Delaware Transparency in Coverage
Out-of-Network Liability and Balance Billing
This is important information. We use a network of participating providers (“Network Providers”) to provide services for you. Out-of-Network providers do not have a contract with AmeriHealth Caritas Next at the time you receive services. We will not cover services you receive from Out-Of-Network providers except in very limited circumstances. Participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of AmeriHealth Caritas Next. The availability of any provider cannot be guaranteed, and our provider network is subject to change.
Our plan contracts with Network Providers to provide covered services to you. This means that we will not pay for services you might receive from Out-Of-Network Providers unless:
- You have an emergency medical condition or,
- We authorize services from an Out-Of-Network Provider because the medically necessary services you need are not available from a Network Provider
- You receive medically necessary services from an Out-of-Network provider based in a Network facility
Additionally, if a Network Provider stops participating in our network and you are in active treatment for a serious condition or illness, you may be allowed to continue receiving care from that Out-Of-Network Provider until treatment for the condition is completed or you change providers to a Network Provider, whichever comes first.
If you receive care from an Out-of-Network Provider, you may be responsible for paying any charges over the allowed amount in addition to any applicable copayment, deductible, coinsurance, and noncovered expenses. This is called Balance Billing. Balance Billing is the difference between the Out-of-Network provider's charge and AmeriHealth Caritas Next's allowed amount for the service(s).
- For example, if the Out-of-Network Provider's charge is $100 and AmeriHealth Caritas Next's allowed amount is $80, the provider may bill you for the remaining $20.
By comparison, a Network Provider may not bill you for the difference between their charge and AmeriHealth Caritas Next's negotiated rate.
AmeriHealth Caritas Next plans to comply with the provisions of the No Surprises Act of the 2021 Consolidated Appropriations Act and any associated rules or regulations that CMS or other regulatory authorities may issue.
Enrollee Claims Submission
How you get your bill paid - Network Providers
When you visit a Network Provider, show your AmeriHealth Caritas Next ID card and pay any required copay. After your visit, the Network Provider will bill AmeriHealth Caritas Next. This bill is called a claim. We will process the claim according to the terms of your insurance plan and any payment due to the Network Provider will be paid directly.
How you get your bill paid - Out-of-Network Providers
When you visit an Out-of-Network Provider, show your ID card and ask the Provider if they will bill your insurance company. Out-of-Network providers may agree to submit a bill on your behalf, but they are not required to. This bill is referred to as a claim. We will process the claim according to the terms of your insurance plan. If the claim fits into one of the Out-of-Network payment exceptions listed above and if authorized by you, any payment due will be made to the Provider. Otherwise, any payment due will be made to you.
Remember that any amount due to the Provider or you (AmeriHealth Caritas Next allowed amount) may be less than the amount the Provider charged and, therefore, you may still be required to pay the difference between the two amounts (balance billed amount) directly to the Provider in situations where balance-billing is permissible.
If your provider does not agree to submit a bill on your behalf, you must send a completed claim form and an itemized bill to the address listed on your AmeriHealth Caritas Next ID card. Or, you can call the Customer Service number on your AmeriHealth Caritas Next ID card for information about how to submit a claim.
This is important information. To pay a claim, AmeriHealth Caritas Next must receive written notice of your claim and the claim itself by a certain date. The written notice of claim must be received within 20 days from the date of service or as soon as reasonably possible as determined by AmeriHealth Caritas Next. Following notification of the claim, AmeriHealth Caritas Next must receive your claim within 180 days of the date the service was provided. If you provide the claim within 20 days from the date of service, written notice is not required. If you do not provide notice or the claim itself within the timeframes outlined above the claim will not be covered, except in the absence of legal capacity of the member.
P.O. Box 7411
London, KY 40742-7411
P.O. Box 516
Essington, PA 19029
Grace Periods and Claims Pending Policies During the Grace Period
Monthly premium payments are due on or before the first day of each month for coverage for that month. After paying at least one full month’s premium, you will have a grace period of 15 days from the next premium due date to pay your next premium amount.
Those receiving a federal premium subsidy will have a grace period of 3 consecutive months from the next premium due date to pay all outstanding premium amounts. A grace period is a time period during which AmeriHealth Caritas Next will not terminate your coverage even if you have not paid your premium. Coverage will remain in force during the grace period.
If we don’t receive full payment of your premium within the grace period, your coverage will end as of the last day of the grace period. (For those receiving a federal premium subsidy, it will end on the last day of the first month of the grace period.). If you fail to pay your premium payments on time, we will send you a notice of late payment with an explanation of how the associated grace period works.
AmeriHealth Caritas Next will still pay for all appropriate claims for services rendered during the course of a 15 day grace period. Similarly, for those receiving a federal premium subsidy, AmeriHealth Caritas Next will pay for all appropriate claims for services rendered during the first month of the grace period.
However, claims for services received in the second and third month of the grace period may be pended. When a claim is pended, that means no payment will be made to the provider unless and until your late premium is paid in full. In addition to notifying you of any remaining unpaid premiums during the second and third months of a grace period, we will also notify any providers of the possibility of claims being denied, if applicable.
During the course of a grace period for those receiving a federal premium subsidy, we will continue to collect the subsidies from the U.S. Department of the Treasury (“Department”) on your behalf. However, if you have not paid the entire amount of premium owed by the end of the three month grace period, we will return the subsidies for the second and third month to the Department at this time and provide you with prompt notice of the termination of your coverage.
Coverage for you and any dependents will be retroactively terminated as of the last day of the first month of the grace period. You cannot enroll again once coverage ends this way unless you qualify for a Special Enrollment Period or during the next open enrollment period.
A retroactive denial is the reversal of a previously paid claim, through which the member then becomes responsible for payment.
Claims may be denied retroactively, even after the member has obtained services from the provider based on retroactive changes to eligibility, which include, but are not limited to failure to pay premiums and instructions from the Marketplace.
Best practices to reduce the chance of retroactive denials:
- Make premium payments on time and in full
- Talk to your provider about whether any service they perform is a covered benefit
- Whenever possible, obtain your medical services and prescriptions from in-network providers and pharmacies
Enrollee Recoupment of Overpayments
Member recoupment of overpayments is the refund of a premium overpayment by the member due to overbilling by the plan. Any premium overpayments will normally be credited to your account and applied to future premiums due. Should you wish to obtain a direct refund, you can contact Customer Service to request one.
Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities
Medical necessity is used to describe care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. Covered benefits and services under our plan must be medically necessary. We use clinical criteria, scientific evidence, professional practice standards and expert opinion in making decisions about medical necessity. The cost of services and supplies which are not medically necessary will not be eligible for coverage and will not be applied to deductibles or out-of-pocket amounts.
Prior authorization is a process through which an issuer approves a request to access a covered benefit before members access the benefit. Certain services or supplies may need to be reviewed before you receive them to make sure, among other things, that they are medically necessary and being provided by a Network Provider and/or in an appropriate setting.
If you are receiving services from a Network Provider, the Provider will be responsible for obtaining any necessary prior authorizations on your behalf before you receive services. If the prior authorization is denied and you still want to receive these services, they will not be covered by AmeriHealth Caritas Next, and you may be responsible for payments billed by the Provider.
If you are obtaining services outside of our Service Area or from an Out-Of-Network Provider, you are responsible for making sure that any necessary prior authorizations have been secured in advance or else the service may not be covered. If you do not get prior authorization, you may have to pay up to the full amount of the charges in situations where balance billing is permitted. Coverage will also depend on any limitations or exclusions, payment of premium, eligibility at the time of service, and any deductible or cost sharing amounts.
A decision on a request for prior authorization for medical services will be made within five (5) business days of us receiving the request submitted through electronic pre-authorization or eight (8) business days of us receiving the request not submitted through electronic pre-authorization. Requests must include all required supporting documentation.
Drug Exceptions Timeframes and Enrollee Responsibilities
We hope that your drug coverage will work well for you. But it is possible that there could be a prescription drug you are currently taking, or one that you and your provider think you should be taking, that is not on our formulary (drug list). These medications are initially reviewed for medical necessity and appropriateness by AmeriHealth Caritas Next through the formulary exception review process. You or an authorized representative can submit the request to us by calling, faxing or mailing the information found on the Pharmacy Formulary Exception Request form:
200 Stevens Drive
Philadelphia, PA 19113 CC: 236
For a standard exception review, we will make our decision no later than 72 hours of receiving the request and any additionally required information. You can request an expedited (fast) exception if you or your provider believe that your health could be seriously harmed by waiting up to 72 hours for a decision. You can indicate your exigent circumstance on the form and request an expedited review. We will give you a decision on expedited requests no later than 24 hours after we receive the request and any additionally required information.
If the non-formulary request is denied and you feel we have denied the request incorrectly, you may challenge the decision through AmeriHealth Caritas Next’s internal dispute process. If a decision is made to uphold the denial pursuant to our internal dispute process, then upon exhaustion of that process, you have the right to pursue either a standard or, if warranted and appropriate, an expedited external review by an impartial, third-party reviewer known as an Independent Utilization Review Organization (IURO). Your denial notice will explain your right to external review and provide instructions on how to make this request. An external review request can be made by you, your authorized representative, or your prescribing provider.
An expedited external review may be warranted upon exhaustion of the internal appeals process if your health could be seriously compromised by having to wait for resolution of a standard external review. If your request for a standard external review is accepted, it is decided within 45 days of receipt of your request. If your request for an expedited external review is accepted, it is decided within three (3) days of your request.
Alternatively, and depending on the extent to which you or your provider believe that your health could be seriously harmed by waiting for resolution of AmeriHealth Caritas Next’s internal dispute process, you may request and be granted an immediate expedited external review by the IURO. Once again, requests for expedited external review are resolved within three (3) days.
We must follow the IURO's decision. If the IURO reverses our decision on a standard external review, we will provide coverage for the non-formulary within three days of receiving notice of the reversal. If the IURO reverses our decision on an expedited external review, we will provide coverage for the non-formulary within one day of receiving notice.
Information on Explanation of Benefits (EOBs)
Each time we process a claim submitted by you or your health care provider, we explain how we processed it in the form of an Explanation of Benefits (EOB).
The EOB is not a bill. It simply explains how your benefits were applied to that particular claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you're responsible for paying the provider. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.