2026 North Carolina 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 seek emergency services, or

  • We authorize services from an Out-of-Network Provider because the medically necessary services you need are not available from a Network Provider, or

  • 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, they become an Out-of-Network Provider. If you are in active treatment for a serious condition or illness, you may continue receiving care from that Out-of-Network Provider through your continuity/transition of care coverage. This coverage will end when treatment for the condition is completed or you change providers to a Network Provider, whichever comes first. This coverage is provided for a maximum of 90 days.

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 will comply with the provisions of the No Surprises Act of the 2021 Consolidated Appropriations Act and any associated rules or regulations that the Centers for Medicare & Medicaid Services (CMS) or other regulatory authorities may issue. You will not be penalized and will not incur out-of-network benefit levels unless participating Providers able to meet your health needs are reasonably available without unreasonable delay or you agree to sign over your rights. You will not be charged for balance bills for out-of-network care (emergency services or care by a non-participating Provider at an in-network facility) without your informed consent or prior authorization.

Member 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 cost-share. 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. You may also call the Member Services 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 the claim by a certain date. Claims must be received by AmeriHealth Caritas Next within 180 days of the date the service was provided. Claims not received within 180 days from the service date will not be covered, except in the absence of legal capacity of the member.

View the Claims Forms Link with Submission Instructions and Contacts (PDF).

Medical Claims:
P.O. Box 7411
London, KY 40742-7411

Pharmacy Claims:
P.O. Box 516
Essington, PA 19029
CC: 236

AmeriHealth Caritas Next Member Services:
1-833-613-2262

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. 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. 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 following the due date.

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.

If we don’t receive full payment of your premium within the grace period, your coverage will end on the last day of the last month for which a premium has been paid. (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 pend payment on medical claims and still pay for all appropriate pharmacy 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 that 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.

Retroactive Denials

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 Health Insurance 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

Member 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. If you believe you have paid too much for your premium and would like a direct refund, please call the AmeriHealth Caritas Next Member Services phone number on the back of your ID card.

Medical Necessity and Prior Authorization Time Frames and Member 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 that 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 that they are medically necessary and being provided by a network provider.

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 PA is denied and the provider still provides you with these services, the provider cannot bill you for these denied services.

If you are obtaining services outside of our service area or from an out‐of‐network provider, you will need to make sure that any necessary PA has been received before receiving services or the service may not be covered under this plan. Coverage will also depend on any limitations or exclusions for this plan, payment of premium, eligibility at the time of service, and any deductible or cost‐sharing amounts. If you do not obtain PA before an elective admission to a hospital or certain other facilities, you may face a penalty.

A decision on a request for prior authorization for medical services will be made within three (3) business days of us receiving the request, including all required supporting documentation.

If we have approved an ongoing course of treatment to be provided over a period of time or number of treatments:

  • Any reduction or termination by us of a current course of treatment (other than by plan amendment or termination) before the end of such period of time or number of treatments will result in an adverse benefit determination. We will notify the member and provider of the adverse benefit determination at a time sufficiently in advance of the reduction or termination to allow the member or provider to appeal and obtain a determination on review of that adverse benefit determination before the benefit is reduced or terminated.
  • Any request by a member or provider to extend the course of treatment beyond the period of time or number of treatments, where delay in the decision could reasonably appear to seriously jeopardize the life or health of the member or jeopardize the member’s ability to regain maximum function, shall be decided as soon as possible, taking into account the medical exigencies. We will notify the member and the member’s provider of the benefit determination, whether adverse or not, within 24 hours after the plan’s receipt of the request, provided that any such request is received by the plan at least 24 hours prior to the expiration of the prescribed period of time or number of treatments. Notification of any adverse benefit determination concerning a request to extend the course of treatment shall be made in accordance with this plan. 

Formulary Drug Exceptions Time Frames and Member Responsibilities and Rights

Prior Authorization and Exception requests

For formulary drugs that have restrictions such as prior authorization (PA), step therapy (ST), quantity limitations (QL), and age limitations (AL), a prior authorization request may be submitted for decisions. AmeriHealth Caritas Next’s PBM will review the requests and will determine if a request meets the clinical drug criteria requirements.

For non-formulary drugs, non-formulary exception requests can be made. Non-formulary exception requests are reviewed on a case-by-case basis. Your provider will be asked to provide medical reasons and any other important information about why you need an exception. AmeriHealth Caritas Next’s PBM will review the requests and will determine if a request is consistent with our medical necessity guidelines.

We will cover non-formulary prescription drugs if the outpatient drug is prescribed by a network provider to treat a covered person for a covered chronic, disabling, or life-threatening illness if the drug:

  • Has been approved by the U.S. FDA for at least one indication; and

  • Is recognized for treatment of the indication for which the drug is prescribed in:

    • A prescription drug reference compendium approved by the Insurance Commissioner for purposes of this section; or

    • Substantially accepted peer-reviewed medical literature

and

  • There are no formulary drugs that can be taken for the same condition. If there are formulary alternatives to treat the same condition, then documentation must be provided that the member has had a treatment failure with, or is unable to tolerate, two or more formulary alternative medications.
  • Prescription drug samples, coupons, or other incentive programs will not be considered a trial and failure of a prescribed drug in place of trying the formulary-preferred or nonrestricted access prescription drug.

AmeriHealth Caritas Next’s PBM will review the request. If the requested drug is approved, it will be covered according to our medical necessity guidelines. If the request is not approve then you, your authorized representative, or your provider can appeal the decision.

If the request for a non-formulary drug is approved, the medication will be covered on the highest tier.

You, your authorized representative, or your provider can visit our website to review the formulary and find covered drugs. You can access a searchable and a printable formulary on our website.

You*, your authorized representative*, or your provider can request both formulary drug prior authorizations (PA, ST, QL, and AL) and non-formulary exceptions in the following ways:

  • Electronically: directly to AmeriHealth Caritas Next’s PBM, through Electronic Prior Authorization (ePA) in your Electronic Health Record (EHR) tool software, or you can submit through either of the following online portals:

    • CoverMyMeds

    • Surescripts

  • By fax: [1-855-756-9901] for standard (nonurgent) requests [1-866-533-5497] for expedited (fast)* requests
  • By mail

    • 200 Stevens Drive

      Philadelphia, PA 19113 CC: 236]

  • By telephone at: 1-844-280-9131

*If you or your authorized representative submit the request for a prior authorization or non-formulary exception your provider must provide follow-up clinical documentation.

Once all necessary and relevant information to make a decision is received, AmeriHealth Caritas Next’s PBM will review the request. If the request is approved, they will provide an approval response to your provider with a duration of approval. If the request is denied, they will provide a denial response to you and your provider.

Prior authorization and non-formulary exception requests will be completed and notifications sent within the following timeframes:

  • Standard (non-urgent): no later than 72 hours after we receive the request and any additionally required information.
  • Expedited (fast)*: no later than 24 hours after we receive the request and any additionally required information.

*Expedited (fast) request can be made based on exigent circumstances. Exigent circumstances exist when you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug. You can indicate your exigent circumstance on the form and request an expedited review.

If the prior authorization request is denied and you feel we have denied the request incorrectly, you may challenge the decision through the internal appeal process of AmeriHealth Caritas Next.

You can ask for an appeal yourself. You may also ask a friend, a family member, your provider, or a lawyer to help you. You can call AmeriHealth Caritas Next at 1-833-613-2262 (TTY 711) if you need help with your appeal request. It is easy to ask us for an appeal by using one of the options below:

  • Mail: Fill out and sign the Appeal Request Form in the notice you receive about our decision. Mail it to the address listed on the form. We must receive your form no later than 180 days after the date on this notice. 

  • Fax: Fill out, sign, and fax the Appeal Request Form in the notice you receive about our decision. You will find the fax numbers listed on the form.

  • By phone: Call 1-833-613-2262 (TTY 711) and ask for an appeal

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 review organization (IRO).

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 IRO. Once again, requests for expedited external review are resolved within three (3) days.

We must follow the IRO's decision. If the IRO reverses our decision on a standard external review, we will provide coverage for the drug product within three days of receiving notice of the reversal. If the IRO reverses our decision on an expedited external review, we will provide coverage for the non-formulary within one day of receiving notice. An IRO review may be requested by the member, member’s representative, or member’s prescribing provider by web, mail, or fax at the address below:

For more information on appeals please see the section on appeals of the Member Handbook.

Non-formulary exception request denial rights

For non-formulary exception request denials, you also 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 Review Organization (IRO).

You may exercise your right to external review with an Independent Review Organization (IRO) upon initial denial or following a decision to uphold the initial denial pursuant to the internal appeal process of AmeriHealth Caritas Next. If a decision is made to uphold the initial denial, your denial notice will explain your right to external review and provide instructions on how to make this request. An IRO review may be requested by the member, member’s representative, or member’s prescribing provider by contacting AmeriHealth Caritas Next via mail, phone, or fax at the following address:

  • Mail: [Member Appeals, AmeriHealth Caritas Next, P.O. Box 7417, London, KY 40742-7417]
  • Phone: 1-833-613-2262 (TTY 711)
  • Fax: 1-844-201-6798

An expedited external review may be warranted if based on exigent circumstances, your request for a standard external review is accepted, it is decided within 72 hours of receipt of your request. If your request for an expedited external review is accepted, it is decided within 24 hours of receipt of your request.

We must follow the IRO’s decision. If the IRO reverses our decision on a standard external review, we will provide coverage for the non-formulary item for the duration of the prescription. If the IRO reverses our decision on an expedited external review, we will provide coverage for the non-formulary item for duration of the exigency.

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 or to the service you received. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you may be 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.

Coordination of Benefits

Coordination of benefits (COB) is required when you are covered under one or more additional group or individual plans, such as one sponsored by your spouse’s employer. An important part of coordinating benefits is determining the order in which the plans provide benefits. One plan provides benefits first. This is called the primary plan. The primary plan provides its full benefits as if there were no other plans involved. The other plans then become secondary. Further information about COB can be found in your Evidence of Coverage (PDF).