2025 Transparency Notice

2025 Transparency Notice HMO
2025 Transparency Notice HMO - Ambetter Health Solutions

2025 Transparency Notice HMO

A) Out-of-network liability and balance billing

The Ambetter network is the group of providers, including but not limited to physicians, hospitals, pharmacies, other facilities and health care professionals, we contract with to provide care for you. If a provider is in our network, services are covered by your health insurance plan. Network providers may not bill you for covered expenses beyond your applicable cost sharing amounts (e.g., copayment, coinsurance, and/or a deductible).

If you receive services from a non-network provider, you may be responsible for the difference between the amount the provider charges for the service (billed amount) and the allowed amount that we pay. However, you will not be responsible for balance billing for non-network care that is subject to balance billing protections and otherwise covered under your contract. If you are balance billed in these situations, please contact Member Services immediately at the number listed on the back of your member identification card.

When receiving care at a network hospital it is possible that some hospital-based providers may not be network providers. If you provide notice and consent to waive balance billing protections, you may be responsible for payment of all or part of the balance bill. Any amount you are obligated to pay to the non-network provider in excess of the eligible expense will not apply to your deductible amount or maximum out-of-pocket.

B) Enrollee Claim Submission

Providers will typically submit claims on your behalf, but sometimes you may need to submit claims yourself for covered services. This may happen if your provider is not contracted with us.

We must receive written proof of loss within 90 calendar days of the loss or as soon as is reasonably possible. Proof of loss furnished more than one year late will not be accepted, unless you or your covered dependent member had no legal capacity to submit such proof during that year.

If you have paid for services we agreed to cover, you can request reimbursement for the amount you paid, less any deductible, copayment or cost sharing that is your financial responsibility. We must receive notice of claim within 30 calendar days after the occurrence or commencement of any loss or as soon as reasonably possible.

To request reimbursement for a covered service, you need a copy of the detailed claim or bill from the provider. You also need to submit an explanation of why you paid for the covered services along with the Member Reimbursement Claim Form (PDF) posted at Ambetter.BuckeyeHealthPlan.com under “For Members-Forms and Materials”. Send this to us at the following address:

Ambetter from Buckeye Health Plan
Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-5010

Benefits will be paid within 30 calendar days after receipt of proof of loss. Should we determine that additional supporting documentation is required to establish responsibility of payment, we shall pay benefits within 45 calendar days after receipt of proof of loss. If we do not pay within such period, we shall pay interest at the rate of 18 percent per annum from the 31st calendar day after receipt of such proof of loss to the date of late payment.

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.

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.

If you receive a subsidy payment

After you pay your first bill, you have a three-month grace period. During the first month of your grace period, we will keep paying claims for covered services you receive. If you continue to receive services during the second and third months of your grace period, we may hold these claims. If your coverage is in the second or third month of a grace period, we will notify you and your healthcare providers about the possibility of denied claims.

If you don’t receive a subsidy payment

After you pay your first bill, you have a grace period of 60 calendar days. During this time, we will continue to cover your care, but we may hold your claims. We will notify you, your providers and HHS about this non-payment and the possibility of denied claims.

D) Retroactive Denials

"Retroactive denial of a previously paid claim" or "retroactive denial of payment" means any attempt by a carrier retroactively to collect payments already made to a provider with respect to a claim by reducing other payments currently owed to the provider, by withholding or setting off against future payments, or in any other manner reducing or affecting the future claim payments to the provider.

There are instances where claims may be denied retroactively if you received services from a provider or facility that is not in our network, terminate coverage with Ambetter, provide late notification of other coverage due to new coverage, or have a change in circumstance, such as divorce or marriage. This causes Ambetter to request recoupment of payment from the Provider.

Retroactive denials can be avoided by paying your premiums on time and in full, and making sure you talk to your provider about whether the service performed is a covered benefit. You can also avoid retroactive denials by obtaining your medical services from an in-network provider.

If you believe the denial is in error, you are encouraged to contact Member Services by calling the number on your member identification card.

E) Recoupment of Overpayments

If you believe you have paid too much for your premium and should receive a refund, please contact Member Services immediately at the number listed on the back of your member identification card. 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 e-Cashiering, interactive voice response (IVR), auto pay, or member portal, as well as credit card payments sent to our lockbox vendor, will be refunded via e-Cashiering. Payments made via e-Check will also be refunded electronically. Payments made by check to our lockbox vendor and payments that were processed in-house at our Little Rock location must be refunded manually via live check.

F) Medical Necessity and Prior Authorization

Services are only covered if they are medically necessary. Medically necessary services are those that:

Are consistent with the symptoms or diagnosis;
Are provided according to generally accepted standards of medical practice;• Are not custodial care;
Demonstrate that the member is reasonably capable of improving in his/her functional ability;
Are not solely for the convenience of the provider or the member;
Are not experimental or investigational;
Are provided in the most cost-effective care facility or setting;
Do not exceed the scope, duration, or intensity of that level of care that is needed to provide safe, adequate, and appropriate diagnosis or treatment; and
When specifically applied to a hospital confinement, it means that the diagnosis and treatment of your medical symptoms or conditions cannot be safely provided as an outpatient.

Some covered service expenses require prior authorization. There are some network eligible service expenses for which you must obtain the prior authorization.

For services or supplies that require prior authorization, as shown on the Schedule of Benefits, you must obtain authorization from us before you:

Receive a service or supply from a non-network provider;
Are admitted into a network facility by a non-network provider; or
Receive a service or supply from a network provider to which the member was referred by a non-network provider.

Prior Authorization requests must be received by phone/e-fax/Provider portal as follows:

At least 5 calendar days prior to an elective or scheduled admission as an inpatient in a hospital, extended care or rehabilitation facility, or hospice facility or as soon as reasonably possible.
At least 30 calendar days prior to the initial evaluation for organ transplant services or as soon as reasonably possible.
At least 30 calendar days prior to receiving clinical trial services or as soon as reasonably possible.
Within 24 hours (or as soon as reasonably possible) of any inpatient admission, including emergent inpatient admissions.
At least 5 calendar days prior to the start (or as soon as reasonably possible) of home health care except those members needing home health care after hospital discharge.

After prior authorization has been received, we will notify you and your provider if the request has been approved or denied as follows:

For urgent care services, within one calendar day of receipt of the request.
For urgent concurrent review within 48 hours of receipt of the request.
For non-urgent pre-service requests within 10 calendar days of receipt of the request.
For post-service requests, within 30 calendar days of receipt of the request.

In situations where additional information is needed to make a decision, these timeframes may be extended in accordance with applicable law.

Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements will result in benefits being denied.

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.

Network providers cannot bill you for services for which they fail to obtain prior authorization as required.

G) Drug Exceptions Timeframes and Enrollee Responsibilities

Sometimes members need access to drugs that are not listed on the formulary. Members or provider can submit a drug exception request to us by contacting Member Services or by sending a written request to the following address:

Ambetter from Buckeye Health Plan
Attn: Member Services
4349 Easton Way
Suite 120
Columbus, OH 43219

Standard exception request

A member, a member’s authorized representative or a member’s prescribing physician may request a standard review of a decision that a drug is not covered by the plan. Within 72 hours of the request being received, we will provide the member, the member’s authorized representative or the member’s prescribing physician with our coverage determination. Should the standard exception request be granted, we will provide coverage of the non-formulary drug for the duration of the prescription, including refills.

Expedited exception request

A member, a member’s authorized representative or a member’s prescribing physician may request an expedited review based on exigent circumstances. Exigent circumstances exist when a member is suffering from a health condition that may seriously jeopardize the 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. The request can be made in writing or via telephone. Within 24 hours of the request being received, we will provide the member, the member’s authorized representative or the member’s prescribing physician with our coverage determination. Should the expedited exception request be granted, we will provide coverage of the non-formulary drug for the duration of the exigency.

External exception request review

If we deny a request for a standard exception or for an expedited exception, the member, the member’s authorized representative or the member’s prescribing physician may request that the original exception request and subsequent denial of such request be reviewed by an independent review organization (IRO).

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.

I) Coordination of Benefits

The Coordination of Benefits (COB) provision applies when you have healthcare coverage under more than one Plan.

The order of benefit determination rules governs the order which each Plan will pay a claim for benefits. The Plan that pays first is called the Primary Plan. The Primary Plan must pay benefits according to its policy terms without regard to the possibility that another Plan may cover some expenses. The Plan that pays after the Primary Plan is the Secondary Plan. The Secondary Plan may reduce the benefits it pays so that payments from all Plans do not exceed 100 percent of the total Allowable Expense.

2025 Transparency Notice HMO - Ambetter Health Solutions

A) Out-of-network liability and balance billing

The Ambetter Health network is the group of providers, including but not limited to physicians, hospitals, pharmacies, other facilities and health care professionals, we contract with to provide care for you. If a provider is in our network, services are covered by your health insurance plan. Network providers may not bill you for covered expenses beyond your applicable cost sharing amounts (e.g., copayment, coinsurance, and/or a deductible).

B) Enrollee Claim Submission

Providers will typically submit claims on your behalf, but sometimes you may need to submit claims yourself for covered services. This may happen if your provider is not contracted with us.

Ambetter Health Solutions
Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-5010

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.

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.

If you receive a subsidy payment

If you don’t receive a subsidy payment

D) Retroactive Denials

There are instances where claims may be denied retroactively if you received services from a provider or facility that is not in our network, terminate coverage with Ambetter Health, provide late notification of other coverage due to new coverage, or have a change in circumstance, such as divorce or marriage. This causes Ambetter Health to request recoupment of payment from the Provider.

If you believe the denial is in error, you are encouraged to contact Member Services by calling the number on your member identification card.

E) Recoupment of Overpayments

F) Medical Necessity and Prior Authorization

Services are only covered if they are medically necessary. Medically necessary services are those that:

Are consistent with the symptoms or diagnosis;
Are provided according to generally accepted standards of medical practice;
Are not custodial care;• Demonstrate that the member is reasonably capable of improving in his/her functional ability;
Are not solely for the convenience of the provider or the member;
Are not experimental or investigational;
Are provided in the most cost-effective care facility or setting;
Do not exceed the scope, duration, or intensity of that level of care that is needed to provide safe, adequate, and appropriate diagnosis or treatment; and
When specifically applied to a hospital confinement, it means that the diagnosis and treatment of your medical symptoms or conditions cannot be safely provided as an outpatient.

Some covered service expenses require prior authorization. There are some network eligible service expenses for which you must obtain the prior authorization.

For services or supplies that require prior authorization, as shown on the Schedule of Benefits, you must obtain authorization from us before you:

Receive a service or supply from a non-network provider;
Are admitted into a network facility by a non-network provider; or
Receive a service or supply from a network provider to which the member was referred by a non-network provider.

Prior Authorization requests must be received by phone/e-fax/Provider portal as follows:

At least 5 calendar days prior to an elective or scheduled admission as an inpatient in a hospital, extended care or rehabilitation facility, or hospice facility or as soon as reasonably possible.
At least 30 calendar days prior to the initial evaluation for organ transplant services or as soon as reasonably possible.
At least 30 calendar days prior to receiving clinical trial services or as soon as reasonably possible.
Within 24 hours (or as soon as reasonably possible) of any inpatient admission, including emergent inpatient admissions.
At least 5 calendar days prior to the start (or as soon as reasonably possible) of home health care except those members needing home health care after hospital discharge.

After prior authorization has been received, we will notify you and your provider if the request has been approved or denied as follows:

For urgent care services, within one calendar day of receipt of the request.
For urgent concurrent review within 48 hours of receipt of the request.
For non-urgent pre-service requests within 10 calendar days of receipt of the request.
For post-service requests, within 30 calendar days of receipt of the request.

In situations where additional information is needed to make a decision, these timeframes may be extended in accordance with applicable law.

Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements will result in benefits being denied.

Network providers cannot bill you for services for which they fail to obtain prior authorization as required.

G) Drug Exceptions Timeframes and Enrollee Responsibilities

Ambetter Health Solutions
Attn: Member Services
4349 Easton Way
Suite 120
Columbus, OH 43219

Standard exception request

Expedited exception request

External exception request review

H) Information on Explanations of Benefits

I) Coordination of Benefits

The Coordination of Benefits (COB) provision applies when you have healthcare coverage under more than one Plan.