Claims Payment Policy Information for Pennsylvania Small Group Plans
The information contained on this page applies to health benefit plans that will be effective starting in the 2018 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 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.
A retroactive denial is the reversal of a previously paid claim, through which the enrollee then becomes responsible for payment.
Claims are processed when a provider sends UnitedHealthcare a claim for payment. When your coverage ends, we will still pay claims for Covered Health Care Services that you received before the date your coverage ended. If your coverage ends after a claim is processed, the claim may be reprocessed and denied if the services were completed after the date your coverage ended. This could happen if coverage has ended because payment was not received on time. Retroactive denials can be prevented by paying premiums on a timely basis.
Grace periods and claims pending
Your coverage can end if your monthly health insurance premiums are not paid. But before your coverage can end, there is a short period of time to pay called a “grace period.” A grace period of 31 days will be granted for the payment of any policy charge not paid when due. During the grace period, the policy will continue in force. All claims for covered services received by the member during the grace period will be paid, as well as any previously submitted (pending) claims. All appropriate claims will be paid for services rendered to the enrollee during the first month of the grace period and claims may be pended for services rendered to the enrollee in the second and third months of the grace period. Please note: a second and third month grace period may not apply to you. It only applies to individuals with exchange based coverage, who qualify for a special tax credit.
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 the toll-free number on the back of your ID card.
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 EOBOpens 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.
Just Plain Clear® English and Spanish Glossary
We know that health care and health insurance terms can be hard to understand. UnitedHealth Group created the Just Plain Clear glossary to help you make informed decisions.
Just Plain Clear® GlossaryOpens a new window
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