2025 Transparency Notice

HMO 2025 Transparency Notice
EPO 2025 Transparency Notice

2025 HMO 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).

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 may happen if your provider is not contracted with us.

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

To request reimbursement for a covered service, you need a copy of the detailed claim from your provider. You also need to submit a copy of the Member Reimbursement Claim Form (PDF) posted at Ambetter.pshpgeoriga.com under “For Member – Forms and Materials.” Send all the documentation to us at the following address:

Ambetter from Peach State Health Plan
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 30 calendar days or less.

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

For services that do not fall under Georgia state law balance billing protections, benefits will be processed within 30 calendar days after receipt of proper proof of loss. For services that fall under Georgia state law balance billing protections, benefits will be paid within 15 working days for clean claims filed electronically or 30 calendar days for clean claims filed on paper.

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 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 60-day grace period. During this time, we will continue to cover your care, but we may hold your claims. We will notify the member of the non-payment of premiums, as well as providers of 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.

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 a network provider.

If you believe the denial is in error, you are encouraged to contact member’s services department 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 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 eCashering. 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 any medical service, items, supply, or treatment to diagnose and treat a member's illness or injury:

Is consistent with the symptoms or diagnosis;
Is provided according to generally accepted standards of medical practice;
Is not custodial care;
Is not solely for the convenience of the provider or the member;
Is not experimental or investigational;
Is provided in the most cost effective care facility or setting;
Does not exceed the scope, duration, or intensity of that level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment; 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.

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

Prior Authorization Required

Some medical and behavioral health covered service expenses require prior authorization. In general, network providers must obtain authorization from us prior to providing a service or supply to a member. However, there are some network eligible service expenses for which you must obtain the prior authorization.

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

Receives a service or supply from a non-network provider;
Are admitted into a network facility by a non-network provider; or
Receives a service or supply from a network provider to which you or your dependent member was referred by a non-network provider.

Prior authorization requests (medical and behavioral health) must be received by phone, efax, or provider web 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 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 1 calendar day of receipt of the request.
For urgent pre-service reviews, within 72 hours from receipt of request.
For non-urgent pre-service reviews, within 7 calendar days of receipt of the request.
For post-service requests 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.

Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements will result in benefits being reduced. Please see the 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 Peach State Health Plan
Attn: Member Services
1100 Circle 75 Parkway, Suite 1100
Atlanta, GA 30339

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. 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 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 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 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. 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 request, we will provide coverage of the non-formulary drug 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 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

Coordination of Benefits exists when an enrollee is covered by another plan besides Ambetter and determines which plan pays first. We coordinate benefits with other payers as required by any federal or state laws. Medicaid is always the payer of last resort.

2025 EPO Transparency Notice

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 from Peach State Health Plan
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 30 calendar days or less.

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.

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’s services department 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 any medical service, items, supply, or treatment to diagnose and treat a member's illness or injury:

Is consistent with the symptoms or diagnosis;
Is provided according to generally accepted standards of medical practice;
Is not custodial care;
Is not solely for the convenience of the provider or the member;
Is not experimental or investigational;
Is provided in the most cost effective care facility or setting;
Does not exceed the scope, duration, or intensity of that level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment; 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.

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

Prior Authorization Required

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:

Receives a service or supply from a non-network provider;
Are admitted into a network facility by a non-network provider; or
Receives a service or supply from a network provider to which you or your dependent member was referred by a non-network provider.

Prior authorization requests (medical and behavioral health) must be received by phone, efax, or provider web 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 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 1 calendar day of receipt of the request.
For urgent pre-service reviews, within 72 hours from date of receipt of request.
For non-urgent pre-service reviews, within 7 calendar days of receipt of the request.
For post-service requests 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.

Failure to Obtain Prior Authorization

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

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

G) Drug Exceptions Timeframes and Enrollee Responsibilities

Prescription Drug Exception Process

Ambetter Health Solutions
Attn: Member Services
1100 Circle 75 Parkway, Suite 1100
Atlanta, GA 30339

Standard exception request

Expedited exception request

External exception request review

H) Information on Explanations of Benefits

I) Coordination of Benefits

Coordination of Benefits exists when an enrollee is covered by another plan besides Ambetter Health and determines which plan pays first. We coordinate benefits with other payers as required by any federal or state laws. Medicaid is always the payer of last resort.