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2024 Transparency Notice
A) Out-of-network liability and balance billing
The Ambetter network is the group of providers, including but not limited to physicians, hospitals, pharmacies, other facilities and health care professionals, we contract with to provide care for you. If a provider is in our network, services are covered by your health insurance plan. Network providers may not bill you for covered expenses beyond your applicable cost sharing amounts (e.g., copayment, coinsurance, and/or a deductible).
If you receive services from a 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 your plan 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.
When receiving care at a network hospital, 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. 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 the non-network provider in excess of the eligible expense will not apply to your deductible amount or maximum out-of-pocket amount. We encourage you to inquire about the providers who will be treating you before you begin your treatment, so that you can understand their network participation status with Ambetter.
As a member of Ambetter, non-network providers should not bill you for covered services for any amount greater than your applicable network cost sharing responsibilities when balance billing protections apply to covered services. 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;
- Non-emergency health care services provided to a member at a network hospital or at a network ambulatory surgical center unless the member gave notice and consent pursuant to the federal No Surprises Act to be balance billed by the non-network provider; or
- 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 usually happens if your provider is not contracted with us.
We must receive written proof of loss within 90 calendar days of the loss or as soon as is reasonably possible. Failure to furnish such proof within the time required shall 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.
If you have paid for services we agreed to cover, you can request reimbursement for the amount you paid. We can adjust your deductible amount, copayment amount 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 need to submit a Member Reimbursement Claim Form (PDF), which is posted at AmbetterhealthofDelaware.com under “For Members,” “Form and Materials,” “Forms.” If such forms are not available on that website, we will, upon receipt of a notice of claim, furnish such form to you within 15 calendar days. Send all the documentation to us at the following address:
Ambetter Health of Delaware
Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-5010
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 (we understand that stuff happens sometimes).
During your grace period, you will still have coverage. However, if you do not pay before the grace period ends, you run the risk of losing your coverage. During the 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. So make sure you pay your bills on time!
If you receive a subsidy payment
After you pay your first bill, you have a 3-month grace period. During the first month of your grace period, we will keep paying claims for covered services you receive. If you continue to receive services during the second and third months of your grace period, we may hold these claims. If your coverage is in the second or third month of a grace period, we will notify you and your health care providers about the possibility of denied claims.
If you do not 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 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 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
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 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:
- 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.
Prior Authorization Required
Some covered services 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 the Schedule of Benefits, you must obtain authorization from us before the member:
- Receives a service or supply from a non-network provider;
- Is admitted into a network facility by a non-network provider; or
- Receives a service or supply from a network provider to which the member was referred by a non-network provider.
Prior authorization requests must be received by phone/e-fax/provider portal as follows:
- At least five calendar days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, or hospice facility.
- At least 30 calendar days prior to the initial evaluation for organ transplant services.
- At least 30 calendar days prior to receiving clinical trial services.
- Within 24 hours of any inpatient admission, including emergent inpatient admissions.
- At least five calendar days prior to the start of home health care.
After prior authorization has been requested and all required or applicable documentation has been submitted, we will notify you and your provider if the request has been approved as follows:
- For urgent concurrent review within 24 hours of receipt of the request.
- For urgent pre-service, within 72 hours from date of receipt of request.
- For non-urgent pre-service requests within five calendar days.
- For post-service requests, within 30 calendar days of receipt of the request.
Failure to Obtain Prior Authorization
Failure to comply with the prior authorization requirements will result in benefits being reduced.
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 an emergency. However, you must contact us as soon as reasonably possible after the emergency occurs.
G) Drug Exceptions Timeframes and Enrollee Responsibilities
Prescription Drug Exception Process
Sometimes members need access to drugs that are not listed on the formulary. Members or providers can submit a drug exception request to us by contacting Member Services at the number on the back of your member identification card or by sending a written request to the following address:
Ambetter Health of Delaware
Attn: Member Services
750 Prides Crossing, Suite 200
Newark, DE 19713
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. 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.
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. 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 at the number on the back of your member identification card.
I) Coordination of Benefits
Ambetter Health of Delaware 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 Health of Delaware 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 of Delaware 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.