Claims Payment Policy Information for Virginia Individual Exchange Plans
The information contained on this page applies to health benefit plans that will be effective starting in the 2017 plan year. This information is subject to change pending review by state and federal regulators.
Out-of-network liability and balance billing
If you see a provider outside of the network, you may be responsible for the full cost. Your health plan does not cover out-of-network services except as specifically described in your Schedule of Benefits.
Emergency health services provided by out-of-network providers will be covered at the network rate. You will owe your co-pay, co-insurance or deductible amount.
You may also be responsible for the difference between the amount billed by the out-of-network provider and the amount UnitedHealthcare would pay a network provider. This is called as balance billing. The difference will not apply to your out of pocket maximum or your coinsurance maximum.
Network doctors will submit your claims to UnitedHealthcare. If you see a provider that’s not in the network, you may have to submit the claim yourself.
Grace periods and claims pending during the grace period
Your coverage can end if you fall behind in paying your monthly health insurance premium. But before your coverage can end, you have a short period of time to pay called a “grace period.”
If you get federal financial assistance in the form of an Advance Payment of Tax Credit (APTC), and have paid at least one month’s premium during the benefit year, you will be given a three-month grace period to pay your premium. To keep your coverage, you must pay all premiums owed in full before the three-month grace period ends. Your coverage will end if you don’t pay your premiums in full before the grace period ends.
UnitedHealthcare will pay claims for covered health services during the first month of the grace period. In the second and third months of the grace period, claims will be pended. This means that no claims will be paid or processed in these months unless full premium payment is received by the end of the three-month grace period.
If you don’t qualify for an APTC, you’ll have a grace period of 31 days but only if you paid your first premium. During the grace period, you will still have coverage. If full payment is not received within this 31-day grace period, your coverage will be canceled, and you will be responsible for the cost of services received during the grace period.
Claims are processed when a provider sends UnitedHealthcare a claim for payment. If your coverage ends after a claim is processed, the claim will be reprocessed and denied. This could happen if coverage has ended because payment was not received on time or if your subsidy amount changes.
Getting your money back if you overpaid
If you have paid too much on your premium, either in error or because of a change in your premium amount, we will apply the additional amount to the next monthly payment, or you can request a refund. To request a refund, call 1-800-708-2848.
Medical necessity and prior authorization timeframes and member responsibilities
Some services may need prior authorization and/or be subject to review for medical necessity. Prior authorization means that approval from UnitedHealthcare may be required before you get a service, have a surgery or fill a prescription for the service or prescription to be covered by your plan.
If you don’t get prior authorization as required, you may be responsible for paying for certain benefits and services. Prior authorization must be obtained before a scheduled service as soon as reasonably possible. Review your Schedule of Benefits to see recommended prior authorization timeframes for certain services.
Drug exceptions timeframes and member responsibilities
Your Right to Request an Exclusion Exception
When a Prescription Drug Product is excluded from coverage, you or your representative may request an exception to gain access to the excluded Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours.
If your request requires immediate action and a delay could significantly increase the risk to your health, or the ability to regain maximum function, call us as soon as possible. We will provide a written or electronic determination within 24 hours.
If you are not satisfied with our determination of your exclusion exception request, you may be entitled to request an external review. You or your representative may request an external review by sending a written request to us to the address set out in the determination letter or by calling the toll-free number on your ID card. The Independent Review Organization (IRO) will notify you of our determination within 72 hours.
Expedited External Review
If you are not satisfied with our determination of your exclusion exception request and it involves an urgent situation, you or your representative may request an expedited external review by calling the toll-free number on your ID card or by sending a written request to the address set out in the determination letter. The IRO will notify you of our determination within 24 hours.
Information on Explanations of Benefits (EOBs)
The Explanation of Benefits (EOB) is a statement sent to you that shows what medical treatments and services were paid on behalf of the member. EOBs are always displayed online after a claim is processed. UnitedHealthcare sends health statements to members that show several claims during a specified time frame. These statements are not bills.
For help reading an EOB, please see Understanding your EOB(Opens a new window).
Coordination of Benefits (COB)
Coordination of Benefits is a way to figure out who pays first when two or more health insurance plans are responsible for paying the same medical claim. If you have more than one health plan, your plan documents will tell you which plan pays first, called the primary plan, and which plan pays second, called the secondary plan.
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