Coverage Information - Quick Tips
Below is information about your Ambetter coverage including claims information, prior authorization and more. For a full summary of your benefits and coverage, always refer to your Evidence of Coverage or Schedule of Benefits.
A) Out-of-network liability and balance billing
Except for emergency services, you should always try to see providers that are in our network. But if you need to see an out-of-network provider, you will need to arrange care with your PCP and get approval from us. We have to approve an appointment with any out-of-network provider before you get non-emergency or non-urgent treatment.
If we approve your appointment with an out-of-network provider, your copayment and deductible will not change. We will let you know when the authorization is approved. If you don’t receive our prior authorization, we cannot provide any benefit, coverage or reimbursement. You will be financially responsible for any and all payments.
When receiving care at one of our in-network hospitals, it is possible that some hospital-based providers (for example, anesthesiologists, radiologists, pathologists) may not be under contract with us as in-network providers. These providers may bill you for the difference between our allowed amount and the provider’s billed charge — this is known as "balance billing." We encourage you to inquire about the providers who will be treating you before you begin your treatment, so you can understand their participation status with us.
B) Enrollee Claim Submission
Providers will typically submit claims on your behalf, but sometimes you may be financially responsible for covered services. This usually happens if:
- Your provider is not contracted with us
- You have an out-of-area emergency
If you have paid for services we agreed to cover, you can request reimbursement for the amount you paid. We can adjust your deductible, copayment or cost sharing to reimburse you.
To request reimbursement for a covered service, you need a copy of the detailed claim from the provider. You also need to submit an explanation of why you paid for the covered services. Send this to us at the following address:
Ambetter from CeltiCare 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 days or less.
We will notify you, in writing, that we have either accepted or rejected your claim for processing within 15 days as well. If we are unable to come to a decision about your claim within 15 days, we will let you know and explain why we need additional time.
We will accept or reject your claim no later than 45 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
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. So make sure you pay your bills on time!
D) Retroactive Denials
There are instances where claims are received and paid due to the member showing active in the claims system, however, the member should have been terminated. When this happens Ambetter requests recoupment of payment from the Provider.
Reasons for termination can be untimely payment of premiums, late notification of other coverage, or a change in circumstance, such as divorce or marriage.
If the member feels that the termination is in error, they are encouraged to contact our member’s services department.
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, 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) 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 means pre-approval for services. Prior authorization is necessary for services that must be approved by Ambetter before you get the service. Check with your PCP, the ordering provider or Ambetter Member Services to see if the service requires authorization. When a prior authorization request from your provider is received by Ambetter, it is reviewed by our nurses and doctors. We will let your doctor and you know if the service is approved or denied. Information about the review process, including the time frames for making a decision and notifying you and your provider of the decision, is located in the following Utilization Review section.
When a prior authorization request from your provider is received by Ambetter, it is reviewed by our nurses and doctors. We will let your doctor and you know if the service is approved or denied.
G) Drug Exceptions Timeframes and Enrollee Responsibilities
Standard exception request
A member, a member’s designee 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 designee 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 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 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. 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 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 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 72 hours following receipt of the request, if the original request was a standard exception, and no later than 24 hours following its receipt of the request, if the original request was an expedited exception.
If we grant an external exception review of a standard exception request, we will provide coverage of the non-formulary drug for the duration of the prescription. If we grant an external exception review of an expedited exception request, we will provide coverage of the non-formulary drug for the duration of the exigency.
H) Information on Explanations of Benefits
An explanation of benefits (EOB) is a statement that we send to members to explain what medical treatments and/or services we paid for on behalf of a member. This shows the amount billed by the provider, the issuer’s payment, and the enrollee’s financial responsibility pursuant to the terms of the policy. We will send an EOB to a member after we receive and adjudicate a claim on your behalf from a provider. If you need assistance interpreting your Explanation of Benefits, please contact Member Services at 1-877-687-1186 (TTY/TDD 1-877-941-9234).
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 including Workman’s Compensation, to establish payment of services for the provider. Medicaid is always the payer of last resort.