Ambetter Health Solutions 2026 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 should not bill you for covered services 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 called “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. However, you are not responsible for balance billing when balance billing protections apply to covered services.

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.

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

1. You receive a covered emergency service or ground 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.
2. 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.
3. 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 will file claims on your behalf with us for covered services. Present your member identification card at the time of service for the provider to bill us for your care. Contact Member Services if you receive a bill for covered services.

We must receive written proof of loss within 90 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 pay out of pocket for covered services because the provider requires more than your appropriate cost sharing, you can request reimbursement for the amount you paid. When appropriate, we adjust your deductible, copayment, or cost sharing to reimburse you. We must receive notice of claim within 30 days after the occurrence or commencement of any loss or as soon as reasonably possible.

Your reimbursement request for a covered service should include:

• A copy of the detailed claim or bill from the treating provider
• The Member Reimbursement Claim Form (PDF), including the required documents listed on the form

Send all complete documentation to:

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

We will acknowledge receiving your reimbursement request and will process your request within 30 business days of receipt.

If we are unable to come to a decision about your claim within 30 business days, we will let you know and explain why we need additional time.

If approved reimbursements are processed and payment will be issued to you within 45 calendar days of receipt.

If we reject your claim, our notices include the reason why and your appeal rights as detailed in your appeals packet.

C) Grace Periods and Claims Pending

If premiums are not paid by the due date, you will enter a grace period. The grace period is extra time given to pay.

During your grace period, you keep your coverage. However, if you don’t pay before the grace period ends, you run the risk of losing your coverage. During grace periods, we may hold or pend claim reimbursement requests. Neither you nor your treating provider is responsible for the cost of any claim reimbursement requests.

If your coverage terminates for not paying your premium, you are not eligible to enroll with us again until Open Enrollment or a Special Enrollment period.

Premium payments are due in advance on a calendar month basis. Monthly payments are due on or before the first day of each month for coverage effective during such month. There is a 60-calendar day grace period. This provision means that if any required premium is not paid on or before the date it is due, it may be paid during the grace period. During the grace period, the policy will stay in force; however, claims may pend for covered services rendered to the member during the grace period. We will notify the member, as well as providers, of the possibility of denied claims when the member is in the grace period.

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 deny retroactively for example if you 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. These scenarios will result in Ambetter recouping 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 recoupment is in error, you are encouraged to contact Member Services 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, are refunded via eCashering. Payments made via eCheck are 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 paper check.

F) Medical Necessity and Prior Authorization

Services are covered when medically necessary. Medically necessary services are health care services that a health care provider, exercising prudent clinical judgment would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease or its symptoms, and that are:

• In accordance with generally accepted standards of medical practice;
• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
• Not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations, the views of physicians practicing in relevant clinical areas and any other relevant factors.

The fact that a provider may prescribe, order, recommend or approve a treatment, service, supply, or medicine does not in itself make the treatment, service, supply or medicine medically necessary as defined in this policy. The terms medically necessary, medically indicated, and medical necessity may be used interchangeably throughout this document.

Prior Authorization Required

Selected services and treatments included in your health plan require approval before you receive them to qualify for coverage payment referred to as prior authorization.

Although a service or treatment lists as a covered benefit, Ambetter requires a prior authorization before you receive the service or treatment. Even those services that are determined to be medically necessary by us must have prior authorization in order to be covered. Physicians and networks cannot deny a service or treatment for failure to obtain prior authorization. Only we can deny coverage of medical services for failure to obtain prior authorization. You can ask your primary care provider or our Member Services Department any questions you have concerning prior authorizations. Prior authorization does not guarantee coverage.

Circumstances in which the services ARE NOT covered include, but are not limited to:

• Other plan provisions are not satisfied (for example, members not enrolled or eligible for service on the date the service is received, or the service is not a covered service);
• Fraudulent, materially erroneous or incomplete information is submitted; or
• A material change in the member’s health condition occurs between the provision date of the prior authorization and the date of the treatment that makes the proposed treatment no longer medically necessary for such member.

In the event that Ambetter certifies the medical necessity of a course of treatment limited by number, time period or otherwise, a request for treatment beyond the certified course of treatment shall be deemed to be a new request.

Except for emergency services, ALL medical services and treatments require the direct coordination of your primary care physician and received within the service area. If they are not, services may be denied by Ambetter.

The following services or supplies may require prior authorization:

1. Hospital confinements
2. Hospital confinement as the result of a medical emergency
3. Hospital confinement for psychiatric care
4. Outpatient surgeries and major diagnostic tests
5. All inpatient services
6. Extended care facility confinements
7. Rehabilitation facility confinements
8. Skilled nursing facility confinements
9. Transplants and
10. Chemotherapy, specialty drugs and biotech medications.

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 should be submitted for medical necessity review as soon as the need for services identified. Requests must be received by telephone, fax, or provider web portal. Faxed requests must be submitted by providers using the required Arizona Department of Insurance and Financial Institutions (DIFI) form, or the plan is not able to review the request.

After prior authorization has been received, we will notify you and your provider of our decision as required by applicable law:

1. For urgent concurrent reviews, received at least 24 hours prior to the expiration of a previously approved course of treatment, within 24 hours of receipt of the request. For all other urgent concurrent reviews, within 72 hours of receipt of request.
2. For urgent pre-service review, within three calendar days from date of receipt of request.
3. For non-urgent pre-service requests, within 14 calendar days of receipt of the request.
4. 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. 

Except for medical emergencies, prior authorization must be obtained before services are rendered or expenses are incurred.

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 from the network provider to comply with the prior authorization requirements will result in benefits being reduced or denied.

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

Standard Exception Request

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 Health Solutions
Attn: Member Services
1850 W. Rio Salado Parkway, Suite 211
Tempe, Arizona 85281

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 Appeal Request

Your request: You or your treating provider may request an  expedited appeal if we deny your request at the initial appeal. You or your treating provider have 60 calendar days from the receipt date to decide if we should change our decision and pay the denied claim. You may file standard health care appeals in writing to

Mail: Ambetter Health
Attn: Ambetter Appeals and Grievance Dept.
P.O. Box 10341
Van Nuys, CA 91410-0341
Fax: (877) 615-7734 OR
Email: AzCHGrievanceAndAppeals@azcompletehealth.com

To help us make a decision on your appeal, you or your provider should also send us any additional information (that you have not already sent us) to show why we should authorize the requested service or pay the claim.

Our acknowledgement: We have 5 business days after we receive your request for Formal Appeal (“the receipt date”) to send you and your treating provider a notice that we got your request.

Our decision: For a denied service that you have not yet received, we have 30 calendar days after the receipt date to decide whether we should change our decision and authorize your requested service.

We send you and your treating provider our decision in writing that explains the reasons for our decision. We include information on the documents we used to base our decision.

• If we deny your expedited appeal, you have four months to appeal after you receive our appeal decision to send us your written request for external independent review. We will acknowledge receiving your request within one business day.
• If we grant your request, we authorize the service, and the appeal is over.
• Please refer to your Arizona Health Care Insurer Appeals Process Information Packet for detailed information on all levels of the appeal process. The Arizona Health Care Insurer Appeals Process Information Packet was delivered with your policy.

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 72 hours of the request being received (24 hours for exigent circumstances), 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 exigency.

Expedited Appeal Request

If you disagree with our decision, an expedited appeal is available as described in your Arizona Health Care Insurer Appeals Process Information Packet. 

Your doctor is able to contact our Medical Director to talk about the reasons for our decision (also referred to as a peer to peer” review). Information Packet. 

External exception request review

Your request: You may request a Expedited External Independent Review only after you have appealed through standard initial appeal and expedited appeal. You have four months after you receive our expedited appeal decision to send us your written request for External Independent Review. Send your request and any more supporting information to:

Mail: Ambetter Health Solutions
Attn: Ambetter Appeals and Grievance Dept.
P.O. Box 10341
Van Nuys, CA 91410-0341
Email: AzGrievanceAndAppeals@azcompletehealth.com
Fax: (877) 615-7734
Toll Free Call: (833) 543-3145 (TTY: 711)

Neither you nor your treating provider is responsible for the cost of any external independent review.

The process: There are two types of expedited external independent appeals, depending on the issues in your case:

Medical Necessity Cases

For Urgent Services Not Yet Provided (Pre-Service):

Expedited Medical Review: For urgently needed services where you and your treating provider decide that the standard initial appeal process (about 30 calendar days) is likely to cause a significant negative change in your medical condition. 

We have 72 hours after receiving the information from the treating provider to decide whether we should change our decision and authorize the requested service. 

Expedited Appeal: If we deny your expedited medical review, you and your treating provider may request an expedited appeal. 

We shall provide notice of the expedited appeal decision within 72 hours. 

Note: If the expedited appeal request does not include the treating provider certification, we review the appeal under the non-urgent initial appeal process.

Expedited External, Independent Review: You may request an expedited external independent appeal only after you have appealed through the expedited medical review and expedited appeal levels of review. You have four (4) months after you receive our expedited appeal decision to send us your written request for an expedited external independent review. We will acknowledge receiving your request within one business day.

Contract Coverage Cases

The Director of the Arizona Department of Insurance and Financial Institutions oversees this appeals process. The director maintains a copy of each health plan’s utilization review policy; receive, process, and act on requests from health plans for external independent review; review and enforce or overturn the decisions of the health plans; and file appropriate reports with the Arizona legislature. In instances where the director is sometimes unable to determine issues of coverage, they forward the case to the independent review organization (IRO) to complete a review within 21 calendar days of receipt. The director has five business days after receiving the IRO’s decision to send the decision to you, your treating provider and us. When necessary, the director must transmit appeal records to the Superior Court or the Office of Administrative Hearings and issue final administrative decisions.

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 that 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 1-866- 918-4450.

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.

2026 Transparency Notice for Ambetter Health underwritten by Ambetter of Florida Inc.

A) Non-network liability and balance billing

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 are not responsible for balance billing when balance billing protections apply to covered services.

As a member, non-network providers should not bill you for covered services for any amount greater than your applicable in-network cost responsibilities when balance billing protections apply to covered services that are:

1. Emergency services provided to a member, as well as services provided after the member is stabilized unless the member gave notice and consent to be balance billed for the post-stabilization services;
2. Non-emergency health care services provided to a member at a network hospital or at a network ambulatory surgical center unless if member gave notice and consent pursuant to the federal No Surprises Act to be balance billed by the non-network provider; or
3. Air ambulance services provided to a member by a non-network provider.

B) Member 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 written proof of loss within 90 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 had no legal capacity to submit such proof during that year.

To request reimbursement for a covered service, you need a copy of the detailed claim from your provider. You will also need to submit a copy of the member reimbursement claim form (PDF) posted at AmbetterHealth.com under “Forms and Materials”. Send all the documentation to us at the following address:

Ambetter Health
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 45 days or less.

We will notify you, in writing, that we have either accepted or rejected your claim for processing within 15 business days after our receipt of all requested information. If we are unable to come to a decision about your claim within 15 business days, we will let you know and explain why we need additional time.

We will accept or reject your claim no later than 120 calendar days after we receive it. If we reject your claim, the notice will state the reason why. If we agree to pay all or part of your claim, we will pay it no later than 14 business days after the notice has been made.

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. We will continue to pay all appropriate claims for covered services rendered to the member during the first month of the grace period and may pend claims for covered services rendered to the member in the second and third month of the grace period.

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 don’t receive a subsidy payment:

Premium payments are due in advance, on a calendar month basis. Monthly payments are due on or before the first day of each month for coverage effective during such month. There is a 60-day grace period. If your payment is not received by day 30, your account will move into suspended status. Please ensure your payment is posted at least 10 days prior to due date to ensure timely processing and payment posting. This provision means that if any required premium is not paid on or before the date it is due, it may be paid during the grace period. During the grace period, the contract will stay in force. We will notify Health and Human Services (HHS), as necessary, of the non-payment of premiums, the member, as well as providers of the possibility of denied claims when the member is in the grace period.

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: receive 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 the 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 that is issued is dependent on the method of payment. Payments made with a debit/credit card via e-Cashiering, interactive voice response (IVR) system, 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 paper check.

F) Medical Necessity and Prior Authorization

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

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

Prior Authorization Required

Some medical and behavioral covered service expenses require prior authorization. Network providers must obtain authorization from us prior to providing a service or supply to a member. However, 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 your Schedule of Benefits, you must obtain authorization from us before the you or your dependent member:

1. Receives a service or supply from a non-network provider;
2. Is admitted into a network facility by a non-network provider; or
3. Receives a service or supply from a network provider to which you or your dependent member were referred by a non-network provider.

Pursuant to the federal No Surprises Act, emergency services received from a non-network provider are covered services that do not require prior authorization from you or your provider.

Prior Authorization (medical and behavioral health) requests must be received by telephone, eFax, or provider web portal as follows:

1. At least five calendar days prior to an elective admission as an inpatient in a Hospital, extended care or Rehabilitation facility, or Hospice facility.
2. At least 30 calendar days prior to the initial evaluation for organ transplant services.
3. At least 30 calendar days prior to receiving clinical trial services.
4. Within one business day of any inpatient admission.5. At least five 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 of our decision as required by applicable law:

1. For urgent concurrent reviews received at least 24 hours prior to the expiration of a previously approved course of treatment, within 24 hours of receipt of the request. For all other urgent concurrent reviews, within 72 hours of receipt of request.
2. For urgent pre-service reviews, within three calendar days from date of receipt of request.
3. For non-urgent pre-service reviews, within 15 calendar days of receipt of the request.
4. 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.

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 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 Member Responsibilities

Prescription drug exception process is applicable when:

1. The drug is not covered based on our formulary.
2. We are discontinuing coverage of the drug.
3. The prescription drug alternatives required to be used in accordance with a step therapy requirement:
   • has been ineffective in the treatment; or
   • has caused an adverse reaction or harm to a member.

To obtain prior authorization for a non-formulary drug, your provider must fill out the Prior Authorization form. Prior Authorization forms and associated fax numbers are found on our website under Provider Section. Additionally, provider can submit Non-Formulary Drug Exception Request through CoverMyMeds. Services will respond via fax or phone within 24 hours of receipt of all necessary information for urgent requests, and within 72 hours for non-urgent requests, unless state law requires faster response. If the request is disapproved, the notice of disapproval will contain a clear explanation of the specific reasons for disapproving the prior authorization request, or if the request was incomplete, the explanation will identify the missing material information that is necessary to complete the request.

Standard exception request

A member, a member’s authorized representative or a member’s prescribing physician may request a standard review of a drug exception decision. 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 requested drug for the duration of the prescription, including refills not to exceed the standard duration of treatment as established by clinical guidelines and criteria. Please see the Grievance and Complaints Procedures provision for appeals information.

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 the requested 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 requested 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 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 member’s financial responsibility pursuant to the terms of the policy. We will send an EOB to you 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. 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 contracts. Ambetter Health 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 Health 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.

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).

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 should not be balance billed when balance billing protections apply to covered services. 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.

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 AmbetterHealth.com. Send all the documentation to us at the following address:

Ambetter Health
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  business 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 calnedar-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 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.

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:

1. Is consistent with the symptoms or diagnosis;
2. Is provided according to generally accepted standards of medical practice;
3. Is not custodial care;
4.  Is not solely for the convenience of the provider or the member;
5. Is not experimental or investigational;
6. Is provided in the most cost effective care facility or setting;
7. 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
8. 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:

1. Receives a service or supply from a non-network provider;
2. Are admitted into a network facility by a non-network provider; or
3. 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:

1. At least five calendar days prior to an elective admission as an inpatient in a Hospital, extended care or Rehabilitation facility, Hospice facility, or residential treatment facility.
2. At least 30 calendar days prior to the initial evaluation for organ transplant services.
3. At least 30 calendar days prior to receiving clinical trial services.
4. Within 24 hours of any inpatient admission, including emergent inpatient admissions.
5. At least five 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 of our decision as required by applicable law:

1. For urgent concurrent reviews received at least 24 hours prior to the expiration of a previously approved course of treatment, within 24 hours of receipt of the request. For all other urgent concurrent reviews, within 72 hours of receipt of request.
2. For urgent pre-service reviews, within 72 hours from date of receipt of request.
3. For non-urgent pre-service reviews, within seven calendar days of receipt of the request.
4. 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 Health Solutions
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 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.

A) Non-Network Liability and Balance Billing

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 amount charged 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 are not responsible for balance billingbe 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 amounts or cost sharing that is your financial responsibility.

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 AmbetterHealth.com. Send all the documentation to us at the following address:

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

Benefits will be paid within 30 calendar days for clean claims filed electronically or 45 calendar days for clean claims filed on paper. "Clean claims" means a claim submitted by you or a provider that has no defect, impropriety or particular circumstance requiring special treatment preventing payment. If we have not received the information, we need to process a claim, we will ask for the additional information necessary to complete the claim. You will receive a copy of that request for additional information. In those cases, we cannot complete the processing of the claim until the additional information requested has been received. We will make our request for additional information within 30 calendar days of our initial receipt of the claim and will complete our processing of the claim within 15 calendar days after our receipt of all requested information.

C) Grace Periods and Claims Pending

If you do not pay your premium by its due date, you will 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 do not 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 will not be eligible to enroll with us again until Open Enrollment or a Special Enrollment period.

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 Health and Human Services (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 service. 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 Services by calling the number on the back of 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) system, 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 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. 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 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:

1. Receive a service or supply from a non-network provider;
2. Are admitted into a network facility by a non-network provider; or
3. Receive a service or supply from a network provider to which you or your dependent member were 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/e-fax/provider portal as follows:

1. At least five calendar days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility or hospice facility.
2. At least 30 calendar days prior to the initial evaluation for organ transplant services.
3. At least 30 calendar days prior to receiving clinical trial services.
4. Within 24 hours of any inpatient admission, including emergent inpatient admissions.
5. At least five 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 of our decision as required by applicable law:

1. For urgent concurrent reviews received at least 24 hours prior to the expiration of a previously approved course of treatment, within 24 hours of receipt of the request. For all other urgent concurrent reviews, within 72 hours of receipt of request.
2. For urgent pre-service reviews, within 48 hours of receipt of the request.
3. For non-urgent pre-service reviews within five business days of receipt of the request.
4. 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.

Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements will result in benefits being reduced. A non-network provider can balance bill you for these services.

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 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 providers can submit a drug exception request to us by contacting Member Services or by sending a written request to the following address:

Ambetter Health
429 North Pennsylvania Street
Suite 109
Indianapolis, IN 46204

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 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 designee 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 designee 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, the member, the member’s designee, 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 designee, or the member’s prescribing physician of our coverage determination no later than three business days following receipt of the request if the original request was a standard exception and no later than one business day 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 member’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

Ambetter coordinates benefits with other payers when a member is covered by two or more group health benefit plans. 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 contracts.  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. 

A) Non-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 not in the 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 we agreed to pay and the full billed amount charged 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 limit. However, you are not responsible for balance billing when balance billing protections apply to covered services.

When receiving care at an Ambetter network facility, 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.

As a member of Ambetter, non-network providers should not bill you for covered services for any amount greater than your applicable in-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

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. We can adjust your deductible, copayment or cost sharing to reimburse you. 

Written notice of claim must be given to the insurer within 20 calendar days after the occurrence or commencement of any loss or as soon as thereafter as is reasonably possible.

To request reimbursement for a covered service, you need a copy of the detailed claim from your provider. You will also need to submit a copy of the member reimbursement claim form (PDF) posted at AmbetterHealth.com. Send all the documentation to us at the following address:

Ambetter Health 
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 15 calendar days upon receipt of an electronic claim or 30 calendar days upon receipt of a non-electronic claim.

We will notify you, in writing, that we have either accepted or rejected your claim for processing within 15 calendar days upon receipt of an electronic claim or 30 calendar days upon receipt of a non-electronic claim. If we are unable to come to a decision about your claim within 30 calendar days, we will let you know and explain why we need additional time.

We will accept or reject your claim no later than 30 calendar days after we receive it. If we reject your claim, the notice will state the reason why. If we agree to pay all or part of your claim, we will pay it no later than 30 calendar days after receipt of a clean non-electronic claim or 15 calendar days upon receipt of a clean electronic claim.

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.

Premium payments are due in advance, on a calendar month basis. Monthly payments are due on or before the first day of each month for coverage effective during such month. There is a 60 calendar day grace period. This provision means that if any required premium is not paid on or before the date it is due, it may be paid during the grace period. During the grace period, the contract will stay in force; however, claims may pend for covered services rendered to the member during the grace period. We will notify the member, as well as providers, of the possibility of denied claims when the member is in the grace period.

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: receive 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 Member 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 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 any medical service, supply or treatment authorized by a physician to prevent, stabilize, diagnose or treat a member’s illness or injury which:

1. Is consistent with the symptoms or diagnosis;
2. Is provided according to generally accepted standards of medical practice;
3. Is not custodial care;
4. Is not solely for the convenience of the physician or the member;
5. Is not experimental or investigational;
6. 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;
7. Is no more costly than an alternative covered service that is likely to produce equivalent therapeutic outcome; and
8. 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 the member:

1. Receives a service or supply from a non-network provider;
2. Is admitted into a network facility by a non-network provider; or
3. Receives 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 must be obtained for the following services, except for urgent care or emergency services. This list is not exhaustive, to confirm if a specific service requires Prior authorization, please contact Member Services.

• Non-emergency health care services provided by non-network providers;
• Reconstructive procedures;
• Diagnostic tests such as specialized labs, procedures and high technology imaging;
• Injectable drugs and medications;
• Inpatient health care services;
• Specific surgical procedures;
• Nutritional supplements;
• Pain management services; and
• Transplant services.

Prior authorization requests (medical and behavioral health) must be received by telephone, eFax, or provider web portal as follows:

1. At least five calendar days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, hospice facility, or residential treatment facility,
2. At least 30 calendar days prior to the initial evaluation for organ transplant services,
3. At least 30 calendar days prior to receiving clinical trial services,
4. Within 24 hours of any inpatient admission, and
5. At least five 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 of our decision as required by applicable law:

1. For urgent concurrent reviews received at least 24 hours prior to the expiration of a previously approved course of treatment, within 24 hours of receipt of the request. For all other urgent concurrent reviews, within 72 hours of receipt of request.
2. For urgent pre-service reviews, within 72 hours of receipt of request.
3. For non-urgent pre-service reviews within 15 calendar days of receipt of all information necessary to make a determination.
4. For post-service or retrospective reviews, within 30 calendar days of receipt.

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

Except for medical emergencies, prior authorization must be obtained before services are rendered or expenses are incurred.

Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements will result in benefits being reduced. Please see your 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

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

Ambetter Health
8325 Lenexa Dr., Suite 410
Lenexa, KS 66214

1. 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 the drug that is the subject of the protocol exception.

2. 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.

3. 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 three business days following receipt of the request, if the original request was a standard exception, and no later than one business day 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 (COB)

Ambetter coordinates benefits with other payers when a member is covered by more than one plan. It is a contractual provision of a majority of health benefit contracts. 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 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.

A) Non-network liability and balance billing

If you receive services from a provider that is not in the 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 maximum out-of-pocket limit. However, you are not responsible for balance billing when balance billing protections apply to covered services.

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 in-network cost sharing responsibilities when:

1. 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.
2. 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.
3. 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) Member 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 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.

To request reimbursement for a covered service, you need a copy of the detailed claim from your provider. You will also need to submit a copy of the member reimbursement claim form posted at AmbetterHealth.com . Send all the documentation to us at the following address:

Ambetter Health
Attn: Claims Department
P.O. Box 25480
Little Rock, AR 72221

C) Grace Periods and Claims Pending

A grace period of 60 calendar days will be granted for the payment of each premium due after the first premium.  During the grace period, the policy continues in force.

Premium payments are due in advance, on a calendar month basis. Monthly payments are due on or before the first day of each month for coverage effective during such month. This provision means that if any required premium is not paid on or before the date it is due, it may be paid during the grace period. During the grace period, the policy will stay in force; however, claims may pend for covered services rendered to the member during the grace period. We will notify HHS, as necessary, of the non-payment of premiums, the member, as well as providers of the possibility of denied claims when the member is in the grace period.

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: receive 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 the Member 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 e-Cashiering, interactive voice response (IVR) system, 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 paper check.

F) Medical Necessity and Prior Authorization

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

1. Is consistent with the symptoms or diagnosis.
2. Is provided according to generally accepted standards of medical practice.
3. Is not custodial care.
4. Is not solely for the convenience of the physician or the member.
5. Is not experimental or investigational.
6. Is provided in the most cost-effective care facility or setting.
7. 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
8. 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 covered service expenses (medical and behavioral health) require prior authorization. In general, non-network providers must obtain authorization from us prior to providing a service or supply to a member. However, there are some network eligible expenses for which you must obtain the prior authorization.

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

1. Receive a service or supply from a non-network provider.
2. Are admitted into a network facility by a non-network provider; or
3. Receive a service or supply from a network provider to which you or your dependent member were referred to 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 requests (medical and behavioral health) must be received by phone/e-fax/provider portal as follows:

1. At least five calendar days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, hospice facility, or residential treatment facility.
2. At least 30 calendar days prior to the initial evaluation for organ transplant services.
3. At least 30 calendar days prior to receiving clinical trial services.
4. Within 24 hours of an admission for inpatient mental health or substance use disorder treatment.
5. At least five calendar days prior to the start of home health care.

After prior authorization has been received, we will notify you and your provider of our decision as required by applicable law.

1. For urgent concurrent reviews received at least 24 hours prior to the expiration of a previously approved course of treatment, within 24 hours of receipt of the request. For all other urgent concurrent reviews, within 72 hours of receipt of request.
2. For urgent pre-service reviews, within 72 hours from date of receipt of request.
3. For non-urgent pre-service reviews within 15 calendar days of receipt of the request.
4. 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. All medical practitioners, 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 services that require prior authorization, refer to the Schedule of Benefits or contact Member Services. 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.

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 Member Responsibilities

Prescription Drug Exception Process

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

Ambetter Health
Attn: Member Services
P.O. Box 25408
Little Rock, AR 72221

1. 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 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 be granted, we will provide coverage of the non-formulary drug for the duration of the prescription, including refills, or the drug that is the subject of the protocol exception. 

2. 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.

3. 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 member’s financial responsibility pursuant to the terms of the policy. We will send an EOB to you 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. 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 Health 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 Health, 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.

Missouri 2026 Transparency Notice PPO

A) Non-network liability and balance billing

1. 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 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 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 are not responsible for balance billing when balance billing protections apply to covered services. As a member, non-network providers should not bill you for covered services for any amount greater than your applicable in-network cost responsibilities when balance billing protections apply to covered services that are: Emergency services provided to a member, as well as services provided after the member is stabilized unless the member gave notice and consent to be balance billed for the post-stabilization services;
2. Non-emergency health care services provided to a member at a network hospital or at a network ambulatory surgical center unless if member gave notice and consent pursuant to the federal No Surprises Act to be balance billed by the non-network provider; or
3. Air ambulance services provided to a member by a non-network provider.

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.

Written proof of loss must be furnished to us in case of claim for loss for which this contract provides any periodic payment contingent upon continuing loss within 90 calendar days after the termination of the period for which the insurer is liable and in case of claim for any other loss within 90 calendar days after the date of such loss. Failure to furnish such proof within the time required will not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required. Subject to due written proof of loss, all accrued indemnities for loss for which this contract provides periodic payment will be paid monthly. 

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.

To request reimbursement for a covered service, you need a copy of the detailed claim from your provider. You also need to submit the copy of the member reimbursement claim form (PDF) posted at AmbetterHealth.com under “Member Resources”. Send all the documentation to us at the following address:

Ambetter Health Solutions
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.

We will notify you, in writing, that we have either accepted or rejected your claim for processing within 30 business days as well. If we are unable to come to a decision about your claim within 30 business days, we will let you know and explain why we need additional time.

We will accept or reject your claim no later than 30 days after we receive it. If we reject your claim, the notice will state the reason why. If we agree to pay all or part of your claim, we will pay it no later than the 29 business days after the notice has been made.

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 don’t receive a subsidy payment

Premium payments are due in advance, on a calendar month basis. Monthly payments are due on or before the first day of each month for coverage effective during such month. There is a 60 calendar day grace period. This provision means that if any required premium is not paid on or before the date it is due, it may be paid during the grace period. During the grace period, the contract will stay in force; however, claims may pend for covered services rendered to the member during the grace period. We will notify the member, as well as providers, of the possibility of denied claims when the member is in the grace period.

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: receive 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.

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

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.

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 means, based on our determination, any medical service, items, supply or treatment to diagnose and treat a member’s illness or injury:

1. Is consistent with the symptoms or diagnosis;
2. Is provided according to generally accepted standards of medical practice;
3. Is not custodial care;
4. Is not solely for the convenience of the physician or the member;
5. Is not experimental or investigational;
6. 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
7. 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.

Prior Authorization Required

Some medical and behavioral health covered services require prior authorization. In general, network providers must obtain prior authorization from us prior to providing a network eligible service or supply to a member. However, there are some cases in which you must obtain the prior authorization. For example, if you:

1. Wish to receive a service or supply from a non-network provider;
2. Are admitted into a network facility by a non-network provider; or
3. Are requesting a non-covered service.

Prior authorization must be obtained for the following services, except for urgent care or emergency services. This list is not exhaustive. To confirm if a specific service requires prior authorization, please contact Member Services.

1. Non-emergency health care services provided by non-network providers ;
2. Reconstructive procedures;
3. Diagnostic tests such as specialized labs, procedures and high technology imaging;
4. Injectable drugs and medications;
5. Inpatient health care services;
6. Specific surgical procedures;
7. Nutritional supplements;
8. Pain management services; and Transplant services.

Prior authorization requests (medical and behavioral health) can be submitted by your provider electronically or via telephone, eFax, or provider web portal. Although not required, submitting requests within the recommended timeframes below will allow for timely review of prior authorization requests:

1. At least five calendar days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, hospice facility or residential treatment facility.
2. At least 30 calendar days prior to the initial evaluation for organ transplant services.
3. At least 30 calendar days prior to receiving clinical trial services.
4. Within 24 hours of any inpatient admission, including emergent inpatient admissions.
5. At least five 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 requested and all necessary information, including the results of any face-to-face clinical evaluation or second opinion that may be required has been submitted, we will notify you and your provider if the request has been approved as follows:

1. For urgent concurrent review, within one calendar day of receipt of the request.
2. For immediate or urgent request situations within 60 minutes, when the lack of treatment may result in an emergency room visit or emergency admission
3. For non-urgent pre-service requests regarding proposed admission, procedure or service, within 36 hours, which shall include one business day, of obtaining all necessary information
4. For urgent pre-service requests, within 24 hours from the date of receipt of the request of service.
5. For post-service requests and retrospective reviews, we will make our determination within 30 calendar days of receipt of the request. We will notify you in writing of the determination within ten calendar days of making the determination

Except for medical emergencies, prior authorization must be obtained before services are rendered or expenses are incurred.

Failure to Obtain Prior Authorization

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 Member 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 Health Solutions
Attn: Member Services
7711 Carondelet Ave. 
St. Louis, MO 63105

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 or a protocol exception for step therapy. 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, 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 external 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 member’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 (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.

Due to Missouri Law, Ambetter does not coordinate benefits with other commercial plans. However, coordination with Medicare may be required to avoid duplication of benefits when Ambetter members who become eligible for and enroll in Medicare. In that instance, Medicare is considered to be the primary payer, with Ambetter paying secondary up to Medicare’s allowable amount, subject to our benefits. It is important to note that dually enrolled members may not qualify for any government premium subsidies they once qualified for prior to Medicare becoming effective. If a member has any questions or concerns regarding being dually enrolled with Medicare and Ambetter, please contact the Health Insurance Marketplace for more information on the best course of action.

Ambetter complies with federal and state laws and 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.

Missouri 2026 Transparency Notice EPO

A) Non-network liability and balance billing

1. 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 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 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. As a member, non-network providers should not bill you for covered services for any amount greater than your applicable in-network cost responsibilities when balance billing protections apply to covered services that are: Emergency services provided to a member, as well as services provided after the member is stabilized unless the member gave notice and consent to be balance billed for the post-stabilization services;
2. Non-emergency health care services provided to a member at a network hospital or at a network ambulatory surgical center unless if member gave notice and consent pursuant to the federal No Surprises Act to be balance billed by the non-network provider; or
3. Air ambulance services provided to a member by a non-network provider.

B) Member 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.

Written proof of loss must be furnished to us in case of claim for loss for which this contract provides any periodic payment contingent upon continuing loss within 90 calendar days after the termination of the period for which the insurer is liable and in case of claim for any other loss within 90 calendar days after the date of such loss. Failure to furnish such proof within the time required will not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required. Subject to due written proof of loss, all accrued indemnities for loss for which this contract provides periodic payment will be paid monthly. 

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.

To request reimbursement for a covered service, you need a copy of the detailed claim from your provider. You also need to submit the copy of the member reimbursement claim form (PDF) posted at AmbetterHealth.com under “Member Resources”. Send all the documentation to us at the following address:

Ambetter Health 
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.

We will notify you, in writing, that we have either accepted or rejected your claim for processing within 30 business days as well. If we are unable to come to a decision about your claim within 30 business days, we will let you know and explain why we need additional time.

We will accept or reject your claim no later than 30 days after we receive it. If we reject your claim, the notice will state the reason why. If we agree to pay all or part of your claim, we will pay it no later than the 29 business days after the notice has been made.

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 don’t receive a subsidy payment

Premium payments are due in advance, on a calendar month basis. Monthly payments are due on or before the first day of each month for coverage effective during such month. There is a 30 calendar day grace period. This provision means that if any required premium is not paid on or before the date it is due, it may be paid during the grace period. During the grace period, the contract will stay in force; however, claims may pend for covered services rendered to the member during the grace period. We will notify the member, as well as providers, of the possibility of denied claims when the member is in the grace period.

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: receive 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.

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

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.

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 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 means, based on our determination, any medical service, items, supply or treatment to diagnose and treat a member’s illness or injury:

1. Is consistent with the symptoms or diagnosis;
2. Is provided according to generally accepted standards of medical practice;
3. Is not custodial care;
4. Is not solely for the convenience of the physician or the member;
5. Is not experimental or investigational;
6. 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
7. 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.

Prior Authorization Required

Some medical and behavioral health covered services require prior authorization. In general, network providers must obtain prior authorization from us prior to providing a network eligible service or supply to a member. However, there are some cases in which you must obtain the prior authorization. For example, if you:

1. Wish to receive a service or supply from a non-network provider;
2. Are admitted into a network facility by a non-network provider; or
3. Are requesting a non-covered service.

Prior authorization must be obtained for the following services, except for urgent care or emergency services. This list is not exhaustive. To confirm if a specific service requires prior authorization, please contact Member Services.

1. Non-emergency health care services provided by non-network providers ;
2. Reconstructive procedures;
3. Diagnostic tests such as specialized labs, procedures and high technology imaging;
4. Injectable drugs and medications;
5. Inpatient health care services;
6. Specific surgical procedures;
7. Nutritional supplements;
8. Pain management services; and Transplant services.

Prior authorization requests (medical and behavioral health) can be submitted by your provider electronically or via telephone, eFax, or provider web portal. Although not required, submitting requests within the recommended timeframes below will allow for timely review of prior authorization requests:

1. At least five calendar days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, hospice facility or residential treatment facility.
2. At least 30 calendar days prior to the initial evaluation for organ transplant services.
3. At least 30 calendar days prior to receiving clinical trial services.
4. Within 24 hours of any inpatient admission, including emergent inpatient admissions.
5. At least five 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 requested and all necessary information, including the results of any face-to-face clinical evaluation or second opinion that may be required has been submitted, we will notify you and your provider if the request has been approved as follows:

1. For urgent concurrent review, within one calendar day of receipt of the request.
2. For immediate or urgent request situations within 60 minutes, when the lack of treatment may result in an emergency room visit or emergency admission
3. For non-urgent pre-service requests regarding proposed admission, procedure or service, within 36 hours, which shall include one business day, of obtaining all necessary information
4. For urgent pre-service requests, within 24 hours from the date of receipt of the request of service.
5. For post-service requests and retrospective reviews, we will make our determination within 30 calendar days of receipt of the request. We will notify you in writing of the determination within ten calendar days of making the determination

Except for medical emergencies, prior authorization must be obtained before services are rendered or expenses are incurred.

Failure to Obtain Prior Authorization

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 Member 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 Health 
Attn: Member Services
7711 Carondelet Ave. 
St. Louis, MO 63105

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 or a protocol exception for step therapy. 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. 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, 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 external 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 member’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 (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.

Due to Missouri Law, Ambetter does not coordinate benefits with other commercial plans. However, coordination with Medicare may be required to avoid duplication of benefits when Ambetter members who become eligible for and enroll in Medicare. In that instance, Medicare is considered to be the primary payer, with Ambetter paying secondary up to Medicare’s allowable amount, subject to our benefits. It is important to note that dually enrolled members may not qualify for any government premium subsidies they once qualified for prior to Medicare becoming effective. If a member has any questions or concerns regarding being dually enrolled with Medicare and Ambetter, please contact the Health Insurance Marketplace for more information on the best course of action.

Ambetter complies with federal and state laws and 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.

A) Non-network liability and balance billing

If you receive services from a provider that is not in the 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 network costs for the same service and might not count toward your annual maximum out-of-pocket limit. However, you are not responsible for balance billing 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.

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 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.

To request reimbursement for a covered service, you need a copy of the detailed claim from your provider. You also need to submit the member reimbursement claim form (PDF) posted at AmbetterHealth.com. Send all the documentation to us at the following address:

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

All benefits payable under this contract for a loss, other than loss for which this contract provides any periodic payment, will be paid within 25 calendar days after receipt of due written proof of such loss in the form of a clean claim where claims are submitted electronically, and will be paid within 35 calendar days after receipt of due written proof of such loss in the form of clean claim where claims are submitted in paper format. Upon request, the insurer shall provide to the insured or the provider submitting a claim a written list of the information required and the documentation required for the insurer to deem a claim to be clean, and the insurer shall then be bound to such list. Benefits due under the policies and claims are overdue if not paid within 25 calendar days or 35 calendar days, whichever is applicable, after the insurer receives a clean claim containing necessary medical information and other information essential for the insurer to administer preexisting condition, coordination of benefits and subrogation provisions. Not later than 25 calendar days after the date the insurer actually receives an electronic claim, the insurer shall pay the appropriate benefit in full, or any portion of the claim that is clean, and notify the provider (where the claim is owed to the provider) or the member (where the claim is owed to the member) of the reasons why the claim or portion thereof is not clean and will not be paid and what substantiating documentation and information is required to adjudicate the claim as clean. For services that do not fall under the federal No Surprises Act balance billing protections, not later than 35 calendar days after the date the insurer actually receives a paper claim, the insurer shall process the appropriate benefit in full, or any portion of the claim that is clean, and notify the provider (where the claim is owed to the provider) or the member (where the claim is owed to the member) of the reasons why the claim or portion thereof is not clean and will not be paid and what substantiating documentation and information is required to adjudicate the claim as clean. Any claim or portion thereof resubmitted with the supporting documentation and information requested by the insurer shall be processed within 20 calendar days after receipt. For services that do not fall under the federal No Surprises Act balance billing requirements, we will pay or deny a clean claim within 30 calendar days of receipt regardless of how the claim was submitted.

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 —payment of your claims.

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.

Premium payments are due in advance, on a calendar month basis. Monthly payments are due on or before the first day of each month for coverage effective during such month. There is a 60 calendar day grace period. This provision means that if any required premium is not paid on or before the date it is due, it may be paid during the grace period. During the grace period, the contract will stay in force; however, claims may pend for covered services rendered to the member during the grace period. We will notify the member, as well as providers, of the possibility of denied claims when the member is in the grace period. We will notify the member, of the non-payment of premiums, as well as providers of the possibility of denied claims when the member is in the grace period.

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 Health 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 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 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 medically necessary. Medically necessary services are those that:

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

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

1. Receive a service or supply from a non-network provider;
2. Are admitted into a network facility by a non-network provider; or
3. Receive a service or supply from a network provider to which you or your dependent member were 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 telephone, fax or provider portal as follows:

1. At least five calendar days prior to an elective admission as an inpatient in a hospital, extended care, or rehabilitation facility, hospice facility, or residential treatment facility.
2. At least 30 calendar days prior to the initial evaluation for organ transplant services.
3. At least 30 calendar days prior to receiving clinical trial services.
4. Within 24 hours of any inpatient admission, including emergent inpatient admissions.
5. At least five 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:

1. For urgent concurrent reviews within 1 calendar day of receipt of the request.
2. For urgent pre-service reviews, within 48 hours from date of receipt of the request.
3. For non-urgent pre-service reviews within 7 calendar days from date of receipt of the request.
4. For post-service or retrospective reviews, within 30 calendar days from date 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.

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 Member 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 Health
Attn: Member Service
1020 Highland Colony Parkway, Suite 502
Ridgeland, MS 39157

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 members life, health, or ability to regain maximum function or when an 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 member’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 health care coverage under more than one plan as stated herein.

The order of benefit determination rules govern 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 contract 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.

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).

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 should 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 AmbetterHealth.com under “For Members-Forms and Materials”. Send this to us at the following address:

Ambetter Health 
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 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.

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:

1. Receive a service or supply from a non-network provider;
2. Are admitted into a network facility by a non-network provider; or
3. 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:

1. At least five 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.
2. At least 30 calendar days prior to the initial evaluation for organ transplant services or as soon as reasonably possible.
3. At least 30 calendar days prior to receiving clinical trial services or as soon as reasonably possible.
4. Within 24 hours (or as soon as reasonably possible) of any inpatient admission, including emergent inpatient admissions.
5. At least five 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 of our decision as required by applicable law:

1. For urgent concurrent reviews, received at least 24 hours prior to the expiration of a previously approved course of treatment, within 24 hours of receipt of the request. For all other urgent concurrent reviews, within 48 hours of receipt of request.
2. For urgent pre-service reviews, within 48 hours of receipt of the request.
3. For non-urgent pre-service requests within ten calendar days of receipt of the request.
4. 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 Health 
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.

A) Non-Network Liability and Balance Billing

 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 charged 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 are not responsible for balance billing when balance billing protections apply to covered services.

B) Member 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 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) at posted at AmbetterHealth.com under “Member Resources”.

Send all the documentation to us at the following address:

Ambetter Health
Attn.: Claims Department
PO Box 5010
Farmington, MO 63640-5010

Benefits will be paid within 30 calendar days for clean claims filed electronically or on paper. "Clean claims" means a claim submitted by you or a provider that has no defect, impropriety, or particular circumstance requiring special treatment preventing payment. If we have not received the information, we need to process a claim, we will ask for the additional information necessary to complete the claim. You will receive a copy of that request for additional information. In those cases, we cannot complete the processing of the claim until the additional information requested has been received. We will make our request for additional information within 20 calendar days of our initial receipt of the claim and will complete our processing of the claim within 30 calendar days after our receipt of all requested information.

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 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: 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.

If you believe the denial is in error, you are encouraged to contact the 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 that is issued is dependent on the method of payment. Payments made with a debit/credit card via e-Cashiering, interactive voice response (IVR) system, auto pay, 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 paper check.

F) Medical Necessity and Prior Authorization

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

1. Are consistent with the symptoms or diagnosis;
2. Are provided according to generally accepted standards of medical practice; 
3. Are not custodial care; 
4. Are not solely for the convenience of the provider or the covered person;
5. Are not experimental or investigational; 
6. Are provided in the most cost-effective care facility or setting;
7. 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
8. 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.

Prior Authorization Required

Some covered service expenses require prior authorization. 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 the member:

1. Receives a service or supply from a non-network provider; or
2. Are admitted into a network facility by a non-network provider; or
3. Receive a service or supply from a network provider to which you or your dependent member were referred to 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) requests must be received by phone/e-fax/Provider portal as follows:

1. At least five calendar days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, hospice, or residential treatment facility.
2. At least 30 calendar days prior to the initial evaluation for organ transplant services.
3. At least 30 calendar days prior to receiving clinical trial services.
4. Within 24 hours of any inpatient admission, including emergent inpatient admissions.
5. 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 received, we will notify you and your provider of our decision as required by applicable law:

1. For urgent concurrent reviews received at least 24 hours prior to the expiration of a previously approved course of treatment, within 24 hours of receipt of the request. For all other urgent concurrent reviews, within 72 hours of receipt of request.
2. For urgent pre-service reviews, three calendar days of the receipt of request.
3. For urgent pre-service biomarker testing reviews, within one calendar day from date of receipt of request. 
4. For non-urgent pre-service biomarker testing reviews, within three calendar days from date of receipt of request.
5. For non-urgent pre-service reviews, within 15 days of the receipt of the request.
6. 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. 

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 emergency services.

G) Drug Exceptions Timeframes and Member 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 1-833-543-3145 (TTY: 711) or by sending a written request to the following address:

Ambetter Health
Attn: Member Services
14000 Quail Springs Parkway, Suite 650O
klahoma City, OK 73134

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 member’s financial responsibility pursuant to the terms of the policy. We will send an EOB to you 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 1-833-543-3145 (TTY: 711).

I) Coordination of Benefits

Ambetter of Oklahoma coordinates benefits with other payers when a member is covered by two or more group health benefit plans. 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 contracts. Ambetter of Oklahoma 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 of Oklahoma 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.

A) Non-Network Liability and Balance Billing

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 are not responsible for balance billing  when balance billing protections apply to covered services.

When receiving care at a network facility, it is possible that some hospital-based providers (for example, assistant surgeons, hospitalists, and intensivists) may not be under contract with us 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 us.

B) Member 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 amounts or cost sharing that is your financial responsibility. 

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 AmbetterHelath.com.  Send all the documentation to us at the following address:

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

After receiving written proof of loss, Ambetter from Absolute Total Care will pay within 40 business days for clean claims filed on paper and within 20 business days for clean claims filed electronically all benefits then due during the calendar year 2024. Benefits will be paid to you, or to the provider to whom you have assigned payment of benefits. "Clean claims" means a claim submitted by you or a provider that has no defect, impropriety, or particular circumstance requiring special treatment preventing payment. If we have not received the information, we need to process a claim, we will ask for the additional information necessary to complete the claim. You will receive a copy of that request for additional information. In those cases, we cannot complete the processing of the claim until the additional information requested has been received. We will make our request for additional information within 20 calendar days of our initial receipt of the claim if it was submitted electronically and within 40 calendar days if it was submitted on paper. We will complete our processing of the claim within 30 calendar days after our receipt of all requested information.

C) Grace Periods and Claims Pending

Premium payments are due in advance, on a calendar month basis. Monthly payments are due on or before the first day of each month for coverage effective during such month. There is a 60- calendar day grace period. If your payment is not received by day 30, your account will move into suspended status. Please ensure your payment is posted at least 10 days prior to due date to ensure timely processing and payment posting. This provision means that if any required premium is not paid on or before the date it is due, it may be paid during the grace period. During the grace period, the policy will stay in force; however, claims may pend for covered services rendered to the member during the grace period. We will notify HHS, as necessary, of the non-payment of premiums, and will notify the member, as well as providers of the possibility of denied claims when the member is in the grace period.

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 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 service. 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 Services by calling the number on the back of 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:

1. Is consistent with the symptoms or diagnosis;
2. Is provided according to generally accepted standards of medical practice; 
3. Is not custodial care; 
4. Demonstrate that the member is reasonably capable of improving in his/her functional ability;
5. Is not experimental or investigational treatment; 
6. Is provided in the most cost-effective care facility or setting;
7. 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
8. 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 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 the member:

1. Receives a service or supply from a non-network provider;
2. Is admitted into a network facility by a non-network provider; or
3. Receives 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) requests must be received by phone/e-fax/provider portal as follows:

1. At least five calendar days prior to an elective admission as an inpatient in a hospital, skilled nursing or rehabilitation facility or hospice facility.
2. At least 30 calendar days prior to the initial evaluation for organ transplant services.
3. At least 30 calendar days prior to receiving clinical trial services.
4. Within 24 hours of any inpatient admission.
5. At least five 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:

1. For urgent concurrent review within one calendar day of receipt of the request.
2. For urgent pre-service requests, the lesser of two working or three calendar days from receipt of the request.
3. For non-urgent pre-service reviews, within two working days of receipt of the request.
4. For post-service or retrospective reviews, two working 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. 

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 emergency services.

G) Drug Exceptions Timeframes and Member 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 Health
Attn: Member Services
PO Box 10341
Van Nuys, CA 91410

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 policy 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, 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”). 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.

Non-formulary prescription drugs

Under the Affordable Care Act, you have the right to request coverage of prescription drugs that are not listed on the plan formulary (otherwise known as “non-formulary drugs”). To exercise this right, please contact your PCP or provider. Your PCP or provider can utilize the usual prior authorization request process. See “Prescription Drug Exception Process” for additional details.

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 member’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 EOB, please contact Member Services.

I) Coordination of Benefits

Coordination of Benefits exists when a member is covered by another plan besides Ambetter 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.

A) Non-Network Liability and Balance Billing

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 billed amount 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 maximum out-of-pocket limit.

However, you are not responsible for balance billing when balance billing protections apply to covered services.

B) Member 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. We can adjust your deductible, copayment or cost sharing to reimburse you.

To request reimbursement for a covered service, you need a copy of the detailed claim from your provider. You will also need to submit a copy of the Member Reimbursement Claim Form (PDF) posted at AmbetterHealth.com. Send all the documentation to us at the following address:

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

Claims may also be sent to us at the following address:

Ambetter Health
6200 Hospitality Drive
Franklin, TN 37067

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.

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. Benefits will be paid within 30 calendar days for clean claims on paper; electronic claims will be paid within 21 calendar days.

We will notify you, in writing, that we have either accepted or rejected your claim for processing within 20 days as well. 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.

We will accept or reject your claim no later than 30 days after we receive it. If we reject your claim, the notice will state the reason why. If we agree to pay all or part of your claim, we will pay it no later than the fifth business day after the notice has been made.

C) Grace Periods and Claims Pending

Premium payments are due in advance, on a calendar month basis. Monthly payments are due on or before the first day of each month for coverage effective during such month. There is a 60-calendar day grace period. This provision means that if any required premium is not paid on or before the date it is due, it may be paid during the grace period. During the grace period, the contract will stay in force; however, claims may pend for covered services rendered to the member during the grace period. We will notify Health and Human Services (HHS), as necessary, of the non-payment of premiums, the member, as well as providers of the possibility of denied claims when the member is in the grace period.

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. For instance, 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 of Tennessee to request recoupment of payment from the provider.

Retroactive denials can be avoided by receiving services from a provider or facility that is in our network, timely notification to Ambetter of Tennessee of changes to your or your dependent’s eligibility status or prompt payment of your premium.

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

.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.

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 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:

1. Is consistent with the symptoms or diagnosis;
2. Is provided according to generally accepted standards of medical practice;
3. Is not custodial care;
4. Is not solely for the convenience of the provider or the member;
5. Is not experimental or investigational;
6. Is provided in the most cost-effective care facility or setting;
7. 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
8. 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.

Some covered services (medical and behavioral health) 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 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:

1. Receive a service or supply from a non-network provider;
2. Are admitted into a network facility by a non-network provider; or
3. Receive a service or supply from a network provider to which you or your dependent member were referred to 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:

1. 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.
2. At least 30 calendar days prior to the initial evaluation for organ transplant services.
3. At least 30 calendar days prior to receiving clinical trial services.
4. Within 24 hours of any inpatient admission, including emergent inpatient admissions.
5. At least five 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 of our decision as required by applicable law.

1. For urgent concurrent reviews received at least 24 hours prior to the expiration of a previously approved course of treatment, within 24 hours of receipt of the request. For all other urgent concurrent reviews, within 72 hours of receipt of request.
2. For urgent pre-service reviews, within 2 business days from date of receipt of request.
3. For non-urgent pre-service requests within 2 business days of receipt of the request.
4. For post-service requests, within 30 calendar days of receipt of the request.
5. For standard pharmacy requests, within 15 calendar days of receipt of request and urgent pharmacy requests, within 72 hours or two business days of receipt of request (whichever is lesser).

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.

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 Member 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 Health
Attn: Member Services
PO Box 10341
Van Nuys, CA 91410

Standard exception request

A member, a member’s authorized representative or a member’s prescribing provider 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 provider 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 provider 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 provider 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 provider 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 provider 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 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.

Step Therapy Standard and Urgent Exception Requests

A member, a member's authorized representative or a member's prescribing physician may request a standard or expedited review of a decision that a drug is a protocol exception for step therapy. The request can be made in writing or via telephone. Within 2 business days 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 step therapy protocol exception request be granted, we will provide coverage of the drug that is the subject of the protocol exception for the duration of the prescription, including refills.

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 member’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 1-833-709-4735 (Relay 711).

I) Coordination of Benefits

Coordination of Benefits exists when an member 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 Transparency Notice (HMO) for Ambetter Health from Ambetter Health of Texas, Inc.

A) Non-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 called “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 facility, it is possible that some hospital-based providers may not be network providers. If there is notice and consent and/or Texas waiver to waive balance billing protections for services other than emergency care services, 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.

1. As an enrollee, non-network providers should not bill you for covered services for any amount greater than your applicable in-network cost sharing responsibilities when:
2. Emergency services provided to an enrollee, as well as services provided after the enrollee is stabilized;
3. Non-emergency health care services provided by a non-network provider to an enrollee at a network hospital or at a network ambulatory surgical center unless the enrollee gave notice and consent pursuant to the federal No Surprises Act and there is Texas waiver to be balance billed by the non-network provider; or Air ambulance services provided to an enrollee by a non-network provider.

B) Enrollee Claim Submission

Providers will typically submit claims on your behalf, but sometimes you may have to pay for a covered service and file a claim for reimbursement. 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 days of the date the loss began or as soon as reasonably possible. We must receive a request for reimbursement through receipt of a claim within 90 days of the date of service.

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 a copy of the Member Reimbursement Claim Form (PDF) posted at AmbetterHealth.com. Send all the documentation to us at the following address:

Ambetter Health
Attn: Claims Department – Member Reimbursement
P.O. Box 5010
Farmington, MO 63640-3800

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 15 calendar days or less.

We will notify you, in writing, that we have either accepted or rejected your claim for processing within 15 calendar days after receiving all items necessary to resolve your claim. If we accept your claim, we will make payment within five business days after notifying you of the payment of your claim. If we reject your claim, we will give you the reason your claim is rejected. If we are unable to come to a decision about your claim within 15 calendar days, we will let you know and explain why we need additional time, and will make our decision to accept or reject your claim no later than the 45th calendar day after our notice about the delay for paper claims or no later than the 30th calendar day after our notice about the delay for electronic claims.

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 —payment of your claims. If your premium is not brought current by the end of your grace period, you may be held responsible for services provided to you during that time.

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 don’t receive a subsidy payment

After you pay your first bill, you have a grace period of 30 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 retroactive attempt by a carrier 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, late notification of other coverage due to new coverage, or 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 termination is in error, you are encouraged to contact Member Services 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 that is 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 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) Prior Authorization

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

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

Some medical, pharmaceutical and behavioral health covered services require prior authorization. In general, network providers do not need to obtain authorization from us prior to providing a service or supply to an enrollee. However, there are some covered services for which you must obtain prior authorization.

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

1. Receives a service or supply from a non-network provider;
2. Is admitted into a network facility by a non-network provider; or
3. Receives a service or supply from a network provider to which you or your dependent enrollee were referred by a non-network provider.

We suggest that prior authorization (medical, pharmaceutical and behavioral health) requests are submitted to us by Provider Portal/efax/phone call as follows:

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

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

1. For services that require prior authorization, within three calendar days upon return.
2. For concurrent review, within 24 hours of receipt of the request.
3. For post-stabilization treatment or life-threatening condition, within the timeframe appropriate to the circumstances and condition of the enrollee, but not to exceed one hour of receipt of the request.
4. For post-service requests, within 30 calendar days of receipt of the request.

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 or not covered. 

Network providers cannot bill you for services for which they fail to obtain prior authorization requirements prior to receiving emergency services. However, you must contact us as soon as reasonably possible after you receive the emergency services.

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

Ambetter Health
Attn: Member Services
5900 E. Ben White Blvd.
Austin, Texas 78741

Standard exception request

An enrollee, an enrollee’s authorized representative or an enrollee’s prescribing provider 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 by telephone. Within 72 hours of the request being received, we will provide the enrollee, the enrollee’s authorized representative or the enrollee’s prescribing provider with our coverage determination. If we do not deny a standard exception request within 72 hours, the request is considered granted. 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

An enrollee, an enrollee’s authorized representative or an enrollee’s prescribing provider may request an expedited review based on exigent circumstances. Exigent circumstances exist 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. The request can be made in writing or via telephone. Within 24 hours of the request being received, we will provide the enrollee, the enrollee’s authorized representative or the enrollee’s prescribing provider with our coverage determination. If we do not deny an expedited exception request within 24 hours, the request is considered granted. 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 enrollee or the enrollee’s authorized representative may request that the denial of such request be reviewed by an external review organization. The external review organization will make the determination on the denied exception request and notify the enrollee or the enrollee’s de authorized representative of the 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 or the external review organization grants an exception for a standard or 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 enrollees to explain what medical treatments and/ or services we paid for on behalf of an enrollee. 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 an enrollee after we receive and adjudicate a claim on your behalf from a provider. If you need assistance interpreting your EOB, please contact Member Services.

I) Coordination of Benefits

The Coordination of Benefits (COB) provision applies when a person has healthcare coverage under more than one plan. Plan is defined below.

The order of benefit determination rules govern the order in 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 in accord with 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 equal 100 percent of the total allowable expense.