Claims Payment Policies and Practices

Qualified Health Plan Issuers have provided information to help you understand what is needed for a claim to be paid, or why a claim was denied.

Click the links below to see the information the issuers have provided.

• Anthem Blue Cross

Out-of-network liability, balance billing, and enrollee claim submission

A claim is a request to apply benefits for your health care coverage. Claims are submitted to Anthem Blue Cross for health care services, supplies, drugs, and/or equipment that are provided to you. In most cases, In Network Providers will send claims to Anthem Blue Cross for you. But if you received care from an Out of Network Provider that does not send the claim to Anthem Blue Cross on your behalf, it may be your responsibility to do so. If you are sending a claim to Anthem Blue Cross, we must receive the Claim Form within fifteen (15) months from the date of service in order for Anthem Blue Cross to determine benefits. Anthem Blue Cross will determine if benefits are due in a timely manner. This is typically within thirty (30) days of receiving the claim. You may obtain a copy of the Claim Form by contacting Anthem Blue Cross Customer Service at 855-634-3381 or at the links below.

Links to Claim Form	Medical	Pharmacy - Express Scripts Thru 12/31/19	Pharmacy - IngenioRx Effective 1/1/20
The physical address to mail your Claim Form to is	Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007	Express Scripts ATTN: Commercial Claims P.O. Box 14711 Lexington, KY 40512-4711	IngenioRx Claims Department P.O. Box 52065 Phoenix, AZ 85072-2065

In Network Providers have an agreement with Anthem Blue Cross. Out of Network Providers do not have an agreement with Anthem Blue Cross. Your personal financial costs when using Out of Network Providers may be considerably higher than when you use In Network Providers. Services provided by Out of Network Providers for non-emergency, non-urgent, and/or non-authorized services are not a covered benefit. This means you will be responsible for all charges performed by an Out of Network Provider. For care obtained from an out of network provider that is an emergency, urgent, and/or authorized service, you are responsible for any deductible, coinsurance, or copayment responsibility that we determine you may. In addition, you will also be responsible for any balance of a Provider’s bill that is above the Maximum Allowed Amount determined by Anthem Blue Cross. Covered Services performed at an In Network Facility at which, or as a result of which, you receive services provided by an Out of Network Provider, you will pay no more than the same cost sharing that you would pay for the same Covered Services received from an In Network Provider.

Anthem Blue Cross wants you to understand the benefits of your health care coverage so you can maximize your health care coverage with us. Anthem Blue Cross offers a variety of ways to assist and educate you to be a more informed consumer. For detailed information regarding the benefits of your plan, please refer to your Combined Evidence of Coverage and Disclosure Form. When logged in to www.anthem.com/ca you can also send messages to us electronically. Anthem Blue Cross is also available to answer any questions you have by contacting our Customer Service at 855-634-3381.

Grace periods and claims pending

If you are getting financial help from the government to pay for your health coverage, once you have paid at least one monthly payment, you can get a grace period of up to three months if you fall behind on payments.

We will continue to consider services you receive during the first month of this grace period according to plan benefits. If you receive services after the first month of this grace period, we will hold (also called "pend") claims — meaning, we won’t pay them yet, but we’ll keep them and will process them after receipt of your premium payments.

If you pay all the missed monthly payments before your grace period ends, we will then go back and consider any claims for covered services we were holding (also called “pending”) according to plan benefits.

Reminder: Not all grace periods are three months — you are entitled to three months if you are getting financial help from the government for your monthly payment.

If you don’t pay for all the missed monthly premiums, we have to deny any claims that we are holding or pending. And you will be responsible to pay all charges for those services.

It is best to pay your monthly payment on time every month, to avoid any chance of getting into your grace period.

If you are interested in setting up automatic payments, contact us at 855-634-3381.

Retroactive claim denials

Retroactive denial means going back and denying claims that were paid in the past. One way that could happen is if we paid a claim after we got your monthly payment; but then your bank says there is not enough money in your account and we never get a new payment from you. We will then go back and retroactively deny that claim, and we will need to get the money back that we paid for it.

If a claim was not paid yet, but we were just holding it (or pending it) as described in the previous section, Grace periods and claims pending — it can also be denied if you run out your grace period. But since we did not pay the claim yet, we wouldn’t call it a retroactive denial. It is just called a denial.

One way you can avoid having your claims denied is by always paying your monthly payment on time. If you are late, be sure to pay before your grace period runs out. Contact us at 855-634-3381 to ask us about setting up automatic payments if you think that can help you prevent you from missing your premium payment.

Getting money back if you pay us more than you owe

If you pay more than what you owe for your premium, we will either refund or credit the extra amount to you or your account. Hopefully, our processes will identify any overpayment automatically. But if you believe you have paid more than you needed to, please contact us at 855-634-3381 or log in to your online account at wwww.anthem.com/ca and send us a message. Some health plans will describe this by the official terms "recoupment of overpayments," which means the same thing — getting your money back if you have overpaid.

Medical necessity and prior authorization

Medical necessity is a standard that doctors and health plans use to determine if the care you are getting, or are looking to get, is right for you. It means, is the care reasonable and necessary to protect your life, prevent significant illness or significant disability — or to alleviate severe pain through treatment of diseases, illnesses or injuries? What your plan covers depends on whether the care is medically necessary and right for the situation, and also the details of your plan.

Sometimes, in order to help us figure out ahead of time (before you get the care) if a health service or device is medically necessary and covered by your plan, you or your doctor may need to contact us. This is called getting "prior authorization (preservice review).”

When you go to a doctor or hospital in your plan, they will work with us to see if any of the care you are getting needs prior authorization. If you go to a doctor or hospital that is not in your plan, it's a good idea to check with us first — especially if it's more involved care, for example, surgery. If you are admitted to the hospital, contact us as soon as you can — ideally within 24 hours of admission. That's not necessary for childbirth admissions unless there's a complication and/or mother and baby are not discharged at the same time.

If you or your doctor do not get prior authorization for something that needs it, you could be responsible for more of the cost as stated in your Combined Evidence of Coverage and Disclosure Form.

We will review requests for prior authorization (preservice review) benefits according to the timeframes listed below.

Non Urgent	Urgent
Five (5) business days from the receipt of the request	Seventy-two (72) hours from the receipt of the request

When you need a prescription drug that’s not on your plan’s drug list

If you and your doctor feel you need a prescription drug that's not on your plan's drug list, please have your doctor or pharmacist get in touch with us. We will make a decision within 72 hours of getting the request. We will look at whether it is medically necessary and appropriate compared to the other drugs on our list.

If we deny coverage of the drug, you have the right to request an External Review by an Independent Review Organization (IRO). The IRO will make a coverage decision within 72 hours of receiving your request.

You or your doctor may also submit a request for a prescription drug that is not on your plan's drug list based on what's called "exigent circumstances". For example, if you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or if you are undergoing a current course of treatment using a drug not covered by your plan. In that case, we will make a decision within 24 hours of getting your request.

If we deny coverage for exigent circumstances, you can request an external review by an IRO, similar to above. But a decision will be made more quickly, within 24 hours of getting your request.

Explanation of Benefits (EOB)

After you get care and you or your doctor submits a claim to us for it, we'll send you an Explanation of Benefits (also called EOB for short). It's like recap of your claim. It explains what service you got, the amount the doctor charged, the amount we paid and why — and more. It also tells you how to appeal a claim.

Information on how to read and understand an EOB

Coordination of Benefits

When you or anybody else on your plan, like your spouse or kids, is covered by two different health plans — both plans may need to know about it. If your plan has coordination of benefits, we will work together to make sure you are getting the right benefits. From time to time, you may get a notice asking if anybody is covered by another plan. Not getting this info back to us may delay claim payments. So if you are asked for this information, be sure to let us know as soon as possible.

• Blue Shield of California

URL

https://www.blueshieldca.com/

Blue Shield does not currently have this information available on our website. Most of this information is included in the member’s Evidence of Coverage booklet that once registered can be accessed using the URL above.

Out-of-network liability and balance billing

On the Blue Shield PPO plan you can choose to seek services from a Non-Participating provider for most covered services.

Participating Providers have a contract with Blue Shield and agree to accept Blue Shield’s Allowable Amount as payment in full for Covered Services. As a result, your Cost Share is less when you receive Covered Services from a Participating Provider.

Except for Emergency Services and services received at a Participating Hospital under certain conditions, you will pay more for Covered Services from a Non-Participating Provider. Non-Participating Providers do not have a contract with Blue Shield to accept Blue Shield’s Allowable Amount as payment in full for Covered Services and can balance bill for the difference between the Allowable Amount and the Billed Charges. You will be responsible for any Plan deductibles, copayment and coinsurance amounts, non-covered items and the difference between the billed change and the allowed amount.

Enrollee Claim Submission

When you see a Participating Provider, your provider submits the claim to Blue Shield. When you see a Non-Participating Provider, you may have to submit the claim to Blue Shield or the Benefit Administrator. Claims must be submitted within one year of the service date.

How To Submit A Claim

Type Of Claim	What To Submit	Where To Submit It
Medical Services	Blue Shield claim form; and The itemized bill from your provider	Blue Shield of California P.O. Box 272540 Chico, CA 95927
Pharmacy Services	Prescription Drug claim form; and Related receipts or the pharmacy’s bill	Blue Shield of California P.O. Box 419019 Dep. 191 Kansas City, MO 64141
Mental Health and Substance Use Disorder Services from an MHSA Participating Provider	MHSA online claim form; and The itemized bill from your provider	Blue Shield of California Mental Health Service Administrator P.O. Box 719002 San Diego, CA 92171
Mental Health and Substance Use Disorder Services from an MHSA Non-Participating Provider	Blue Shield claim form; and The itemized bill from your provider	Blue Shield of California P.O. Box 272540 Chico, CA 95927

Grace Periods and Claims Pending

Premium grace period if you do not receive Advance Payments of Premium Tax Credits

Premium grace period if you do not receive Advance Payments of Premium Tax Credits

Premium grace period if you receive Advance Payments of Premium Tax Credits

If the Subscriber previously paid Blue Shield at least one full month’s Premium during the benefit year and is late on a Premium payment, Blue Shield will notify the Subscriber and the Subscriber will have a federal grace period of three consecutive months from the due date to pay all outstanding Premiums. Blue Shield will pay claims for Covered Services during the first month (or first 30 days, whichever is greater) of the federal grace period. Coverage will be suspended for the second and third months of the federal grace period until the Subscriber pays all Premiums owed.

If the three-month federal grace period expires before the Subscriber pays all outstanding Premiums, Blue Shield will terminate coverage. The last day of coverage will be the last day of the first month of the three-month federal grace period (or 30 days from the first day of the first month, whichever is later).

Retroactive Denials

Whenever payment on a claim is made in error, Blue Shield has the right to recover such payment from the Subscriber or, if applicable, the provider or another health benefit plan, in accordance with applicable laws and regulations. With notice, Blue Shield reserves the right to deduct or offset any amounts paid in error from any pending or future claim extent permitted by law. Circumstances that might result in payment of a claim in error include, but are not limited to, payment of benefits in excess of the benefits provided by the health plan, payment of amounts that are the responsibility of the Subscriber (Cost Share or similar charges), payment of amounts that are the responsibility of another payor, payments made after termination of the Subscriber’s coverage, or payments made on fraudulent claims.

To Prevent Retroactive Denials:

• Make sure your providers have your current ID card;
• Know how you can access care;
• Know which services are covered under your plan;
• Know which services are not covered under your plan;
• Know how you must get prior authorization for certain services; and
• Pay your premiums on time

Recoupment of Premium Overpayments

If the Subscriber pays Premiums beyond the date coverage ends, those Premiums are unearned. Blue Shield will refund unearned Premiums to the Subscriber, minus any amount Blue Shield pays for Benefits received after the date coverage ends. Blue Shield will only issue a refund to the Subscriber if the amount the Subscriber paid in unearned Premiums is more than the amount Blue Shield pays for Benefits after coverage ends.

To obtain a refund of a Premium overpayment call the Shield Concierge (HMO) or Customer Service (PPO) phone number on the back of your ID card.

Medical Necessity and Prior Authorization Time Frames and Enrollee Responsibilities

Benefits are only available for services and supplies that are Medically Necessary. Blue Shield reserves the right to review all claims to determine if a service or supply is Medically Necessary. A Physician or other Health Care Provider’s decision to prescribe, order, recommend, or approve a service or supply does not, in itself, make it Medically Necessary.

Coverage for some Benefits requires pre-approval from Blue Shield. This process is called prior authorization. Prior authorization requests are reviewed for Medical Necessity, available plan Benefits, and clinically appropriate setting. The prior authorization process also identifies Benefits that are only covered from Participating Providers or in a specific clinical setting.

If you see a Participating Provider, your provider must obtain prior authorization when required. When prior authorization is required but not obtained, Blue Shield may deny payment to your provider. You are not responsible for Blue Shield’s portion of the Allowable Amount if this occurs, only your Cost Share.

If you see a Non-Participating Provider, you or your provider must obtain prior authorization when required. When prior authorization is required but not obtained, Blue Shield may deny payment and you will be responsible for all billed charges.

You do not need prior authorization for Emergency Services or emergency Hospital admissions at Participating or Non-Participating facilities. For non-emergency inpatient services, your provider should request prior authorization at least five business days before admission.

When a decision will be made about your prior authorization request

Prior authorization or exception request	Time for decision
Routine medical, mental health and substance use disorder, dental, and vision requests	Within five business days
Expedited medical, mental health and substance use disorder, dental, and vision requests	Within 72 hours
Routine prescription Drug requests	Within 72 hours
Expedited prescription Drug requests	Within 24 hours

Expedited requests include urgent medical and exigent pharmacy requests. Once the decision is made, your provider will be notified within 24 hours. Written notice will be sent to you and your provider within two business days.

Drug exception time frames and enrollee responsibilities (not required for SADPs)

Blue Shield’s Drug Formulary is a list of FDA-approved Generic and Brand Drugs. This list helps Physicians or Health Care Providers prescribe Medically Necessary and cost effective Drugs. Drugs not listed on the Formulary may be covered when approved by Blue Shield through the exception request process.

To request coverage for a non-Formulary Drug, you, your representative, your Physician, or your Health Care Provider may submit an exception request to Blue Shield. Once all required supporting information is received, Blue Shield will approve or deny the exception request, based on Medical Necessity, within 72 hours in routine circumstances or 24 hours in exigent circumstances.

To start the exception request process call the Shield Concierge (HMO) or Customer Service (PPO) phone number on the back of your ID card.

Explanation of Benefits (EOB)

Blue Shield or the Benefit Administrator will process your claim within 30 business days of receipt if it is not missing any required information. If your claim is missing any required information, you or your provider will be notified and asked to submit the missing information. Blue Shield cannot process your claim until we receive the missing information.

Once the claim is processed, you may receive an Explanation of Benefits (EOB). The EOB will include valuable information including the provider and date of each service, a description of each service, patient responsibility, deductible status (if applicable) and the amount paid.

Coordination of Benefits

NOT APPLICABLE – Individual and Family Plans do not coordinate with other Individual or Group Health Plans

• CCHP Health Plan

Chinese Community Health Plan is designed for Members to obtain services from a network of doctors. Members may choose to receive services from doctors outside this network. Covered services obtained from out of network providers may result in a higher share of cost for the Member. Certain medical services might need to be pre-authorization by CCHP before the plan will cover it. Some services are not covered unless given by a network provider. Please refer the plan Evidence of Coverage and Summary of Benefit for additional information.

Contracted providers have 90 days to bill claims to CCHP for services provided to Members. Out of network providers or non-contracted providers have six (6) months to bill CCHP for services provider to Members. CCHP process claims within 45 days from the date of receipt.

Members can submit a Reimbursement Request within 90 days from the date of service. This request form is available through our Member Services or CCHP website. Members need to submit the Reimbursement Form to CCHP and attach all necessary information including receipts and medical reports or records to support the request. Once the request is processed in the claims system and the reimbursement is approved, CCHP issues a check directly to the Member.

• Health Net

Claims for Covered Services

Through Covered California TM for individuals and families, Health Net of California, Inc. offers HMO and HSP plans. Health Net Life Insurance Company EPO and Enhanced Care PPO plans are also available.

For small group business, Health Net Life Insurance Company also offers PPO and Enhanced Care PPO plans through Covered California ™.

All of these plans come with a specific doctor network. There is no coverage for out-of-network services on Health Net HMO, HSP or EPO plans, with the exception of urgent care, emergency care or pre-approved services; members must use the network that comes with these plans for all covered services. Health Net PPO and EnhancedCare PPO plans do cover out-of-network services but at a higher out of pocket cost to you.

When you use in-network services, your doctor (or other provider) sends the claim to Health Net. There’s no paperwork for you! Just remember to keep your Explanation of Benefits (EOB) for your records.

Explanation of Benefits (EOBs)

An EOB is not a bill. It is a brief description of the benefits that apply to the services you received. It also shows details about services you received; like the amount your provider billed Health Net, the amount Health Net paid and the portion of services that may be your responsibility. EOBs are sent after Health Net receives and adjudicates claims.

• The sample EOB below shows the most common sections. Depending on the services you receive and your plan type, your EOB may have data in the same or different areas.
  Explanation of Benefits Instructions (pdf)

Submitting a claim for reimbursement

You may have to submit a claim for reimbursement if you get urgent or emergency services, or for pre-approved out of network services.

Medical claims

1. Download and complete one claim form for each member submitting bills for reimbursement.
   
   • English medical claim form
   • Spanish medical claim form
   
   Note: Claims must be submitted within 365 days of service.
2. Mail your claim to:
   

   HealthNet Commercial
   PO BOX 9040, Farmington MO 63640-9040
   

Balance Billing

Balance billing happens when doctors bill you for the difference between the charges they billed and the amount covered by your health plan. Members on PPO or EnhancedCare PPO plans may be balance billed for out-of-network services.

Doctors who are part of the network that comes with your plan do not balance bill our members. If you get services outside the network that comes with your plan, the doctor may bill you. Health Net will not cover any part of the bill unless it was for urgent or emergency services, or if we pre-approved the out-of-network service. You will have to pay the full amount for any non-covered services.

Coverage with more than one health plan for groups

Health Net will manage benefits for members covered by two or more health plans to make sure payments are correct. This is called coordination of benefits (COB).

Paying Individual plan premiums

Your premium payment, the amount you pay for your health plan, is due the last day of each month for coverage effective on the following day. Use one of the following options:

1. Online (our recommendation!). Log in to your member account at myhealthnetca.com to:
   • Choose online monthly bill payment by following the "pay online" instructions.
   • Enroll in automatic bill pay using your prepaid debit card, bank account or credit card. After your auto bill pay account is set up, all future premiums will be charged to that card or account.
2. Mail:
   • Send a check or money order to the address below. Make your check payable to “Health Net” and remember to write your policy number on your check or money order.
     • Health Net CA Individual
       P.O Box 748705
       Los Angeles, CA 90074-8705
3. Phone:
   • Call us at 1-800-539-4193 and use our Interactive Voice Response (IVR) system. It's quick and available 24/7!
   • You can also call 1-888-926-4988 (TTY/TDD 711) between 8 a.m. and 5 p.m. PST to make your payment.
4. MoneyGram®:
   • Find a MoneyGram location near you by visiting MoneyGram.com/BillPayLocations or calling 1-800-926-9400.
     • Remember to bring:
     • Cash for your premium payment. Health Net will pay your MoneyGram transaction fee!
     • Your Health Net member ID number
     • Receive Code: 16375
     • Fill out the blue MoneyGram ExpressPayment® form and use the MoneyGram phone or kiosk to complete your payment.
     • Ask a store associate if you need any help in making your payment.
   • To learn more about making your Health Net invoice payment using MoneyGram, visit www.moneygram.com//us/en/how-to-paybills

Grace Period

A grace period is the time we add to allow you to make your premium payment after the due date. There is not a gap in coverage during the grace period. The length of the grace period depends on which plan you are enrolled in.

30-day grace period

Enrolled members who does not receive federal premium tax credits and/or state premium assistance subsidies will receive a 30-day grace period if there was at least one full month's premium paid during the benefit year. During the grace period, the members will receive a letter explaining the 30 day grace period.

• The 30-day grace period begins on the 1st day of the month, with no gap in coverage.
• Your coverage remains after the 30 days as long as all past due premium payments are paid. If not paid for, your health coverage will end at the end of the grace period.

90-day grace period for members who get premium tax credits

Enrolled members who receive federal premium tax credits and/or state premium assistance subsidies will receive a grace period of three consecutive months (90-days) if there was at least one full month's premium paid during the benefit year. During the grace period, the members will receive a letter explaining the 90 day grace period.

• Month 1
  1. The 90-day grace period begins on the 1st day of the month, with no gap in coverage.
  2. Health Net will continue coverage during your grace period.
  3. You still need to pay your premium payments. You also need to pay all copayments, coinsurance or deductible amounts required under the plan contract for this period.
• Months 2 and 3
  1. Health Net will hold/pend your claims until you have paid all past due premium payments to us. During the second and third month of your grace period, any claims submitted to Health Net will be pended. These claims will not be paid until you have paid all past due premium payments to Health Net.
  2. You will keep getting monthly premium payment bills. This means your total amount due will go up each month that you don’t pay.
• At the end of the grace period
  1. If you do not pay the past due premium payments in full by the last day of the three-month grace period, your coverage will terminate for nonpayment of premiums the last day of the first month of the three-month grace period and you will be liable for any claims or authorizations rendered during the second and third months of the three-month grace period. You also have to pay for any health care services you received during months 2 and 3. This includes emergency care.
  2. You will still owe the unpaid premium amount. Also, if you apply for another policy in the future, you may have to pay the unpaid premium amount for your old plan and the first month's premium for your new plan before your coverage starts.
  3. Health Net will keep any premium payments made toward the first month's premium, during which you had coverage, and return all other premium amounts applied to the second or third months.

Denied claims

Under certain conditions, we may deny a claim after you receive services. This is called a retroactive denial. Examples include, but are not limited to:

• You were not eligible at the time of service.
• The service was not a covered plan benefit.
• An approval was needed and not received before the services were given.
• You received non-emergent, non-urgent, non-approved out-of-network services on a plan that does not have an out-of-network benefit tier.

You can help avoid retroactive denials by:

• Paying your premium payments on time.
• Knowing your plan benefits, including which benefits need approval before services are given.

Recoupment of overpayments

Enrollee recoupment of overpayments is the refund of a premium overpayment by the enrollee due to over-billing by the issuer. If an active member believes they overpaid their premiums, the member should contact the Customer Contact Center.

Medical necessity

Medical necessity is used to describe care that is reasonable, necessary and/or appropriate, based on evidence-based clinical standards of care.

Prior authorization

• Prior authorization is a review process. Health Net uses prior authorizations to approve a request to access a covered benefit before you receive the benefit.
• The purpose of the review is to find out if your benefits apply, what is needed medically, and whether the treatment proposed is correct. Other conditions reviewed are level of care, length of stay or place of service.
• Health Net maintains a list of drugs, devices, procedures, and other medical services that require prior authorization.

On an HMO plan your Physician Group will authorize and coordinate all your care, providing you with medical services or supplies you are completely financially responsible for medical care that the contracting Physician Group does not provide or authorize except for medically necessary care provided in a legitimate emergency.

On a PPO or EPO plan some of the covered expenses are subject to a requirement of certification or a noncertification penalty will apply. All certifications are performed by HNL or an authorized designee. Certification must be requested by you within the following periods:

• Five or more business days before the proposed admission date or the commencement of treatment, except when due to a medical emergency;
• 72 hours or sooner, taking into account the medical exigencies, for proposed services needed urgently.
• In the event of being admitted into a Hospital following outpatient emergency room or Urgent Care center services for Emergency Care; please notify the Plan of the inpatient admission within 48 hours, or as soon as reasonably possible; or
• Before admission to a Skilled Nursing Facility or Hospice Care program.
• For Urgent Care requests, HNL will notify the covered person of our decision as soon as possible, taking into account the medical exigencies, but not later than 72 hours from the receipt of the request. If additional information is necessary to make Our determination, HNL will notify the covered person (within 24 hours of the receipt of the request) of the specific information necessary to make the determination and a reasonable time frame (that is not less than 48 hours) to provide the information to HNL. HNL will notify the covered person of our decision no later than 48 hours after the earlier of the receipt of the requested information, or the end of the time period to provide the requested information.
• For all other requests in which the decisions are based in whole or in part on Medical Necessity, HNL will notify the covered person of our decision not later than five (5) business days from the receipt of the request and information that is reasonably necessary to make the determination for time frames of initial benefit determinations that are not based on Medical Necessity.

Prescription drugs

The list of drugs we cover is called the Health Net Essential Rx Drug List.

• For medications not on the list:
  • You can ask your doctor to prescribe one that is on the list.
  • Or, your doctor can call us to ask approval for a drug not on the list and that is not excluded from coverage. These are called non-formulary drugs.
  • Health Net will determine coverage approval no later than 72 hours after getting the request.
• If you have a condition that might threaten your life, health or ability to function normally if not treated right away (exigency), or if you are currently getting treatment using a drug that is not on the Essential Rx Drug list, and not continuing the drug would create an urgent (exigent) circumstance, then you, your designee or your doctor can ask for an expedited review.
  • Expedited requests for prior authorization will be processed within 24 hours after Health Net’s receipt of the request and any additional information requested.
• To request a refund for prescription drugs:
  • If you have paid out-of-pocket for a drug, you may be eligible for reimbursement on prescriptions filled for emergency medical care. Please contact Customer Service for questions about reimbursements. Customer Service

Customer Service

If you have questions about your Health Net plan call Customer Service:

Customer Service	Phone
Customer Service - Individual and Family Plan	1-888-926-4988
Customer Service –Small Group Plan	1-888-926-5133
Enhanced Care PPO Customer Service	1-844-463-8188
24-hour Automated Payment Line	1-800-539-4193
TTY (hearing and speech impaired)	1-888-926-5180

• Kaiser Permanente

Kaiser is not a claims based model, therefore not applicable.

• LA Care Health Plan

Claims and Payment

Filing Deadline

L.A. Care’s timeframe for receipt of an ‘initial claim’ submission is 90 days for contracted providers after the date of service for timely filing for a new claim except for when a contract allows for a different timeframe. The timeframe for receipt of an ‘initial claim’ submission is 180 days for non-contracted providers after the date of service for timely filing for a new claim.

Billing

All paper claims must be submitted on CMS 1500 form for professional services and UB-04 form for facility services. LA Care accepts EDI submissions partnering with Office Ally and Change Health Care (formerly Emdeon). Providers must use good faith effort to bill with the most current coding available.

The following information must be included on every claim:

Professional and Supplier Claims
Providers sending professional and supplier claims to L.A. Care Health Plan on paper must use Form CMS 1500 in a valid version. This form is maintained by the National Uniform Claim Committee (NUCC), an industry organization in which CMS participates.

Institutional Providers:
The completed UB 04 data set or its successor format adopted by the National Uniform Billing Committee (NUBC), submitted in the designated paper or electronic format as adopted by the NUBC. Entries stated as mandatory by NUBC and required by federal statue and regulations and any state designated data requirements included in statues or regulation.

If a claim is submitted with incomplete or invalid information, it may be returned to the submitter as unprocessable. Examples:

Unprocessable Claim - Any claim with incomplete or missing, required information, or any claim that contains complete and necessary information; however, the information provided is invalid. Such information may either be required for all claims or required conditionally.

Incomplete Information - Missing, required, or conditional information on a claim (e.g., no Provider Identification Number (PIN), Universal Product Number (UPN), or National Provider Identifier (NPI).

Invalid Information - Complete required or conditional information on a claim that is illogical, or incorrect (e.g., incorrect PIN, UPN, or NPI), or no longer in effect (e.g., an expired number).

Claims Adjudication

For Covered California Members, LA Care Health Plan is allowed 45 working days from the day of receipt to finalize a claim. Interest is due on a late paid claim.

Each claim is subject to a comprehensive series of quality checks called “edits” and “audits.” Quality checks verify and validate all claim information to determine if the claim should be paid, denied or suspended for manual review. Edit and audit checks include but is not limited to verification of:

• Data validity
• Procedure and diagnosis compatibility
• Provider eligibility on date of service
• Recipient eligibility on date of service
• Medicare or other insurance coverage
• Claim duplication
• Authorization requirements

Provider Portal Claims Verification

The L.A. Care Provider Portal is the preferred method for contracted providers to check claims status. Please see information on how to access the L.A. Care Provider Portal in the Provider Portal section of this handbook.

The secondary method to check claims status is by calling 1-866-LA-CARE6.

Balanced Billing

Balance billing L.A. Care members is prohibited by law. Contracted providers cannot collect reimbursement from an L.A. Care member or persons acting on behalf of a member for any services provided, except to collect any authorized share of cost.

• Molina Healthcare

http://www.molinahealthcare.com/members/ca/en-US/mem/marketplace/resources/Pages/faq.aspx

• Oscar

https://assets.ctfassets.net/plyq12u1bv8a/6p8x3Giz0TQRkJnpgfbXkH/573f03f2c8fb855743fd45ba1da1c3ee/Transparency_in_Coverage_CA_2020.pdf

• Sharp Health Plan

Grace periods and claims pending

1. All members are active for the first 30 days, and sent on files as active. From days 31-90 if they have not made a payment then they are in their Grace Period and are ineligible for services, and not sent as an eligible member on outbound eligibility files and claims are denied.
2. When the member is in the 30 day grace period claims will be paid provided all auth guidelines etc. are followed.

Retroactive denials

Sharp Health Plan does not go back and deny claims that have been previously paid.

Medical necessity and prior authorization time frames and enrollee responsibilities

Except for PCP services, outpatient mental health or chemical dependency office visits, MinuteClinic services, Emergency Services and obstetric and gynecologic services, you are responsible for obtaining valid Authorization before you receive Covered Benefits.

To obtain a valid Authorization:

1. Prior to receiving care, contact your PCP or other approved Plan Provider to discuss your treatment plan.
2. Request prior Authorization for the Covered Benefits that have been ordered by your doctor. Your PCP or other Plan Provider is responsible for requesting Authorization from Sharp Health Plan or your Plan Medical Group.
3. If Authorization is approved, obtain the expiration date for the Authorization. You must access care before the expiration date with the Plan Provider identified in the approved Authorization.

A decision will be made on the Authorization request in a timely fashion based on the nature of your medical condition, but no later than five business days. A letter will be sent to you within two business days of the decision.

If waiting five days would seriously jeopardize your life or health or your ability to regain maximum function or, in your doctor’s opinion, it would subject you to severe pain that cannot be adequately managed without the care or treatment that is being requested, you will receive a decision in a timely fashion based on the nature of your medical condition, but no later than 72 hours after receipt of the Authorization request.

If we do not receive enough information to make a decision regarding the Authorization request, we will send you a letter within five days to let you know what additional information is needed. We will give you or your Provider at least 45 days to provide the additional information. (For urgent Authorization requests, we will notify you and your Provider by phone within 24 hours and give you or your Provider at least 48 hours to provide the additional information).

If you receive Authorization for an ongoing course of treatment, we will not reduce or stop the previously Authorized treatment before providing you with an opportunity to Appeal the decision to reduce or stop the treatment.

The Plan uses evidence based guidelines for Authorization, modification or denial of services as well as Utilization Management, prospective, concurrent and retrospective review. Plan specific guidelines are developed and reviewed on an ongoing basis by the Plan Medical Director, Utilization Management Committee and appropriate physicians to assist in determination of community standards of care. A description of the medical review process or the guidelines used in the process will be provided upon request.

If you change to a new PMG as a result of a PCP change, you will need to ask your new PCP to submit Authorization requests for any specialty care, Durable Medical Equipment or other Covered Benefits you need. The Authorizations from your previous PMG will no longer be valid. Be sure to contact your new PCP promptly if you need Authorization for a specialist or other Covered Benefits.

If services requiring prior Authorization are obtained without the necessary Authorization, you may be responsible for the entire cost.

Drug exception time frames and enrollee responsibilities (not required for SADPs)

Any exception requests a member/provider would like to submit is submitted using the State of California mandated PA/ST Exception Request form and is reviewed following our PA process.

It is the policy of Sharp Health Plan to request from the prescribing provider only the minimum amount of material information necessary to approve or disapprove the prescription drug prior authorization request. It is the policy of the Plan to use and accept only prior authorization requests submitted on the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form 61-211. It is the policy of the Plan to not require the prescribing provider to provide more information than is required by Form 61-211.

1. Requests for PA may be faxed or called in, if desired, (or mailed if necessary) to the Plan. To ensure immediate access to medications without delay, a telephone request may be submitted by the physician
2. All requests are reviewed and a determination is made within twenty-four (24) hours of receipt for urgent requests and seventy-two (72) hours of receipt for routine requests.
3. Requests are evaluated following the recommended guidelines of the P&T Committee under the supervision of appropriately licensed personnel.
4. Providers are sent a determination letter by FAX within the turnaround times stated below.
5. Members are sent a determination letter within the turnaround times stated below.
6. If the request meets the approved guidelines, the request will be approved.
7. If the information submitted does not meet criteria for coverage, or there is no written policy for that drug the request file is forwarded to the Medical Director or Medical Reviewer to review for medical appropriateness and necessity and determination.

Time-frame: 72 hours including weekends and holidays. Exigent: 24 hours including weekends and holidays.

Explanation of benefits (EOB)

Sharp Health Plan will mail the EOB’s on or before the 10th of every month. The EOB’s include any claims processed and paid the previous month and any encounters or pharmacy claims included on the files received in the previous month.

Coordination of benefits

Coordination of Benefits (COB) is a process, regulated by law, which determines the financial responsibility for payment when a Member has coverage under more than one plan. The primary carrier pays up to its maximum liability and the secondary carrier considers the remaining balance for covered services up to, but not exceeding, the benefits that are available and the dentist’s actual charge.

Determination of primary coverage is as follows:

For a Group Medical Insurance Qualified Health Plan: A Group Medical Insurance Qualified Health plan providing pediatric dental essential health benefits is the primary carrier for such covered services. This applies to plans provided on the California Health Benefit Marketplace and to plans provided outside such Marketplace.

For Dependent Children covered under Group Dental Plans: The determination of primary and secondary coverage for Dependent children covered by two parents’ plans follows the birthday rule. The plan of the parent with the earlier birthday (month and day, not year) is the primary coverage. Different rules apply for the children of divorced or legally separated parents; contact the Member Services Department if you have any questions.

• Valley Health Plan

Member Claims

The VHP website has complete directions on how to submit a claim for services members might incur out of plan. Members would only be submitting claims for services that were provided for out of area Emergency or Urgent Care services at a non-contracted provider, from a pre-approved referral to a non-contracted provider, or for a prescription when local network pharmacies are closed.

For care that is provided at an in-network contracted provider, there should be no need for the member to submit their own claim.

The link for members that provides directions on how to submit a claim is: www.valleyhealthplan.org/sites/m/Pages/Medical-Claim-Reimbursement-Form.aspx

This link provides members − in English, Spanish and Vietnamese − the forms and instructions on how to submit a claim form and the time frames associated with reimbursement back to the member.

Provider Claims

Providers that have a contract with VHP must submit their claims within 90 days. Non-contracted providers have up to 180 days to submit a claim to VHP.

VHP has 45 business days to process a clean claim form the time of receipt.

• Western Health Advantage

Both Provider and Consumer claims are processed within 45 working days from the received date of the claim. Under most circumstance, claims should be submitted within 90 days from the date-of-service for provider, 180 days for Consumers. Prior to obtaining services, Providers and Consumers should ensure, if applicable, the services were authorized. If there are questions about a service or authorizations, please contact your PCP, the PCP’s assigned medical group or IPA, or the service provider. If any additional assistance is needed, please contact WHA Member Services.

How and when a Consumer can file a claim

It is important that you present your member ID card at the time of service. The provider will need the information found on your member ID card to bill WHA for the Covered Service(s).

In the unlikely event that you pay for a Covered Service out-of-pocket, you will need to mail or fax the following information to WHA for reimbursement. (Login into your MyWHA account at mywha.org to download the Reimbursement Request form.)

1. A signed and dated summary/explanation detailing the service you received
2. Any supporting documentation from the provider who performed this service
3. Indicate the specific amount you are requesting to be reimbursed
4. Proof of payment
5. Your contact information, including:
• Full name
• Phone number
• Mailing address
• Email address
• WHA member ID

Once WHA receives the above information, you will be notified within 45 business days regarding the outcome of your claim.

Please note: Only services covered under your plan are eligible for reimbursement. Your plan's applicable copayment/coinsurance and/or deductible will determine the total amount you are reimbursed.

For a prescription-only reimbursement contact Express Scripts, WHA’s pharmacy benefit manager, online at express-scripts.com or by calling 800.9038664.

For more information, contact:


Member Services
916.563.2250 or 888.563.2250 toll-free
Monday through Friday (excluding holidays) 8 a.m. to 6 p.m.
For TDD/TYY: 888.877.5378
Email: memberservices@westernhealth.com or use the Secure Message Center
Fax: 916.568.0126


If you haven’t done so all ready, be sure to visit mywha.org, click “Sign Up for MyWHA Tools” and follow the prompts. Once you are registered, you can download a copy of the Reimbursement Request form, see your personal benefit information, including copayment summaries and Combined Evidence of Coverage and Disclosure Form (EOC/DF).

Some common reasons a claim may be denied

1. Lack of eligibility
2. Non emergent care, no authorization
3. Non-participating provider, no authorization
4. Not a covered services/benefit per EOC or copayment summary

Right to an Appeal

An Appeal is a verbal or written formal request to re-review or reconsider a decision that has been made. The Appeal can be related to a payment issue, an administrative action, quality of care or service issue, utilization recommendation, or any of the procedures that deal with the review (reconsideration) of adverse initial decisions made regarding healthcare services. Your Appeal will be reviewed by a doctor who was not involved in the initial review of the issue. This doctor will make an independent second decision after reviewing all available information, which may include review by an independent outside organization. The second decision may agree or disagree with the first decision.

Standard or routine Appeals are completed within 30 calendar days. A delay in a final decision may occur if additional information is needed for the reviewer to make an informed decision.

Expedited or “fast track” Appeals are completed within seventy-two (72) hours upon request if delaying the appeal decision risks jeopardizing your health, which includes severe pain or an imminent and serious threat to the health of the Member, including but not limited to potential loss of life, limb or major bodily function. You have the right to request a “fast track” or expedited Appeal if your doctor agrees there are health risks in delaying the decision. WHA’s Medical Director or appropriately licensed designee will make the decision if the Appeal will be handled as an expedited or standard Appeal.

What is WHA's Appeal and Grievance Procedure?

If you have a Complaint with regard to WHA’s failure to authorize, provide or pay for a service that you believe is covered, a cancellation, termination, non-renewal or rescission of your membership or any other Complaint, please call Member Services for assistance. If your Complaint is not resolved to your satisfaction after working with a Member Services representative, a verbal or written Appeal or Grievance may be submitted to:

Mail:	Western Health Advantage Attn: Appeals and Grievances 2349 Gateway Oaks Drive, Suite Sacramento, CA 95833
Secure Fax:	916.563.2207
Call:	WHA Member Services 916.563.2250 or 888.563.2250
Secure Email:	mywha.org/securemessage

You may also start the Grievance process by completing WHA's online Grievance Form by visiting our website at westernhealth.com.

Please include a complete discussion of your questions or situation and your reasons for dissatisfaction and submit the Appeal or Grievance to WHA Member Relations Unit, Appeals and Grievances Department within one hundred eighty (180) days of the incident or action that caused your dissatisfaction. If you are unable to meet this period, please contact Member Services on how to proceed.

If you are appealing a denial of services included within an already-approved ongoing course of treatment, coverage for the approved services will be continued while the Appeal is being decided.

If you believe that your membership has been or will be improperly canceled, rescinded or not renewed, you may request a review by the Department of Managed Health Care after participating in WHA’s grievance process for thirty (30) days. If your coverage is still in effect when you submit your Grievance to WHA, your coverage will be continued while your Grievance is being decided, including during the time it is being reviewed by the Department of Managed Health Care. All premiums must continue to be paid timely for coverage to continue. At the conclusion of the Grievance, including any appeal to the Department of Managed Health Care, if the issue is decided in your favor, coverage will continue or you will be reinstated retroactively to the date your coverage was initially terminated. All Premiums must be up to date and paid timely.

WHA sends an acknowledgment letter to the Member within five (5) calendar days of receipt of the Appeal or Grievance. A determination is rendered within thirty (30) calendar days of receipt of the Member’s Appeal or Grievance. WHA will notify the Member of the determination, in writing, within three (3) working days of the decision being rendered.

A Grievance Form and a description of the Grievance procedures are available at every Medical Group and Plan facility and on WHA’s website. In addition, a Grievance Form will be promptly sent to you if you request one by calling Member Services. If you would like assistance in filing a Grievance or an Appeal, please call Member Services and a representative will assist you in completing the form or explain how to write your letter. We will also be happy to take the information over the phone verbally or through a secure message.

It is the policy of WHA to resolve all Appeals and Grievances within thirty (30) days of receipt. For appeals of denials of coverage or benefits, you will be given the opportunity to review the contents of the file and to submit testimony to be considered. Written notification of the disposition of the grievance or appeal will be sent to the Member and will include an explanation of the contractual or clinical rationale for the decision. Contact Member Services for more detailed information about the Appeal and Grievance procedure.

If you have a complaint regarding your dental, vision, chiropractic/acupuncture, or mental health services, contact our Plan partners for information regarding how to lodge an Appeal or Grievance.

Grace Period

• The 30-day grace period begins on the 1st day of the month, with no gap in coverage.
• Your coverage remains after the 30 days as long as all past due premium payments are paid. If not paid for, your health coverage will end at the end of the grace period.

30-day grace period

• The 30-day grace period begins on the 1st day of the month, with no gap in coverage.
• Your coverage remains after the 30 days as long as all past due premium payments are paid. If not paid for, your health coverage will end at the end of the grace period.

90-day grace period for members who get premium tax credits

Enrolled members who receive premium payment tax credits have a three-month (90-day) grace period.

• Month 1
  1. Same as above, 30-day grace period.
  2. You still need to pay your premium payments. You also need to pay all copayments, coinsurance or deductible amounts required under the plan contract for this period.
• Months 2 and 3
  1. Western Health Advantage will hold/pend your claims until you have paid all past due premium payments to us.
  2. You will keep getting monthly premium payment bills. This means your total amount due will include your unpaid balance/month(s) plus your current premium due.
• At the end of the grace period
  1. Your health plan will end due to nonpayment of premiums if Western Health Advantage does not receive all premium payment amounts due through the grace period. The total is due by the last day of the grace period. Any claims or authorizations that were held/pended will be denied. You will still owe the unpaid premium amount. You also have to pay for any health care services you received during months 2 and 3. This includes emergency care. If your health plan coverage is ended for nonpayment of premiums, the end date of your health plan will be the last day of the first month of the three-month grace period.

Department of Managed Health Care Information

The California Department of Managed Health Care (DMHC) is responsible for regulating health care service plans. If you have a Grievance against your health plan, you should first telephone your health plan at one of the numbers listed below and use your health plan's Grievance process before contacting the department. Utilizing this Grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a Grievance involving an emergency, a Grievance that has not been satisfactorily resolved by your health plan or a Grievance that has remained unresolved for more than thirty (30) days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, Coverage Decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number, 888.HMO.2219 (888.466.2219), and a TDD line, 877.688.9891, for the hearing and speech impaired. The department's Internet Web site, www.hmohelp.ca.gov, has Complaint forms, IMR application forms and instructions online. The Plan's Grievance process and the Department's Complaint review processes are in addition to any other dispute resolution procedures that may be available to you, and your failure to use these processes does not preclude your use of any other remedy provided by law.

Non-Participating/Out-of-network Providers

Any coverage for services provided by a Physician or other health care provider who is not a Participating Provider requires written Prior Authorization before the service is obtained, except in Medically Necessary Emergency Care situations and Medically Necessary Urgent Care situations that arise outside WHA’s Service Area. If you receive services from a non-Participating Provider without first obtaining Prior Authorization from WHA or your Medical Group, you will be liable to pay the non-Participating Provider for the services you receive.

Balance billing

Non-participating hospitals and Physicians are prohibited under state law from billing you more than your applicable copayment and/or deductible for emergency services. When you receive emergency services from a non-participating hospital or Physician, WHA will receive a bill and will pay the reasonable and customary value for the services, as required by law. Regardless of the amount of the total billed charges, you are never responsible for more than your applicable copayment and/or deductible for emergency services. If you were billed more than your applicable copayment and/or deductible for emergency services provided by a nonparticipating hospital or Physician, you may report the provider to the California Department of Managed Health Care by calling 888.466.2219. You may also contact Appeals and Grievances or WHA’s Member Services at one of the numbers listed below for assistance:

Mail:	Western Health Advantage Attn: Appeals and Grievances 2349 Gateway Oaks Drive, Suite 100 Sacramento, CA 95833
Secure Fax:	916.563.2207
Call:	WHA Member Services 916.563.2250 or 888.563.2250
Secure Email:	mywha.org/securemessage

Retroactive denials

You are responsible for prepayment of monthly Premiums for WHA coverage by the first business day of each month. Health services are covered only for Members whose prepayment fees have been received by WHA, and coverage extends only through the period for which such payment is received. If you have made arrangements for a third party to pay your premium, you remain ultimately responsible for payment. If a third-party payor cancels electronic funds transfer, or otherwise fails to pay your premium, you must make alternate payment arrangements prior to your next premium payment due date. Coverage may be terminated as allowed by law if payments are not made. You are responsible for any services obtained following the date of termination.

Explanation of benefits (EOB)

An explanation of benefits (EOB) statement often arrives via mail and closely resembles a medical bill. The EOB provides details about a medical insurance claim that has been processed and explains what portion was paid to the health care provider and what portion of the payment, if any, is the patient's responsibility. The EOB is not a bill. Any EOB may be supplied or requested.

Coordination of benefits (COB)

Coordination of benefits (“COB”) is a process used by WHA and other health plans, employer benefit plans, union welfare plans, HMOs, insurance companies, government programs and other types of payors to make sure that duplicate payments are not made for the same claims when more than one Insurer covers a Member. This section summarizes the key rules by which WHA will determine the order of payment of claims while providing that the Member does not receive more than one hundred percent (100%) coverage from all plans combined. All of the benefits provided under this EOC/DF are subject to COB. You are required to cooperate and assist with WHA’s coordination of benefits by telling all of your health care providers if you or your dependents have any other coverage. You are also required to give WHA your Social Security Number and/or Medicare identification number to facilitate coordination of benefits. Please review your plan’s EVIDENCE OF COVERAGE (EOC) for additional details.

Frequently Asked Questions (FAQS)

www.westernhealth.com/mywha/faqs

This information is also referenced in the Member Guidelines and Evidence Of Coverage and Disclosure Form (ECDF). WHA issues the Member Guidelines on an annual basis to its membership and the ECDF is available to members on the member portal at myWHA.org.