Transparency in Coverage:
Claims Payment Policies & Other Information
Out-of-Network Liability and Balance Billing
Out-of-network services are from doctors, hospitals, and other health care professionals that have not contracted with your plan. A health care professional who is out of your plan network can set a higher cost for a service than professionals who are in your health plan network. Depending on the health care professional, the service could cost more or not be paid for at all by your plan. Charging this extra amount is called balance billing.
Enrollee Claim Submission
A claim is a request to an insurance company for payment of health care services. As a member, you may need to submit a claim yourself, especially if you see a provider or use a pharmacy outside of the network. If you need to submit a claim, you should do so within 90 days after the date of service or as soon as reasonably possible. If you don't provide this information to us within one year of the date of service, benefits for that health service may be denied or reduced. To file a claim, follow these steps:
- Complete this claim form.
- Attach an itemized bill from the provider for the covered service.
- Make a copy for your records.
- Mail your claim to the following address:
PO Box 5280
Kingston, NY, 12402
Grace Periods and Claims Pending
You are required to pay your premium by the scheduled due date. If you do not do so, your coverage could be terminated. If you are enrolled in an individual health care plan offered on the Health Insurance Marketplace and you receive an advance premium tax credit, you will get a three-month grace period. A grace period is a time period when your plan will not terminate even though you did not pay your premium. We will pay all claims for covered services that are submitted properly during the first month of the grace period. During the second and third months of that grace period, any claims you incur will be pended. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full. If you pay your full outstanding premium before the end of the three-month grace period, we will pay all claims for covered services that are submitted properly for the second and third months of the grace period. If you do not pay all of your outstanding premium by the end of the three-month grace period, your coverage will terminate, and we will not pay for any pended claims submitted for you during the second and third months of the grace period. Your provider may balance bill you for those services.
If you are enrolled in an individual health care plan but you do not receive an advance premium tax credit, in most cases you will receive a 31-day grace period. Your plan may pay claims for covered services received during your grace period. If you do not pay your delinquent premium in full by the end of the grace period, your coverage will be terminated and you may be responsible for the cost of services received during the grace period.
A retroactive denial is the reversal of a claim we have already paid. If we retroactively deny a claim we have already paid for you, you will be responsible for payment. Some reasons why you might have a retroactive denial include a claim that was paid during the second or third month of a grace period or a claim paid for a service for which you were not eligible.
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.
Recoupment of Overpayments
If you believe you have paid too much for your premium and should receive a refund, please call the member service number on the back of your ID card.
Medical Necessity & Prior Authorization Time Frames and Enrollee Responsibilities
We must approve some services before you can get them. This is called prior authorization or preservice review. If you need a service that we must first approve, your in-network doctor will call us for the authorization. An example of a service needing prior authorization is any kind of inpatient hospital care (except maternity care). If you don’t get prior authorization, you may have to pay up to the full amount of the charges. The number to call for prior authorization is included on the ID card you receive after you enroll. Please refer to the specific coverage information you receive after you enroll.
A decision on a request for prior authorization for medical services will typically be made within 72 hours of us receiving the request for urgent cases or 15 days for non-urgent cases. These timeframes may vary by state.
Drug Exception Timeframes and Enrollee Responsibilities
Sometimes our members need access to drugs that are not listed on the plan's formulary (drug list). These medications are initially reviewed by us through the formulary exception review process. A member can submit a formulary exception request by contacting us in writing or calling the member service number on the back of your ID card. Alternatively, a prescribing provider can submit a formulary request through the provider portal.
If the non-formulary request is denied, you may be entitled to submit the case for an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). We must follow the IRO's decision. An IRO review may be requested by a member, member's representative, or prescribing provider by sending a written request to us at the address provided in the determination letter or by calling the member service number on the back of your ID card.
For standard exception review where the request was denied, the timeframe for review is 72 hours from when we receive the request. For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we receive the request. To request an expedited review for exigent circumstances, call the member service number on the back of your ID card.
Explanation of Benefits
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 your provider.
Coordination of Benefits
Coordination of benefits, or COB, is when you are covered under one or more other 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 Coordination of Benefits can be found in your coverage documents.