2025 Transparency Notice

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 provider that is out-of-network, you may have to pay more for services you receive. Non-network providers may be permitted to bill you for the difference between what your plan agreed to pay, and the full amount charged for a service. This is known as “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

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 amount.

If you receive services from a non-network provider, you may have to pay more for services you receive. Non-network providers may be permitted to bill you for the difference between what we agreed to pay and the full billed amount for a service. This is known as balance billing. This amount is likely more than network costs for the same service and might not count toward your annual maximum out-of-pocket amount limit.

However, you will not be balance billed when balance billing protections apply to covered services.

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 usually happens 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 20 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 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.PAhealthwellness.com under “For Member” then “Forms and Materials”. Send all the documentation to us at the following address:

Ambetter from PA Health & Wellness
Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-5010

After getting your claim, we will let you know we have received it, begin an investigation, and request all items necessary to resolve the claim. We will do this in 20 calendar days or less. Benefits will be processed immediately for clean claims.

We will notify you, in writing, that we have either accepted or rejected your claim for processing within 30 calendar days. If we are unable to come to a decision about your claim within 20 calendar days, we will let you know and explain why we need additional time. If we reject your claim, the notice will state the reason why.

C) Grace Periods and Claims Pending

If you don’t pay your premium by its due date, you’ll enter a grace period. This is the extra time we give you to pay.

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 3-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 and your providers 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 from PA Health & Wellness to request recoupment of payment from the provider. We will not retroactively deny reimbursement as a result of an overpayment determination more than 24 months after the date we initially paid the provider.

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

If you believe the denial is in error, you are encouraged to contact our Member Services department by calling the number on your ID 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 issued is dependent on the method of payment. Payments made with a debit/credit card via eCashiering, Interactive Voice Response (IVR), auto pay, or member portal, as well as credit card payments sent to our lockbox vendor will be refunded via eCashiering. Payments made via eCheck will also be refunded electronically. Payments made by check to our lockbox vendor and payments that were processed in-house at our Little Rock location must be refunded manually via live check.

F) Medical Necessity and Prior Authorization

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

Are the most appropriate level of service for the member considering potential benefits and harm.
Are known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes.

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

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

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.

Pursuant to the federal No Surprises Act, emergency services received from a non-network provider are covered services without prior authorization.

Prior Authorization (medical and behavioral health) requests must be received by phone/efax/provider portal as follows:

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

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

For urgent concurrent reviews, within one calendar day of receipt of the request.
For urgent pre-service reviews, the lesser of two business days or three calendar days from receipt of the request.
For non-urgent pre-service reviews, within two business days of receipt of the request.
For post-service or retrospective reviews, 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.

You do not need to obtain prior authorization from us or from any other person (including your PCP) in order to obtain access to obstetrical or gynecological care from a medical practitioner in our network who specializes in obstetrics or gynecology. The medical practitioner, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan or procedures for making referrals. For a list of participating medical practitioners who specialize in obstetrics or gynecology, contact Member Services.

Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements will result in benefits being reduced. Please see the contract Schedule of Benefits for specific details.

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

Benefits will not be reduced for failure to comply with prior authorization requirements prior to receiving emergency services. However, you must contact us as soon as reasonably possible after you receive the emergency services.

G) Drug Exceptions Timeframes and Enrollee Responsibilities

Prescription Drug Exception Process

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 PA Health & Wellness
Attn: Member Services
1700 Bent Creek Blvd., Ste. 200
Mechanicsburg, PA 17050

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 us or a protocol exception for step therapy. The request can be made in writing or via telephone. Within 72 hours of the request being received, we will provide the member, the member’s authorized representative or the member’s prescribing physician with our coverage determination. Should the standard exception request or step therapy protocol exception request be granted, we will provide coverage of the non-formulary drug for the duration of the prescription, including refills, or of the drug that is the subject of the protocol exception.

Expedited exception request

A member, a member’s 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 member's life, health, or ability to regain maximum function or when a member 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 standard exception or step therapy protocol exception request be granted, we will provide coverage of the non-formulary drug or the drug that is the subject of the protocol exception for the duration of the exigency.

External exception request review

If we deny a request for a standard exception or for an expedited exception,

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. We will make our determination on the external exception request and notify the member, the member’s authorized representative or the member’s prescribing physician of our coverage determination no later than 72 hours following receipt of the request, if the original request was a standard exception, and no later than 24 hours following its receipt of the request, if the original request was an expedited exception.

If we grant an external exception review of a standard exception or step therapy protocol exception request, we will provide coverage of the non-formulary drug or the drug that is the subject of the protocol exception for the duration of the prescription. If we grant an external exception review of an expedited exception request, we will provide coverage of the non-formulary drug or the drug that is the subject of the protocol exception for the duration of the exigency.

H) Information on Explanations of Benefits

An Explanation of Benefits (EOB) is a statement that we send to members to explain what medical treatments and/or services we paid for on behalf of a member. This shows the amount billed by the provider, the issuer’s payment, and the enrollee’s financial responsibility pursuant to the terms of the policy. We will send an EOB to a member after we receive and adjudicate a claim on your behalf from a provider. If you need assistance interpreting your Explanation of Benefits, please contact Member Services.

I) Coordination of Benefits

We coordinate benefits with other payers when a member is covered by two or more group health benefit plans, as defined below. Coordination of Benefits (COB) is the industry standard practice used to share the cost of care between two or more carriers when a member is covered by more than one health benefit plan.

It is a contractual provision of a majority of health benefit policies. Ambetter complies with federal and state regulations for COB and follows COB guidelines published by National Association of Insurance Commissioners (NAIC).

Under COB, the benefits of one plan are determined to be primary and are first applied to the cost of care. After considering what has been covered by the primary plan, the secondary plan may cover the cost of care up to the fully allowed expense according to the plan’s payment guidelines. Ambetter Claims COB and Recovery Unit procedures are designed to avoid payment in excess of allowable expense while also making sure claims are processed both accurately and timely.

“Allowable expense” is the necessary, reasonable, and customary item of expense for health care, when the item is covered at least in part under any of the plans involved, except where a statute requires a different definition. When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered as both an allowable expense and a benefit paid. When Medicare is the Primary Plan, Medicare’s allowable expense is the allowable expense when we are paying claims as the Secondary Plan.