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2020 Transparency Notice

A) Out-of-network liability and balance billing

The Ambetter network is the group of providers and hospitals we contract with to provide care for you. If a provider or hospital is in our network, services are covered by your health insurance plan.

As a member of Ambetter, providers should not bill you for covered services for any amount greater than your applicable cost sharing responsibilities when:

  • A covered service is received from a non-network provider
    • You have a network exception (as defined below) and the non-network provider is approved or authorized by us.A “network exception” occurs when receiving covered services from a provider that is not part of our network (out-of-network) because there is no network provider accessible or available in the Ambetter network that can provide such services to you timely, or we determine it is in your best interest to receive care from a non-network provider.

B) Enrollee Claim Submission

Providers typically submit claims on your behalf, but there be instances providers require you to pay out pocket to receive covered for example for out of network urgent care, or an international emergency.  If this occurs, show your member ID card at the time of service for the provider bills us for your care. Contact us if you receive a bill for covered services 1-888-926-5057.

If you pay out of pocket for covered services because the provider requires more than your appropriate cost sharing, you can request reimbursement for the amount you paid. When appropriate, we adjust your deductible, copayment or cost sharing to reimburse you.

Your reimbursement request for a covered service should include:

  • A copy of the detailed claim or bill from the treating provider
  • The Member Reimbursement Claim Form (available on the Ambetter website, “Member Materials and Forms” section, including the required documents listed on the form 

Send all complete documentation to:

Ambetter from Arizona Complete Health
Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-3800

We acknowledge receiving your reimbursement request and process your request within 15 business days of receipt.

If we are unable to come to a decision about your claim within 15 business days, we will let you know and explain why we need additional time.

If Approved reimbursements are processed and payment issued to you within 45 calendar days of receipt.

If we reject your claim, our notices includes the reason why and your appeal rights as detailed in your Appeals Packet.

C) Grace Periods and Claims Pending

Premiums not paid by the due date, you enter a grace period. The grace period is extra time given to pay (we understand that stuff happens sometimes).

During your grace period, you keep your coverage. However, payments not made before the grace period ends, runs the risk of causing you to lose coverage. During grace periods, we may hold may — or pend — claim reimbursement requests. Neither you nor your treating provider is responsible for the cost of any external independent review. claim reimbursement requests.

If your coverage terminates for not paying your premium, you are not eligible to enroll with us again until Open Enrollment or a Special Enrollment period. So make sure you pay your bills on time!

If you receive a subsidy payment

After the first premium is paid, a grace period of 3 months from the premium due date is given for the payment of premium. Coverage remains in force during the grace period. If full payment of premium is not received within the grace period, coverage will be terminated as of the last day of the first month during the grace period, if Advance Premium Tax Credits are received.

We will continue to pay all appropriate claims for covered services rendered to the member during the first month of the grace period, and may pend claims for covered services rendered to the member in the second and third month of the grace period.  We will notify HHS of the non-payment of premiums, the member, as well as providers of the possibility of denied claims when the member is in the second and third month of the grace period.  We will continue to collect Advance Premium Tax Credits on behalf of the member from the Department of the Treasury, and will return the Advance Premium Tax Credits on behalf of the member for the second and third month of the grace period if the member exhausts their grace period as described above. A member is not eligible to re-enroll once terminated, unless a member has a special enrollment circumstance, such as a marriage or birth in the family or during annual open enrollment periods.

If you don’t receive a subsidy payment

Premium payments are due in advance, on a calendar month basis.  Monthly payments are due on or before the first day of each month for coverage effective during such month. There is a one (1) month grace period. This provision means that if any required premium is not paid on or before the date it is due, it may be paid during the grace period. During the grace period, the contract will stay in force; however, claims may pend for covered services rendered to the member during the grace period. We will notify HHS, as necessary, of the non-payment of premiums, the member, as well as providers of the possibility of denied claims when the member is in the grace period.

D) Retroactive Denials

"Retroactive denial of a previously paid claim" or "retroactive denial of payment" means any attempt by a carrier retroactively to collect payments already made to a provider with respect to a claim by reducing other payments currently owed to the provider, by withholding or setting off against future payments, or in any other manner reducing or affecting the future claim payments to the provider.

There are instances where claims deny retroactively for example if you terminate coverage with Ambetter, provide late notification of other coverage due to new coverage, or have a change in circumstance, such as divorce or marriage. These scenarios result in Ambetter from Arizona Complete Health recouping payment from the Provider.

If you believe the recoupment is in error, you are encouraged to contact member’s services department by calling the number on your ID card.

E) Recoupment of Overpayments

To request a refund of overpaid premium please contact member services. Refunds are processed by two methods, electronically or by a manual check. The type of refund 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 are refunded via eCashering. Payments made via eCheck are 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 covered when medically necessary. Medically necessary services are health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

  • In accordance with generally accepted standards of medical practice;
  • Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
  • Not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

For these purposes, “generally accepted standards of medical practice” means standards based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations, the views of physicians practicing in relevant clinical areas and any other relevant factors.

The fact that a provider may prescribe, order, recommend or approve a treatment, service, supply or medicine does not in itself make the treatment, service, supply or medicine medically necessary as defined in this Policy. This document references terms medically necessary, medically indicated, and medical necessity interchangeably throughout.

Prior Authorization Required

Selected services and treatments included in your health plan require approval before you receive them to qualify for coverage payment referred to as Prior Authorization.

Although a service or treatment lists as a covered benefit, Ambetter requires Prior Authorization before receiving the service or treatment. .  Even those services that are determined to be medically necessary by us must have Prior Authorization in order to be covered.  Physicians and networks cannot deny a service or treatment for failure to obtain Prior Authorization.  Only we can deny coverage of medical services for failure to obtain Prior Authorization. You can ask your Primary Care Provider or our Member Services Deparmtent any questions you have concerning Prior Authorizations.  Prior Authorization does not guarantee coverage. 

Circumstances in which the service ARE NOT covered include, but not limited to:

  • Other plan provisions are not satisfied (for example, member  not enrolled or eligible for service on the date the service is received or the service is not a Covered Benefit);
  • Fraudulent, materially erroneous or incomplete information is submitted; or
  • A material change in the member’s health condition occurs between the provision date of the Prior Authorization and the date of the treatment that makes the proposed treatment no longer medically necessary for such member.  

In the event that Ambetter certifies the medical necessity of a course of treatment limited by number, time period or otherwise, a request for treatment beyond the certified course of treatment shall be deemed to be a new request. 

Except for Emergency Services, ALL medical services and treatments require the direct coordination of your Primary Care Physician within the service area. If they are not, services may be denied by Ambetter.

The following services or supplies may require prior authorization:

  1. Hospital confinements;
  2. Hospital confinement as the result of a medical emergency;
  3. Hospital confinement for psychiatric care;
  4. Outpatient surgeries and major diagnostic tests;
  5. All inpatient services; 
  6. Extended care facility confinements;
  7. Rehabilitation facility confinements;
  8. Skilled Nursing Facility confinements; 
  9. Transplants; and
  10. Chemotherapy, specialty drugs and biotech medications.

Prior Authorization requests are submitted by telephone, efax, or provider web portal as follows:

  1. At least 14 days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, or hospice facility.
  2. At least 30 days prior to the initial evaluation for organ transplant services.
  3. At least 30 days prior to receiving clinical trial services. 
  4. Within 24 hours of an admission to an inpatient behavioral health or substance abuse treatment admission.  No prior authorization shall be required for short-term inpatient withdrawal manage-ment and clinical stabilization services for up to 24 hours.
  5. At least 14 days prior to the start of home healthcare.

After prior authorization request is submitted including all required or applicable documentation, we notify you and your provider if the request has been approved as follows:

  1. For immediate request situations, within 1 business day, when the lack of treatment may result in an emergency room visit or emergency admission.
  2. For urgent concurrent review within 24 hours of receipt of the request.
  3. For urgent pre-service, within 72 hours from date of receipt of request. 
  4. For non-urgent pre-service requests no longer than 14 days of receipt of the re-quest.
  5. For post-service requests, within 30 calendar days of receipt of the request.

Except for medical emergencies, Ambetter requires prior authorization before services are rendered and expenses are incurred. 

Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements results in reduced benefits.

Network providers cannot bill you for services for which they fail to obtain prior authorization as required. Emergency, benefits are not reduced for failure to comply with prior authorization requirements prior to an emergency. However, you must contact us as soon as reasonably possible after the emergency occurs.

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 not covered by the plan. Requests are in writing or via telephone. Within 72 hours of the request being received, Ambetter provides the member (or designee) and the prescribing physician the coverage determination. Grated standard exception requests include coverage of the non-formulary drug for the duration of the prescription, including refills.

Standard Appeal (Level 2) Request

Your request: You or your treating provider may request a Level 2 Formal Appeal if we deny your request at Level 1. You or your treating provider have 60 days from the date of this letter to request a Level 2 Formal Appeal in writing to:

Mail: Ambetter from Arizona Complete Health
Attn: Member Grievances
P.O. Box 277610
Sacramento, CA 95827

Fax: (866) 687-0518 OR

Email: AzCHMarketplace2@azcompletehealth.com

To help us make a decision on your appeal, you or your provider should also send us any additional information (that you have not already sent us) to show why we should authorize the requested service or pay the claim.

Our acknowledgement: We have 5 business days after we receive your request for Formal Appeal (“the receipt date”) to send you and your treating provider a notice that we got your request.

Our decision: For a denied service that you have not yet received, we have 30 days after the receipt date to decide whether we should change our decision and authorize your requested service.

We send you and your treating provider our decision in writing that explains the reasons for our decision.  We include information on the documents we used to base our decision.

  • If we deny your Level 2 appeal, you have four months to appeal to Level 3.
  • If we grant your request, we authorize the service and the appeal is over.
  • We may decide to skip Level 2 and refer your case straight to an independent reviewer at Level 3.

Expedited Exception Request

A member, a member’s designee or a member’s prescribing physician may request an expedited review based on exigent circumstances for example 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 72 hours of the request being received (24 hours for Exigent Circumstances), we provide the member, the member’s designee or the member’s prescribing physician with our coverage determination. For expedited exception requests granted, we provide coverage of the non-formulary drug for the duration of the exigency.

Expedited Appeal (Level 2) Request

If you disagree with the Level 1 decision, a Level 2 Expedited Appeal or Level 2 Formal Appeal is available as described in your Appeal Packet. Enclosed is an optional Level 2 Review Request Form.  The form is not required to request a Level 2 review.

Your doctor is also receiving a copy of this notice. Your doctor is able to contact our Medical Director to talk about the reasons for our decision (also referred to as a peer to peer” review).

Level 2: Expedited Appeal

The request: Your treating provider can file a Level 2 Expedited appeal if:

  • We deny your Level 1 request.
    • If we grant your request, we authorize the service and the appeal process is over.
    • We may decide to skip Levels 1 and 2 and send your case straight to an independent reviewer at Level 3.

Your treating provider can request a Level 2 Expedited Appeal after receiving our Level 1 denial. Your treating provider must immediately send the written request for a Level 2 Expedited Appeal to:

Email: AzCHMarketplace2@azcompletehealth.com

Fax: (866) 687-0518

Our decision: We have 3 business days after we receive the information from your treating provider to decide whether we should change our decision and authorize the requested service.

Within that same business day, we call you and your treating provider with our decision.  We also mail you and your doctor a written copy of our decision, including the reasons for our denial. 

External exception request review

Your request: You may request a Level 3 review only after you have appealed through Levels 1 and 2. You have four months after you receive our Level 2 decision to send us your written request for External Independent Review. Send your request and any more supporting information to:

Mail: Ambetter from Arizona Complete Health
Attn: Member Grievances
P.O. Box 277610
Sacramento, CA 95827

Email: AzCHMarketplace2@azcompletehealth.com

Fax: (866) 687-0518

Toll Free Call: (866) 918-4450 (TTY: 711)

Neither you nor your treating provider is responsible for the cost of any external independent review.

The process: There are two types of Level 3 appeals, depending on the issues in your case:

Medical Necessity Cases

Within five-business days of receiving your request, AzCH mails a written acknowledgement of the request to you, the Director of Insurance, and your treating provider. The following is included in the mailing to the ADOI Director:

  • A copy of your request for a Level3 review;
  • A copy of your policy
  • Evidence of coverage or similar document;
  • All medical records and supporting documentation used to render our decision;
  • A summary of the applicable issues including a statement of our decision;
  • The criteria used and clinical reasons for our decision; and the relevant portions of our utilization review guidelines.
  • The name and credentials of the health care provider who reviewed and upheld the denial at the earlier appeal levels.

Within five business days of receiving our information, the Insurance Director sends all the submitted information to an external independent reviewer organization (the “IRO”).

Within 21 days of receiving the packet of information, the IRO makes a decision and send the decision to the ADOI Director. The Director may extend the review timeframe an additional 31 days for good cause.

Within five business days of receiving the IRO’s decision, the Insurance Director mails a notice of the decision to you, your treating provider and AzCH.

If the IRO decides that we should provide the service, AzCH authorizes the service. If the IRO agrees with our decision to deny the service, the appeal is over. Your only further option is to pursue your claim in Superior Court.

Contract Coverage Cases

Within five business days of receiving your request, AzCH:

  1. Mails a written acknowledgement of your request to the ADOI, you, and your treating provider.
  2. AzCH Send the Director of Insurance provider. The following is included in the mailing to the ADOI Director:
  • A copy of your request for a Level 3 review;
  • A copy of your policy
  • Evidence of coverage or similar document;
  • All medical records and supporting documentation used to render our decision;
  • A summary of the applicable issues including a statement of our decision;
  • The criteria used and clinical reasons for our decision; and the relevant portions of our utilization review guidelines.
  • The name and credentials of the health care provider who reviewed and upheld the denial at the earlier appeal levels.

The ADOI Director makes a coverage determination, issues a decision, and sends a written notice to AzCH, you, and your treating provider within 15 business days.

In instances where the Insurance Director is sometimes unable to determine issues of coverage, the IRO completes a review within 21 days of receipt. The Insurance Director has five business days after receiving the IRO’s decision to send the decision to you, your treating provider and AzCH.

If you, your treating provider, or AzCH disagree with the ADOI Director’s final decision on a contract coverage issue, a request for a hearing with the Office of Administrative Hearings (“OAH”) can be filed within 30 days of receiving the Director’s decision. OAH schedules and completes a hearing for appeals from expedited Level 3 decisions.

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 1-888-926-5057.

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 as required by any federal or state laws. Medicaid is always the payer of last resort.