2023 Aviso sobre la transparencia

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 non-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 called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual maximum out-of-pocket limit.

When receiving care at an Ambetter network facility, it is possible that some hospital-based providers (for example, assistant surgeons, hospitalists, and intensivists) may not be under contract with Ambetter as network providers. We encourage you to inquire about the providers who will be treating you before you begin your treatment, so that you can understand their network participation status with Ambetter.

As a member of Ambetter, non-network providers should not bill you for covered services for any amount greater than your applicable network cost sharing responsibilities when:

You receive a covered emergency service or air ambulance service from a non-network provider. This includes services you may get after you are in stable condition, unless the non-network provider obtains your written consent.
You receive non-emergency ancillary services (emergency medicine, anesthesiology, pathology, radiology, and neonatology, as well as diagnostic services (including radiology and laboratory services)) from a non-network provider at a network hospital or network ambulatory surgical facility.
You receive other non-emergency services from a non-network provider at a network hospital or network ambulatory surgical facility, unless the non-network provider obtains your written consent.

B) Enrollee Claim Submission

Network providers are contractually, but sometimes you may need to submit claims yourself for covered services. This usually happens if:

Your provider is not contracted with us
You have an out-of-area emergency.

If you have paid for services we agreed to cover, you can request reimbursement for the amount you paid. We can adjust your deductible, copayment or cost sharing to reimburse you. We must receive notice of claim within 30 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 ambetterofillinois.com under “For Members – Forms and Materials”. Send all the documentation to us at the following address:

Ambetter of Illinois
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 days or less.

Benefits will be paid within 30 business 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 30 days after receipt of proof of loss. If we do not pay within such period, we shall pay interest at the rate of nine percent per annum from the 30th 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 pay (we understand that stuff happens sometimes).

During your grace period, you will still have coverage. However, if you don’t pay before a grace period ends, you run the risk of losing your coverage. During a grace period, we may hold — or pend — your claim payment.

If your coverage is terminated for not paying your premium, you won’t be eligible to enroll with us again until Open Enrollment or a Special Enrollment period. So make sure you pay your bills on time!

If you receive a subsidy payment

After you pay your first bill, you have a 90 day 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 days. During this time, we will continue to cover your care, but we may hold your claims. We will notify the member 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.

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

Members may call in to request a refund of overpaid premium. Refunds are processed by two methods, electronically or by a manual check. The type of refund issued is dependent on the method of payment. Payments made with a debit/credit card via eCashiering, IVR, auto pay, member portal as well as credit card payments sent to our lockbox vendor will be refunded via eCashiering. Payments made via eCheck will also be refunded electronically. Payments made by check to our lockbox vendor and payments that were processed in-house at our Little Rock location must be refunded manually via live check.

F) Medical Necessity and Prior Authorization

Services are only covered if they are medically necessary. Medically necessary services are any medical service, item, 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 medical practice standards;
Is not custodial care;
Is not solely for the convenience of the physician 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 service expenses.

Some covered service expenses require prior authorization. In general, network providers must obtain authorization from us prior to providing a service or a supply to a member. 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 you were referred by a non-network provider.

Prior Authorization requests must be received by phone/efax/provider web portal as follows:

At least 5 days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, or hospice facility.
At least 30 days prior to the initial evaluation for organ transplant services.
At least 30 days prior to receiving clinical trial services.
Within 24 hours of any inpatient admission, including emergent inpatient admissions.
At least 5 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 requested and all required or applicable documentation has been submitted, we will notify you and your provider if the request has been approved as follows:

For urgent concurrent reviews, within 24 hours of receipt of the request.
For urgent pre-service reviews, within 48 hours from date of receipt of request.
For non-urgent pre-service reviews, within 5 days of receipt of the request.
For post-service or retrospective reviews, within 30 calendar days of receipt of the request.

Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements will result in benefits being reduced. There is a penalty if treatment is not authorized prior to service. The penalty is a 20 percent reduction of the eligible expenses for all charges related to the treatment, not to exceed $1,000. The penalty applies to all otherwise eligible expenses that are:

Incurred for treatment without prior authorization;
Incurred during additional hospital days without prior authorization; or
Determined to be inappropriately authorized following a retrospective review, or inappropriately authorized due to intentional misrepresentation of facts or false statements.

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

In cases of emergency, benefits will not be reduced for failure to comply with prior authorization requirements. However, you must contact us as soon as reasonably possible after the emergency occurs.

G) Drug Exceptions Timeframes and Enrollee Responsibilities

Prescription Drug 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 at 1-855-745-5507 (TTY/TDD 1-844-517-3431) or by sending a written request to the following address:

Ambetter of Illinois
Attn: Member Services
200 East Randolph Street
Chicago, IL 60601

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 member's life, health, or ability to regain maximum function or when an member is undergoing a current course of treatment using a non-formulary drug. Within 24 hours of the request being received, we will provide the member, the member’s 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 at 1-855-745-5507 (TTY/TDD 1-844-517-3431).

I) Coordination of Benefits with a Medicare plan

If a member and/or dependent member is enrolled in Medicare and Ambetter of Illinois insured by Celtic Insurance Company, Medicare will be the primary payer and Ambetter of Illinois insured by Celtic Insurance Company will be the secondary payer. Ambetter of Illinois insured by Celtic Insurance Company will not pay benefits until after Medicare has paid its share of the costs. Ambetter of Illinois insured by Celtic Insurance Company will reimburse part or all of the allowable expense left unpaid. The member will be responsible for the remaining out‐of‐pocket expenses as applicable.

A member or dependent member enrolled in Ambetter of Illinois insured by Celtic Insurance Company and Medicare is required to notify the Health Insurance Marketplace. The member’s profile will be updated to indicate the member has Medicare coverage. Members will no longer be eligible to receive a premium subsidy for the Health Insurance Marketplace plan once Medicare coverage becomes effective.