URL

https://www.blueshieldca.com/

Blue Shield does not currently have this information available on our website. Most of this information is included in the member’s Evidence of Coverage booklet that once registered can be accessed using the URL above.

Out-of-network liability and balance billing

On the Blue Shield PPO plan you can choose to seek services from a Non-Participating provider for most covered services.

Participating Providers have a contract with Blue Shield and agree to accept Blue Shield’s Allowable Amount as payment in full for Covered Services. As a result, your Cost Share is less when you receive Covered Services from a Participating Provider.

Except for Emergency Services and services received at a Participating Hospital under certain conditions, you will pay more for Covered Services from a Non-Participating Provider. Non-Participating Providers do not have a contract with Blue Shield to accept Blue Shield’s Allowable Amount as payment in full for Covered Services and can balance bill for the difference between the Allowable Amount and the Billed Charges. You will be responsible for any Plan deductibles, copayment and coinsurance amounts, non-covered items and the difference between the billed change and the allowed amount.

Enrollee Claim Submission

When you see a Participating Provider, your provider submits the claim to Blue Shield. When you see a Non-Participating Provider, you may have to submit the claim to Blue Shield or the Benefit Administrator. Claims must be submitted within one year of the service date.

How To Submit A Claim

Type Of Claim	What To Submit	Where To Submit It
Medical Services	Blue Shield claim form; and The itemized bill from your provider	Blue Shield of California P.O. Box 272540 Chico, CA 95927
Pharmacy Services	Prescription Drug claim form; and Related receipts or the pharmacy’s bill	Blue Shield of California P.O. Box 419019 Dep. 191 Kansas City, MO 64141
Mental Health and Substance Use Disorder Services from an MHSA Participating Provider	MHSA online claim form; and The itemized bill from your provider	Blue Shield of California Mental Health Service Administrator P.O. Box 719002 San Diego, CA 92171
Mental Health and Substance Use Disorder Services from an MHSA Non-Participating Provider	Blue Shield claim form; and The itemized bill from your provider	Blue Shield of California P.O. Box 272540 Chico, CA 95927

Grace Periods and Claims Pending

Premium grace period if you do not receive Advance Payments of Premium Tax Credits

The Subscriber has a 30-day grace period from the due date to pay all outstanding Premiums before coverage is canceled due to nonpayment of Premiums. Coverage will continue during the grace period. If the Subscriber does not pay all outstanding Premiums within the grace period, coverage will end 30 days after the last day of paid coverage. The Subscriber will be liable for all Premiums owed, even if coverage is canceled. This includes Premiums owed for coverage during the 30-day grace period.

Premium grace period if you receive Advance Payments of Premium Tax Credits

If the Subscriber previously paid Blue Shield at least one full month’s Premium during the benefit year and is late on a Premium payment, Blue Shield will notify the Subscriber and the Subscriber will have a federal grace period of three consecutive months from the due date to pay all outstanding Premiums. Blue Shield will pay claims for Covered Services during the first month (or first 30 days, whichever is greater) of the federal grace period. Coverage will be suspended for the second and third months of the federal grace period until the Subscriber pays all Premiums owed.

If the three-month federal grace period expires before the Subscriber pays all outstanding Premiums, Blue Shield will terminate coverage. The last day of coverage will be the last day of the first month of the three-month federal grace period (or 30 days from the first day of the first month, whichever is later).

Retroactive Denials

Whenever payment on a claim is made in error, Blue Shield has the right to recover such payment from the Subscriber or, if applicable, the provider or another health benefit plan, in accordance with applicable laws and regulations. With notice, Blue Shield reserves the right to deduct or offset any amounts paid in error from any pending or future claim extent permitted by law. Circumstances that might result in payment of a claim in error include, but are not limited to, payment of benefits in excess of the benefits provided by the health plan, payment of amounts that are the responsibility of the Subscriber (Cost Share or similar charges), payment of amounts that are the responsibility of another payor, payments made after termination of the Subscriber’s coverage, or payments made on fraudulent claims.

To Prevent Retroactive Denials:

• Make sure your providers have your current ID card;
• Know how you can access care;
• Know which services are covered under your plan;
• Know which services are not covered under your plan;
• Know how you must get prior authorization for certain services; and
• Pay your premiums on time

Recoupment of Premium Overpayments

If the Subscriber pays Premiums beyond the date coverage ends, those Premiums are unearned. Blue Shield will refund unearned Premiums to the Subscriber, minus any amount Blue Shield pays for Benefits received after the date coverage ends. Blue Shield will only issue a refund to the Subscriber if the amount the Subscriber paid in unearned Premiums is more than the amount Blue Shield pays for Benefits after coverage ends.

To obtain a refund of a Premium overpayment call the Shield Concierge (HMO) or Customer Service (PPO) phone number on the back of your ID card.

Medical Necessity and Prior Authorization Time Frames and Enrollee Responsibilities

Benefits are only available for services and supplies that are Medically Necessary. Blue Shield reserves the right to review all claims to determine if a service or supply is Medically Necessary. A Physician or other Health Care Provider’s decision to prescribe, order, recommend, or approve a service or supply does not, in itself, make it Medically Necessary.

Coverage for some Benefits requires pre-approval from Blue Shield. This process is called prior authorization. Prior authorization requests are reviewed for Medical Necessity, available plan Benefits, and clinically appropriate setting. The prior authorization process also identifies Benefits that are only covered from Participating Providers or in a specific clinical setting.

If you see a Participating Provider, your provider must obtain prior authorization when required. When prior authorization is required but not obtained, Blue Shield may deny payment to your provider. You are not responsible for Blue Shield’s portion of the Allowable Amount if this occurs, only your Cost Share.

If you see a Non-Participating Provider, you or your provider must obtain prior authorization when required. When prior authorization is required but not obtained, Blue Shield may deny payment and you will be responsible for all billed charges.

You do not need prior authorization for Emergency Services or emergency Hospital admissions at Participating or Non-Participating facilities. For non-emergency inpatient services, your provider should request prior authorization at least five business days before admission.

When a decision will be made about your prior authorization request

Prior authorization or exception request	Time for decision
Routine medical, mental health and substance use disorder, dental, and vision requests	Within five business days
Expedited medical, mental health and substance use disorder, dental, and vision requests	Within 72 hours
Routine prescription Drug requests	Within 72 hours
Expedited prescription Drug requests	Within 24 hours

Expedited requests include urgent medical and exigent pharmacy requests. Once the decision is made, your provider will be notified within 24 hours. Written notice will be sent to you and your provider within two business days.

Drug exception time frames and enrollee responsibilities (not required for SADPs)

Blue Shield’s Drug Formulary is a list of FDA-approved Generic and Brand Drugs. This list helps Physicians or Health Care Providers prescribe Medically Necessary and cost effective Drugs. Drugs not listed on the Formulary may be covered when approved by Blue Shield through the exception request process.

To request coverage for a non-Formulary Drug, you, your representative, your Physician, or your Health Care Provider may submit an exception request to Blue Shield. Once all required supporting information is received, Blue Shield will approve or deny the exception request, based on Medical Necessity, within 72 hours in routine circumstances or 24 hours in exigent circumstances.

To start the exception request process call the Shield Concierge (HMO) or Customer Service (PPO) phone number on the back of your ID card.

Explanation of Benefits (EOB)

Blue Shield or the Benefit Administrator will process your claim within 30 business days of receipt if it is not missing any required information. If your claim is missing any required information, you or your provider will be notified and asked to submit the missing information. Blue Shield cannot process your claim until we receive the missing information.

Once the claim is processed, you may receive an Explanation of Benefits (EOB). The EOB will include valuable information including the provider and date of each service, a description of each service, patient responsibility, deductible status (if applicable) and the amount paid.

Coordination of Benefits

Individual and Family Plans do not coordinate with other Individual or Group Health Plans. However, if you are also covered with Medicare or have more than one employer sponsored group health plan, after receiving information from you, we will determine which plan provides benefits first. Further information about coordination of benefits and Limitation for Duplicate Coverage can be found in your Evidence of Coverage.

• BSC-QDP

Qualified Dental Plans

CFR 155.1040(a) TRANSPARENCY IN COVERAGE REQUIREMENTS
URL	https://www.blueshieldca.com/ Blue Shield does not currently have this information available on our website. Most of this information is included in the member’s Evidence of Coverage booklet that once registered can be accessed using the URL above.
Out-of-network liability and balance billing	When you receive Covered Services from a Non-Plan Dentist, you will be reimbursed up to a specified maximum amount as outlined in the section of your Evidence of Coverage (EOC) booklet entitled “Summary of Benefits and Member Copayments”. You will be responsible for the remainder of the Dentist’s billed charges. You should discuss this beforehand with your Dentist if he is not a Plan Dentist. Any difference between a Dental Plan administrator’s or Blue Shield of California’s payment and the Non-Plan Dentist's charges are your responsibility.
Enrollee Claim Submission	When you see a Participating Provider, your provider submits the claim to Blue Shield. When you see a Non-Participating Provider, you may have to submit the claim to Blue Shield or the Benefit Administrator. Claim forms are available at https://www.blueshieldca.com/. Claims must be submitted within one year of the service date. How To Submit A Claim Type Of Claim What To Submit Where To Submit It Dental Services Blue Shield claim form; and The itemized bill from your provider Blue Shield of California P.O. Box 30567 Salt Lake City, UT 84130-0567
Grace Periods and Claims Pending	Premium grace period if you do not receive Advance Payments of Premium Tax Credits The Subscriber has a 30-day grace period from the due date to pay all outstanding Premiums before coverage is canceled due to nonpayment of Premiums. Coverage will continue during the grace period. If the Subscriber does not pay all outstanding Premiums within the grace period, coverage will end 30 days after the last day of paid coverage. The Subscriber will be liable for all Premiums owed, even if coverage is canceled. This includes Premiums owed for coverage during the 30-day grace period.
Retroactive Denials	Whenever payment on a claim is made in error, Blue Shield has the right to recover such payment from the Subscriber or, if applicable, the provider or another health benefit plan, in accordance with applicable laws and regulations. With notice, Blue Shield reserves the right to deduct or offset any amounts paid in error from any pending or future claim extent permitted by law. Circumstances that might result in payment of a claim in error include, but are not limited to, payment of benefits in excess of the benefits provided by the health plan, payment of amounts that are the responsibility of the Subscriber (Cost Share or similar charges), payment of amounts that are the responsibility of another payor, payments made after termination of the Subscriber’s coverage, or payments made on fraudulent claims. To Prevent Retroactive Denials: Make sure your providers have your current ID card; Know how you can access care; Know which services are covered under your plan; Know which services are not covered under your plan; Know how you must get prior authorization for certain services; and Pay your premiums on time
Recoupment of Premium Overpayments	To obtain a refund of a Premium overpayment call the Customer Service phone number on the back of your ID card.
Medical Necessity and Prior Authorization Time Frames and Enrollee Responsibilities	All services must be Dentally Necessary. The fact that a Plan Dentist or other Plan Dentist may prescribe, order, recommend, or approve a service or supply does not, in itself, determine Dental Necessity. Services which are of Dental Necessity include only those which have been established as safe and effective and are furnished in accordance with generally accepted national and California dental standards which, as determined by a contracted Dental Plan Administrator, are: a. Consistent with the symptoms or diagnosis of the condition; and b. Not furnished primarily for the convenience of the Member, the attending Dentist or other provider; and c. Furnished in a setting appropriate for delivery of the Service (e.g., a Dentist’s office). You are responsible for assuring that the Dentist you choose is a Plan Dentist. Note: A Plan Dentist’s status may change. It is your obligation to verify whether the Dentist you choose is currently a Plan Dentist in case there have been any changes to the list of Plan Dentists. A list of Plan Dentists located in your area, can be obtained by contacting a Dental Plan Administrator at 1-877-885-0254. You may also access a list of Plan Dentists through Blue Shield of California’s Internet site located at http://www.blueshieldca.com. You are also responsible for following the Precertification of Dental Benefits Program which includes obtaining or assuring that the Dentist obtains precertification of Benefits. When a decision will be made about your prior authorization request Prior authorization or exception request Time for decision Routine Dental Services Within five business days Urgent services in situations in which the routine decision making process might seriously jeopardize the life or health of a member or when a member is experiencing severe pain Within 72 hours Failure to meet these responsibilities may result in the denial of Benefits. However, by following the Precertification process both you and the Dentist will know in advance which services are covered and the Benefits that are payable.
Explanation of Benefits (EOB)	Blue Shield or the Benefit Administrator will process your claim within 30 business days of receipt if it is not missing any required information. If your claim is missing any required information, you or your provider will be notified and asked to submit the missing information. Blue Shield cannot process your claim until we receive the missing information. Once the claim is processed, you may receive an Explanation of Benefits (EOB). The EOB will include valuable information including the provider and date of each service, a description of each service, patient responsibility, deductible status (if applicable) and the amount paid.
Coordination of Benefits	Per DHMO/PPOFamily Dental Plan EOC, all individual and family medical plans include an embedded Pediatric dental Benefit on the health benefits exchange. For purposes of coordinating Pediatric Benefits the medical plan is the primary dental Benefit plan and the Family Dental PPO Plan is the secondary dental Benefit plan.

• CCHP Health Plan

Out-of-network liability and balance billing

Chinese Community Health Plan is designed for Members to obtain services from a network of doctors. Members may choose to receive services from doctors outside this network. Covered services obtained from out of network providers may result in a higher share of cost for the Member. Certain medical services might need to be pre-authorization by CCHP before the plan will cover it. Some services are not covered unless given by a network provider. Please refer the plan Evidence of Coverage and Summary of Benefit for additional information.

Enrollee claim submission

Contracted providers have 90 days to bill claims to CCHP for services provided to Members. Out of network providers or non-contracted providers have six (6) months to bill CCHP for services provider to Members. CCHP process claims within 45 days from the date of receipt.

Grace periods and claims pending

The grace period will begin one day after the premium due date, this period will continue for 30 consecutive days (90 consecutive days for individuals receiving tax credits) during which CCHP will continue to provide coverage consistent with the terms of the health plan contract. Members will be sent a notice of suspension due to nonpayment of premiums on the first day of the effective grace period (one day after the premium due date). The notice is sent separate from the original premium bill and will include the dollar amount due to CCHP, disclosure of the grace period, and other necessary information.

Recoupment of overpayments

Members can submit a Reimbursement Request within 90 days from the date of service. This request form is available through our Member Services or CCHP website. Members need to submit the Reimbursement Form to CCHP and attach all necessary information including receipts and medical reports or records to support the request. Once the request is processed in the claims system and the reimbursement is approved, CCHP issues a check directly to the Member.

Drug exception time frames and enrollee responsibilities (not required for SADPs)

CCHP delegates the authority of managing the formulary and making coverage determinations for all lines of business to the contracted PBM . Coverage exceptions for non-formulary medications are reviewed by the PBM on behalf of CCHP. These reviews will be completed in a timely manner, depending on the urgency of the request.

Prescribers, members, or member representatives are required to complete a coverage determination and exception request form to initiate the reviewing process for non-formulary medications. This form may be obtained by calling CCHP Member Services Center, the contracted PBM Customer Care, or downloaded from the CCHP website.

The completed form, with information regarding medical necessity, will be sent to the contracted PBM via fax. The contracted PBM will have pharmacists and/or medical professionals who are competent in evaluating a clinical issues review and will render a decision, based on medical necessity, in a timely manner, depending on the line of business and/or urgency level of the request. Upon receipt of the completed form to the PBM, Commercial and Exchange standard requests will have a decision rendered within 72 hours. For matters marked urgent – as defined by DMHC – decisions will be made within 24 hours. i) For Commercial and Exchange products, if additional information is not sent within two days of the request, the coverage determination will be denied. ii) An urgent request may apply to exigent circumstances 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.

Explanation of benefits (EOB)

CCHP will send out Explanation Of Benefit (EOB) by the 15th of each month for claims processed in the previous month. EOB is a statement by CCHP to its members explaining what Medical services are paid for on their behalf. The EOB describes the payee, the payer and the patient, the service performed with detail (date of service, description of service, place of service), the amount billed, if any patient’s financial liability and CCHP’s payment.

Coordination of benefits.

The Services covered under the Combined Evidence of Coverage and Disclosure Form are subject to coordination of benefits (COB) rules. If you have a medical or dental plan with another health plan or insurance company, we will coordinate benefits with the other coverage under the COB rules of the California Department of Managed Health Care. Those rules are incorporated into this Combined Evidence of Coverage and Disclosure Form. If both the other coverage and we cover the same Service, the other coverage and we will see that up to 100 percent of your covered medical expenses are paid for that Service. The COB rules determine which coverage pays first, or is "primary," and which coverage pays second, or is "secondary." The secondary coverage may reduce its payment to take into account payment by the primary coverage. You must give us any information we request to help us coordinate benefits.

If you have any questions about COB, please call our Member Services Center:

1-888-775-7888

OR 1-415-834-2118

1-877-681-8898 (TTY)
7 days a week from 8 a.m. to 8 p.m.

• California Dental Network - Information to Come

• Dental Health Services

https://www.dentalhealthservices.com/files/2021_Transparency_in_Coverage_FAQ_091520.pdf

• Delta Dental

https://www.deltadentalins.com/hcx/how-your-marketplace-plan-works.html

• Health Net

https://ifp.healthnetcalifornia.com/learn-more/claims-for-covered-services.html

• Kaiser Permanente

We want to make it as easy as possible for you to understand how your health plan works so you can get the most out of your coverage. This page gives you an overview of Kaiser Permanente’s policies regarding claims, visits to non-participating providers, related out-of-pocket costs and billing, and more. For more detailed information about your plan, please see your Membership Agreement.

Medically necessary care and prior authorization

Certain services require authorization before you get them. In these cases, your participating provider can help you get authorization for care he or she considers medically necessary. We determine when covered services are medically necessary based upon certain standards that take into account your medical condition as well as generally accepted standards of care.

When you receive covered services for which you do not have prior authorization or that you receive from non-participating providers or from non-Plan facilities that have not been approved by us in advance, we will not pay for them except in an emergency.

Some services need special approval through a utilization review. If you need services that require a review and your participating provider believes they’re medically necessary, he or she may submit a request for a utilization review for you, or you may submit a request. We will respond to your request within 15 calendar days.

If the request is denied, Kaiser Permanente will send you a letter. It will explain the reason for our decision and give instructions for filing an appeal if you don’t agree with the determination. Out-of-network liability and balance billing

Out-of-network liability and balance billing

When you get care from participating providers, you won’t be responsible for paying any amounts except for any cost sharing (deductibles, copayments or coinsurance) amounts that you owe. However, you will need to pay for any noncovered services you receive, whether you get them from a participating or a non-participating provider.

If you get covered services without prior authorization — or if you get them from a non-participating provider we haven’t approved in advance — we won’t pay for them, except in an emergency. Charges for these services will be your financial responsibility, and you may be billed directly by the provider for any balance you owe.

Filing claims

You generally won’t have to file a claim if a Kaiser Permanente provider provides the services. The participating provider will send the bill directly to Kaiser Permanente, and we’ll handle the claim.

However, if you visit a non-participating provider without getting a referral, you may need to send us a claim form with an itemized bill for any services you believe Kaiser Permanente should cover. You’ll need to submit your claim no more than 12 months after you get the service. To get a claim form, contact Member Services or download it here. When you submit the claim, please include a copy of your medical records from the non-participating provider. You can send the completed form and itemized bill to:

Kaiser Permanente

CALIFORNIA – SCAL

Claim Address

P.O. Box 7004

Downey, CA 90242-7004

Member Services

1-800-464-4000

Kaiser Permanente

CALIFORNIA – NCAL

Claim Address

P.O. Box 12923

Oakland, CA 94604-2923

Member Services

1-800-464-4000

Grace periods for members receiving premium tax credits

If you have chosen for Kaiser Permanente to receive advance payments of your premium tax credit, your monthly premium payment will be reduced by that amount. You need to pay any part of the premium that isn’t covered by the advance payment. If we don’t get your portion of the monthly premium by the due date, you’ll have a 3-month grace period in which to pay the late premium as well as the premiums owed for the additional 2 months of the grace period.

If you qualify for a grace period, we’ll send you a notice with details. During the first month of the grace period, we’ll pay all appropriate claims for covered services. For the second and third months, we may choose not to pay for services if we don’t get your payment for any outstanding premiums by the end of the grace period. However, you generally won’t have to file a claim if a Kaiser Permanente provider provides the services. A participating provider will send the bill/claim directly to Kaiser Permanente, and we’ll process the claim unless you don’t pay your premium and we have indicated to your participating provider that we may not pay their claim (pended the participating provider’s claim).

Retroactive denial of claims

In certain cases, a claim may be denied retroactively — for example, if you fail to pay your premium or you get services after your membership ends. In the event of a retroactive denial, you’ll be financially responsible for the covered services you received. To ensure a claim is not retroactively denied, premiums must be paid on time. If you have questions about a claim that’s been denied, please contact Member Services.

Reimbursement for overpayments

If we terminate your membership, we’ll refund any premium payments you made after your membership ended. We’ll also pay you any amounts we owe for claims while you were a member. When making these payments, we may deduct any amounts you owe Kaiser Permanente or any participating providers. Refunds for overpayment of premium are provided based on the method of payment used by the member. If you believe you have overpaid your premium and are due a refund, please contact Member Services.

Prescription drug approvals

If you request a non-formulary drug when your Kaiser Permanente provider does not indicate that the non-formulary drug is medically necessary, you will be responsible for the full cost of that drug. However, if your provider documents that:

• A non-formulary drug best treats your medical condition;
• A formulary drug has been ineffective in the treatment of your medical condition; or
• A formulary drug causes or is reasonably expected to cause a harmful reaction, then an exception process is available to your participating provider to seek permission to prescribe a medically necessary non-formulary drug for you.

We will make a coverage determination within 72 hours of receipt for standard requests and within 24 hours of receipt for expedited requests. Contact your provider or Member Services to file a request for an exception to the formulary.

If the exception is approved, your standard prescription drug copayment, coinsurance and/or deductibles would apply.

Medication Exception Process: Upon request, Kaiser Permanente may make an exception to our coverage rules and approve a drug for your prescription benefit that would otherwise not be covered. This requires the drug to be reviewed through our medication exception process where it must be deemed medically necessary. Your provider may request an exception if he or she determines that drug is medically necessary. If we do not approve the formulary exception request, we will send you a letter information you of that decision. You have the right to request a review by an independent review organization (IRO). The process is explained in our denial letter and under “External Review” in the “Grievances, Claims, Appeals, and External Review” section of your Evidence of Coverage. We will be bound by and act in accordance with the decision of the IRO notwithstanding the definition of medically necessary care.

Explanation of Benefits

An Explanation of Benefits (EOB) is a summary of services you’ve received during a specific period. It shows the charges, the date of your visit, and the name of the provider you visited. An EOB is not a bill. It’s available to help you understand the payments made for your covered services and to help you keep track of your expenses. EOBs are sent at least once a month after the Member receives services and the claim is received by Kaiser Permanente to be processed.

Coordination of Benefits

If you have health coverage under more than one plan, the Coordination of Benefits process helps you make the most of your coverages to make sure you get the care you need. It determines the order in which different plans pay for services, which can make it easier to get and pay for care.

The plan that pays first is the primary plan. It’s responsible for paying first regardless of whether another plan covers some expenses so long as the care is covered. The secondary plan pays next. Based on how much the primary plan pays, it may reduce what it pays so the amounts from both plans don’t total more than the allowable expense for specific services.

For more information

If you have any questions or want more information about any of the topics covered here, please contact Member Services. One of our representatives will be happy to help.

© Kaiser Permanente, 2017

• LA Care Health Plan

Claims Payment Policy and Practices

Out-of-network liability and balance billing

LA. Care Health Plan uses a provider network. You will pay less if you use a participating provider in the Plan’s network. You will pay the most if you use a non-participating provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your participating provider might use a non-participating provider for some services (such as lab work). Check with your provider before you get services.

LA Care Members are responsible for all charges when receiving out-of-network care, unless services rendered are deemed a medical emergency or services rendered are approved by the Plan. In some cases, a non-plan provider may provide covered services at an in-network facility where you have been authorized to receive care. You are not responsible for any amounts beyond your cost share for the covered services you receive at plan facilities or at in-network facilities where you have been authorized to receive care.

Balance billing L.A. Care members is prohibited by law. Contracted providers cannot collect reimbursement from an L.A. Care member or persons acting on behalf of a member for any services provided, except to collect any authorized share of cost.

Enrollee claim submission

When you see a Participating Provider, your provider submits the claim to LA Care. When you see a Non-Participating Provider, you may have to submit the claim to LA Care.

Grace periods and claims pending

If you and/or your Enrolled Dependent(s) are receiving advance premium tax credits to defray the cost of your monthly premium, but fail to pay the Member’s portion of the monthly premium to L.A. Care by the due date, L.A. Care will send you a past due notice notifying you that your coverage will be terminated for non-payment of premium effective as of the last day of the first (1st) month of grace period (“Grace Period”). The notice will explain you have a three (3) month Grace Period to make your payments in full before termination. The three (3) month Grace Period is offered only to individuals who are receiving advance premium tax credits.

LA Care will provide covered services to you only during the first month of the Grace Period. During months two (2) and three (3) of the Grace Period your coverage will be suspended. This means that L.A. Care will not provide coverage for any services you received during months two (2) and three (3) of the Grace Period. You may be billed for and have to pay for any services you receive during months two (2) and three (3) if you do not pay all of your three (3) months of overdue premiums by the last day of the three (3) month Grace Period.

Retroactive denials

A retroactive denial is the reversal of a claim we have already paid. If we retroactively deny a claim we have already paid for you, you will be responsible for payment. Some reasons why you might have a retroactive denial include having a claim that was paid during the second or third month of a grace period or having a claim paid for a service for which you were not eligible.

Recoupment of Overpayments

L.A. Care will reimburse members for their individual health insurance premium overpayment upon their written request.

If you believe you have paid too much for your premium and should receive a refund, please contact our Member Services Department at 1-855-270-2327 (TTY 711).

Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities

Medical Necessity refers to all covered services that meet LA Care guidelines for appropriateness and reasonableness by virtue of a clinical review of submitted information. Services are considered reasonable and necessary to protect life, prevent illness or disability, or to ease pain through the diagnosis or treatment of disease, illness, or injury.

LA Care must approve some services before you obtain them. This is called prior authorization or preservice review. For example, any kind of inpatient hospital care (except maternity care) requires prior authorization. If you need a service that we must first approve, your in-network doctor will call us for the authorization. If you don’t get prior authorization, you may have to pay up to the full amount of the charges. The number to call for prior authorization is included on the ID card you receive after you enrolled. Please refer to the specific coverage information you receive after you enrolled. We typically decide on requests for prior authorization for medical services within 72 hours of receiving an urgent request or within 5 days for non-urgent requests.

Drug exception timeframes and enrollee responsibilities

When you need a prescription drug that’s not on your plan’s drug list Sometimes our members need access to drugs that are not listed on the plan’s formulary (drug list). These medications are initially reviewed by LA Care through a formulary exception review process. The member or provider can contact LA Care Member Services 1-855-270-2327 (TTY 711) with any specific questions regarding coverage of a drug.

Non-Formulary Agents
Any drug not found on the formulary (drug list) is considered non-formulary. Coverage for non-formulary agents may be requested by the prescriber. Each request will be reviewed based on individual member needs. Approval will be given if a documented medical need exists.

the ‘Medication Request Process’ is generally not available for drugs that are specifically excluded by benefit design.

A decision for approval or denial of the exception request or prior authorization can be made within 24 hours if the request is urgent or within 72 hours if the request is not urgent. If we fail to respond within the appropriate time frames, the request is deemed granted. Non-approved requests may be appealed. The prescriber must provide information to support the appeal on the basis of medical necessity.

Explanation of Benefits (EOBs)

After you visit your provider, you may receive an Explanation of Benefits (EOB) from LA Care. An EOB is NOT A BILL; it explains how your benefits were applied to that particular claim. It includes details about the services you received, the amount your provider billed LA Care, the amount LA Care paid, and the portion of services that may be your responsibility. EOBs are sent after LA Care receives and adjudicates claims.

• The link below has information on how to read your EOB:
  https://www.lacare.org/sites/default/files/universal/LACC-Member-Tutorial-English-0518.pdf
  
  https://www.lacare.org/sites/default/files/universal/LACC-Member-Tutorial-Spanish-0518.pdf

Coordination of benefits (COB)

Coverage with more than one health plan LA Care will manage benefits for members covered by two or more health plans to make sure payments are correct. This is called coordination of benefits (COB).

• Liberty Dental

https://www.libertydentalplan.com/Individual-Marketplace/California/Transparency-of-Coverage.aspx

• Molina Healthcare

http://www.molinahealthcare.com/members/ca/en-US/mem/marketplace/resources/Pages/faq.aspx

• Oscar

https://www.hioscar.com/asset/transparency_in_coverage_2022

• Sharp Health Plan

Grace periods and claims pending

1. All members are active for the first 30 days, and sent on files as active. From days 31-90 if they have not made a payment then they are in their Grace Period and are ineligible for services, and not sent as an eligible member on outbound eligibility files and claims are denied.
2. When the member is in the 30 day grace period claims will be paid provided all auth guidelines etc. are followed.

Retroactive denials

Sharp Health Plan does not go back and deny claims that have been previously paid.

Medical necessity and prior authorization time frames and enrollee responsibilities

Except for PCP services, outpatient mental health or chemical dependency office visits, MinuteClinic services, Emergency Services and obstetric and gynecologic services, you are responsible for obtaining valid Authorization before you receive Covered Benefits.

To obtain a valid Authorization:

1. Prior to receiving care, contact your PCP or other approved Plan Provider to discuss your treatment plan.
2. Request prior Authorization for the Covered Benefits that have been ordered by your doctor. Your PCP or other Plan Provider is responsible for requesting Authorization from Sharp Health Plan or your Plan Medical Group.
3. If Authorization is approved, obtain the expiration date for the Authorization. You must access care before the expiration date with the Plan Provider identified in the approved Authorization.

A decision will be made on the Authorization request in a timely fashion based on the nature of your medical condition, but no later than five business days. A letter will be sent to you within two business days of the decision.

If waiting five days would seriously jeopardize your life or health or your ability to regain maximum function or, in your doctor’s opinion, it would subject you to severe pain that cannot be adequately managed without the care or treatment that is being requested, you will receive a decision in a timely fashion based on the nature of your medical condition, but no later than 72 hours after receipt of the Authorization request.

If we do not receive enough information to make a decision regarding the Authorization request, we will send you a letter within five days to let you know what additional information is needed. We will give you or your Provider at least 45 days to provide the additional information. (For urgent Authorization requests, we will notify you and your Provider by phone within 24 hours and give you or your Provider at least 48 hours to provide the additional information).

If you receive Authorization for an ongoing course of treatment, we will not reduce or stop the previously Authorized treatment before providing you with an opportunity to Appeal the decision to reduce or stop the treatment.

The Plan uses evidence based guidelines for Authorization, modification or denial of services as well as Utilization Management, prospective, concurrent and retrospective review. Plan specific guidelines are developed and reviewed on an ongoing basis by the Plan Medical Director, Utilization Management Committee and appropriate physicians to assist in determination of community standards of care. A description of the medical review process or the guidelines used in the process will be provided upon request.

If you change to a new PMG as a result of a PCP change, you will need to ask your new PCP to submit Authorization requests for any specialty care, Durable Medical Equipment or other Covered Benefits you need. The Authorizations from your previous PMG will no longer be valid. Be sure to contact your new PCP promptly if you need Authorization for a specialist or other Covered Benefits.

If services requiring prior Authorization are obtained without the necessary Authorization, you may be responsible for the entire cost.

Drug exception time frames and enrollee responsibilities (not required for SADPs)

In the event that our members need access to drugs that are not listed on the plan's formulary (drug list). These medications are initially reviewed by Sharp Health Plan through the formulary exception review process. The member or provider can submit the request to us by faxing the Pharmacy Prior Authorization and Step Therapy Exception Request form prescription-drug-prior-authorization-request-form. If the drug is denied, you have the right to an external review.

If we deny a request for coverage of a drug not on the plan’s formulary, a non-formulary drug, you, your Authorized Representative or your doctor may request that the original exception request and subsequent denial of such request be reviewed by an independent review organization (IRO). You, your authorized representative or your doctor may submit a request for IRO review up to 180 calendar days following the non-formulary drug exception request denial by:

Calling toll free at 1-855-298-4252
• Mailing a written request to:

  Attn: Prescription Claim Appeals MC 109 – CVS Caremark

  P.O. Box 52084

  Phoenix, AZ 85072-2084

• Faxing a written request to: 1-866-442-1172
• Completing the Member Grievance and Appeal form on our website at: sharphealthplan.com

You will be notified of the IRO’s decision within 72 hours for standard requests or 24 hours for expedited requests.

The IRO review process described above is in addition to your rights to file a grievance or appeal with Sharp Health Plan and to file a Grievance or request an independent medical review (IMR) with the California Department of Managed Health Care.

If your appeal involves a request for coverage of a non-formulary Drug (referred to as a non-formulary exception request), we will provide you with a decision within 72 hours. A request may be expedited if urgent, in which case we will provide you with a decision within 24 hours. A non-formulary exception request is considered urgent 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 the member is undergoing a current course of treatment using the non-formulary drug.

Explanation of benefits (EOB)

Sharp Health Plan will mail the EOB’s on or before the 10th of every month. The EOB’s include any claims processed and paid the previous month and any encounters or pharmacy claims included on the files received in the previous month.

Coordination of benefits

Coordination of Benefits (COB) is a process, regulated by law, which determines the financial responsibility for payment when a Member has coverage under more than one plan. The primary carrier pays up to its maximum liability and the secondary carrier considers the remaining balance for covered services up to, but not exceeding, the benefits that are available and the dentist’s actual charge.

Determination of primary coverage is as follows:

For a Group Medical Insurance Qualified Health Plan: A Group Medical Insurance Qualified Health plan providing pediatric dental essential health benefits is the primary carrier for such covered services. This applies to plans provided on the California Health Benefit Marketplace and to plans provided outside such Marketplace.

For Dependent Children covered under Group Dental Plans: The determination of primary and secondary coverage for Dependent children covered by two parents’ plans follows the birthday rule. The plan of the parent with the earlier birthday (month and day, not year) is the primary coverage. Different rules apply for the children of divorced or legally separated parents; contact the Member Services Department if you have any questions.

• Valley Health Plan

Out-of-Network Liability and Balance Billing

Your benefit plan with Valley Health Plan HMO and “Lock-In” provision requires that you obtain all covered services through Plan Providers in your Primary Care Provider’s Network, except in the case of an emergency or an out-of-area urgent care. If you seek services from Non-Plan Providers without a VHP approved referral, you may be financially responsible for the full cost of medical charges.

Plan Providers shall not balance bill or maintain any action at law against any member for any unpaid balances due from VHP for covered services. Except for applicable copayments and deductibles, Plan Providers shall not invoice or balance bill members for the difference between the Provider's billed charges and the reimbursement paid by VHP for covered services.

To find a Network Plan Provider – use our Provider Search by visiting our website at www.valleyhealthplan.org or contact VHP Member Services for assistance at 1.888.421.8444 (toll-free), Monday – Friday 9:00am-5:00pm

Member Claims

The VHP website has complete directions on how to submit a claim for services members might incur out of the plan network. Members would only be submitting claims for services that were provided for out of area Emergency or Urgent Care services at a non-contracted provider, from a pre-approved referral to a non-contracted provider, or for a prescription when local network pharmacies are closed. For care that is provided at an in-network contracted provider, there should be no need for the member to submit their own claim.

For information about reimbursement claims or to get a claim reimbursement form, visit 2480 N. First Street, Suite 160, San Jose, CA 95131, call Member Services at 1.888.421.8444 (toll-free), or go to www.valleyhealthplan.org under "Member Forms and Resources."

Submission of Provider Claims

Providers that have a contract with VHP must submit their claims within 90 days. Non-contracted providers have up to 180 days to submit a claim to VHP. VHP has 45 business days to process a clean claim form the time of receipt.

Grace Periods and Claims Pending

You are required to pay your premium by the scheduled due date. If you do not do so, your coverage could be canceled. VHP is required to give you a three-month grace period, beginning after the last day of paid coverage, to pay your outstanding premium before your coverage terminates.

What happens if my coverage ends?

If your coverage ends because you do not pay your full premium balance by the end of your grace period, you will be financially responsible for the payment of claims for all health care services received after your last day of coverage. You may also owe a tax penalty when you file your state income tax return for the year if you have any gap in qualifying health coverage of three months or more during the year.

Referrals/Prior Authorizations

Before you obtain medical services some services must be approved in advance. This is called prior authorization or preservice review. Valley Health Plan (VHP) contracts with Primary Care Physicians (PCPs) and Plan Providers who are responsible to provide and coordinate Covered Services or Benefits for you, the Member. Except in the case of Emergency Services, Urgently Needed Services, or if VHP has Prior Authorized services, you must receive all of your care from these VHP Plan Providers. If you receive services outside of the VHP Network without Prior Authorization, you may be responsible for the charges.

All VHP Covered Services are provided, arranged for, and/or coordinated by your PCP. To receive Covered Services that requires a referral or Prior Authorization:

• Your VHP PCP must initiate the referral or Prior Authorization including services to a specialist
• As needed, this request is submitted to VHP for approval or denial; and
• VHP must also provide the authorization to you, the Member, before you can receive the services.

You and your PCP will receive written notification whether a referral or Prior Authorization request was approved or denied. VHP has five (5) business days to process a routine request and 72 hours for urgent requests.

Pharmacy Benefits

Prescription drugs are an important part of your health and we want you to understand your benefit. To learn more about your pharmacy coverage, network pharmacies, and list of drugs covered by VHP please visit www.valleyhealthplan.org/members/pharmacy

Prescription Exception Process

Sometimes our members may need access to drugs that are not listed on the plan's formulary drug list. As a member of VHP you may qualify for a prescription exception process. This is especially important if you are new to VHP and were previously on a medication that is not on our prescription formulary.

A member can ask for a drug that is not on the formulary by requesting a “Prescription Drug Prior Authorization or Step Therapy Exception Request” by:

1. Asking the Pharmacy to send a request to the prescribing Provider’s office
2. Contacting VHP Member Services at MemberServices@vhp.sccgov.org or by calling 1.888.421.8444 (toll-free)

Prescription exception requests will be reviewed based on established medical criteria and/or medical necessity.

• Turn around time is 72 hours for non-urgent requests and 24 hours for all urgent requests.
• Formulary exceptions may be allowed if the request is determined to be medically necessary.

Explanation of Benefits (EOB)

Each time we process a claim submitted for your medical service, we explain how we processed it on an Explanation of Benefits (EOB) form.

The EOB is not a bill. It explains how your benefits were applied to that particular claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you're responsible for paying the provider. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.

Coordination of Benefits (COB)

Coordination of benefits, or COB, is when you are covered under one or more other group or individual plans, such as one sponsored by your spouse's employer. An important part of coordinating benefits is determining the order in which the plans provide benefits. One plan provides benefits first. This is called the primary plan. The primary plan provides its full benefits as if there were no other plans involved. The other plans then become secondary. Further information about coordination of benefits can be found in your Evidence of Coverage (EOC) booklet, an online version can be found by visiting www.valleyhealthplan.org under "Member Combined Evidence of Coverage (EOC)."

• Western Health Advantage

Both Provider and Consumer claims are processed within 45 working days from the received date of the claim. Under most circumstance, claims should be submitted within 90 days from the date-of-service for provider, 180 days for Consumers. Prior to obtaining services, Providers and Consumers should ensure, if applicable, the services were authorized. If there are questions about a service or authorizations, please contact your PCP, the PCP’s assigned medical group or IPA, or the service provider. If any additional assistance is needed, please contact Western Health Advantage (WHA) Member Services at 888.563.2250.

How and when a Consumer can file a claim

It is important that you present your member ID card at the time of service. The provider will need the information found on your member ID card to bill WHA for the Covered Service(s).

In the unlikely event that you pay for a Covered Service out-of-pocket, you will need to mail or fax the following information to WHA for reimbursement. The Reimbursement Request form can be accessed by logging into your MyWHA account at: : http://mywha.org

1. A signed and dated summary/explanation detailing the service you received
2. Any supporting documentation from the provider who performed this service
3. Proof of payment
4. Your contact information, including:
   • Full Name
   • Phone number
   • Mailing address
   • Email Address
   • WHA member ID

Once WHA receives the above information, you will be notified within 45 business days regarding the outcome of your claim.

Please note: Only services covered under your plan are eligible for reimbursement. Your plan's applicable copayment/coinsurance and/or deductible will determine the total amount you are reimbursed.

For a prescription-only reimbursement contact the OptumRx Member Services online at optumrx.com or by calling 844.568.4150. OptumRx is WHA’s pharmacy benefit manager.

For more information, contact:

Claim Services
916.563.2250 or 888.563.2250 toll-free
Monday through Friday (excluding holidays) 8 a.m. to 6 p.m.
For TDD/TYY: 888.877.5378
Email: memberservices@westernhealth.com or use the Secure Message Center
Fax: 916.568.0126

If you haven’t done so all ready, be sure to visit mywha.org, click “Sign Up for MyWHA Tools” and follow the prompts. Once you are registered, you can download a copy of the Reimbursement Request form, see your personal benefit information, including copayment summaries and Combined Evidence of Coverage and Disclosure Form (EOC/DF).

Some common reasons a claim may be denied

1. Lack of eligibility
2. Non-emergent care, no authorization
3. Non-participating provider, no authorization
4. Not a covered services/benefit per EOC or copayment summary

Right to an Appeal

An Appeal is a verbal or written formal request to re-review or reconsider a decision that has been made. The Appeal can be related to a payment issue, an administrative action, quality of care or service issue, utilization recommendation, or any of the procedures that deal with the review (reconsideration) of adverse initial decisions made regarding healthcare services. Your Appeal will be reviewed by a doctor who was not involved in the initial review of the issue. This doctor will make an independent second decision after reviewing all available information, which may include review by an independent outside organization. The second decision may agree or disagree with the first decision.

Standard or routine Appeals are completed within 30 calendar days. A delay in a final decision may occur if additional information is needed for the reviewer to make an informed decision.

Expedited or “fast track” Appeals are completed within seventy-two (72) hours upon request if delaying the appeal decision risks jeopardizing your health, which includes severe pain or an imminent and serious threat to the health of the Member, including but not limited to potential loss of life, limb or major bodily function. You have the right to request a “fast track” or expedited Appeal if your doctor agrees there are health risks in delaying the decision. WHA’s Medical Director or appropriately licensed designee will make the decision if the Appeal will be handled as an expedited or standard Appeal.

What is WHA's Appeal and Grievance Procedure?

If you have a Complaint with regard to WHA’s failure to authorize, provide or pay for a service that you believe is covered, a cancellation, termination, non-renewal or rescission of your membership or any other Complaint, please call Member Services for assistance. If your Complaint is not resolved to your satisfaction after working with a Member Services representative, a verbal or written Appeal or Grievance may be submitted to:

Mail: Western Health Advantage

Attn: Appeals and Grievances

2349 Gateway Oaks Drive, Suite 100

Sacramento, CA 95833

Secure Fax: 916.563.2207

Call: WHA Member Services

916.563.2250 or 888.563.2250

Secure Email: mywha.org/securemessage

You may also start the Grievance process by completing WHA's online Grievance Form by visiting our website at westernhealth.com.

Please include a complete discussion of your questions or situation and your reasons for dissatisfaction and submit the Appeal or Grievance to WHA Member Relations Unit, Appeals and Grievances Department within one hundred eighty (180) days of the incident or action that caused your dissatisfaction. If you are unable to meet this period, please contact Member Services on how to proceed.

If you are appealing a denial of services included within an already-approved ongoing course of treatment, coverage for the approved services will be continued while the Appeal is being decided.

If you believe that your membership has been or will be improperly canceled, rescinded or not renewed, you may request a review by the Department of Managed Health Care after participating in WHA’s grievance process for thirty (30) days. If your coverage is still in effect when you submit your Grievance to WHA, your coverage will be continued while your Grievance is being decided, including during the time it is being reviewed by the Department of Managed Health Care. All premiums must continue to be paid timely for coverage to continue. At the conclusion of the Grievance, including any appeal to the Department of Managed Health Care, if the issue is decided in your favor, coverage will continue or you will be reinstated retroactively to the date your coverage was initially terminated. All Premiums must be up to date and paid timely.

WHA sends an acknowledgment letter to the Member within five (5) calendar days of receipt of the Appeal or Grievance. A determination is rendered within thirty (30) calendar days of receipt of the Member’s Appeal or Grievance. WHA will notify the Member of the determination, in writing, within three (3) working days of the decision being rendered.

A Grievance Form and a description of the Grievance procedures are available at every Medical Group and Plan facility and on WHA’s website. In addition, a Grievance Form will be promptly sent to you if you request one by calling Member Services. If you would like assistance in filing a Grievance or an Appeal, please call Member Services and a representative will assist you in completing the form or explain how to write your letter. We will also be happy to take the information over the phone verbally or through a secure message.

It is the policy of WHA to resolve all Appeals and Grievances within thirty (30) days of receipt. For appeals of denials of coverage or benefits, you will be given the opportunity to review the contents of the file and to submit testimony to be considered. Written notification of the disposition of the grievance or appeal will be sent to the Member and will include an explanation of the contractual or clinical rationale for the decision. Contact Member Services for more detailed information about the Appeal and Grievance procedure.

If you have a complaint regarding your dental, vision, chiropractic/acupuncture, or mental health services, contact our Plan partners for information regarding how to lodge an Appeal or Grievance.

Grace Period

• The 30-day grace period begins on the 1st day of the month, with no gap in coverage.
• Your coverage remains after the 30 days as long as all past due premium payments are paid. If not paid for, your health coverage will end at the end of the grace period.

30-day grace period

• The 30-day grace period begins on the 1st day of the month, with no gap in coverage.
• Your coverage remains after the 30 days as long as all past due premium payments are paid. If not paid for, your health coverage will end at the end of the grace period.

90-day grace period for members who get premium tax credits

Enrolled members who receive premium payment tax credits have a three-month (90-day) grace period.

• Month 1

  1. Same as above, 30-day grace period.
  2. You still need to pay your premium payments. You also need to pay all copayments, coinsurance or deductible amounts required under the plan contract for this period.

• Months 2 and 3

  1. Western Health Advantage will hold/pend your claims until you have paid all past due premium payments to us.
  2. You will keep getting monthly premium payment bills. This means your total amount due will include your unpaid balance/month(s) plus your current premium due.

• At the end of the grace period

  1. Your health plan will end due to nonpayment of premiums if Western Health Advantage does not receive all premium payment amounts due through the grace period. The total is due by the last day of the grace period. Any claims or authorizations that were held/pended will be denied. You will still owe the unpaid premium amount. You also have to pay for any health care services you received during months 2 and 3. This includes emergency care. If your health plan coverage is ended for nonpayment of premiums, the end date of your health plan will be the last day of the first month of the three-month grace period.

Department of Managed Health Care Information

The California Department of Managed Health Care (DMHC) is responsible for regulating health care service plans. If you have a Grievance against your health plan, you should first telephone your health plan at one of the numbers listed below and use your health plan's Grievance process before contacting the department. Utilizing this Grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a Grievance involving an emergency, a Grievance that has not been satisfactorily resolved by your health plan or a Grievance that has remained unresolved for more than thirty (30) days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, Coverage Decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number, 888.HMO.2219 (888.466.2219), and a TDD line, 877.688.9891, for the hearing and speech impaired. The department's Internet Web site, www.hmohelp.ca.gov, has Complaint forms, IMR application forms and instructions online. The Plan's Grievance process and the Department's Complaint review processes are in addition to any other dispute resolution procedures that may be available to you, and your failure to use these processes does not preclude your use of any other remedy provided by law.

Non-Participating/Out-of-network Providers

Any coverage for services provided by a Physician or other health care provider who is not a Participating Provider requires written Prior Authorization before the service is obtained, except in Medically Necessary Emergency Care situations and Medically Necessary Urgent Care situations that arise outside WHA’s Service Area. If you receive services from a non-Participating Provider without first obtaining Prior Authorization from WHA or your Medical Group, you will be liable to pay the non-Participating Provider for the services you receive.

Balance billing

Non-participating hospitals and Physicians are prohibited under state law from billing you more than your applicable copayment and/or deductible for emergency services. When you receive emergency services from a non-participating hospital or Physician, WHA will receive a bill and will pay the reasonable and customary value for the services, as required by law. Regardless of the amount of the total billed charges, you are never responsible for more than your applicable copayment and/or deductible for emergency services. If you were billed more than your applicable copayment and/or deductible for emergency services provided by a nonparticipating hospital or Physician, you may report the provider to the California Department of Managed Health Care by calling 888.466.2219. You may also contact Appeals and Grievances or WHA’s Member Services at one of the numbers listed below for assistance:

Mail: Western Health Advantage

Attn: Appeals and Grievances

2349 Gateway Oaks Drive, Suite 100

Sacramento, CA 95833

Secure Fax: 916.563.2207

Call: WHA Member Services

916.563.2250 or 888.563.2250

Secure Email: mywha.org/securemessage

Retroactive denials

You are responsible for prepayment of monthly Premiums for WHA coverage by the first business day of each month. Health services are covered only for Members whose prepayment fees have been received by WHA, and coverage extends only through the period for which such payment is received. If you have made arrangements for a third party to pay your premium, you remain ultimately responsible for payment. If a third-party payor cancels electronic funds transfer, or otherwise fails to pay your premium, you must make alternate payment arrangements prior to your next premium payment due date. Coverage may be terminated as allowed by law if payments are not made. You are responsible for any services obtained following the date of termination.

Explanation of benefits (EOB)

An explanation of benefits (EOB) statement often arrives via mail and closely resembles a medical bill. The EOB provides details about a medical insurance claim that has been processed and explains what portion was paid to the health care provider and what portion of the payment, if any, is the patient's responsibility. The EOB is not a bill. Any EOB may be supplied or requested.

Coordination of benefits (COB)

Coordination of benefits (“COB”) is a process used by WHA and other health plans, employer benefit plans, union welfare plans, HMOs, insurance companies, government programs and other types of payors to make sure that duplicate payments are not made for the same claims when more than one Insurer covers a Member. This section summarizes the key rules by which WHA will determine the order of payment of claims while providing that the Member does not receive more than one hundred percent (100%) coverage from all plans combined. All of the benefits provided under this EOC/DF are subject to COB. You are required to cooperate and assist with WHA’s coordination of benefits by telling all of your health care providers if you or your dependents have any other coverage. You are also required to give WHA your Social Security Number and/or Medicare identification number to facilitate coordination of benefits. Please review your plan’s EVIDENCE OF COVERAGE (EOC) for additional details.