Terms and Conditions of your policy may be affected by rules or laws applicable at the state level. Please refer to your policy for additional information.
Topics covered: Out-of-Network Liability and Balance Billing. Enrollee Claim Submission. Grace Periods and Claims Pending. Retroactive Denials. Recoupment of Overpayments. Medical necessity and pre-authorization timeframes and enrollee responsibilities. Prescription drug exception timeframes and enrollee responsibilities. Explanation of benefits (EOB). Coordination of benefits.
Benefits are not available when you use a Non-Network Provider except for emergency health services or services received from an ancillary provider at a network facility. Payment for Out-of-Network emergency services may be limited to the plan’s Allowable Amount.
This plan does not cover non-emergency services rendered by Non-Network Providers unless Pre-Authorized by Us.
Limitations may vary due to applicable state laws, please refer to your policy for more information.
When a request for a claim form or the notice of a claim is provided to Us, We will provide the claimant or policyholder the claim forms required for filing. If the claimant does not receive these claim forms within 15 days after the Plan receives notice of claim or the request for a claim form, the claimant will be considered to meet the proof of loss requirement of this Policy. Foreign claims must be translated in U.S. currency prior to being submitted to the Plan for payment.
Claims for Covered Health Services from a Non-Network or Non-Participating Provider must be submitted to Us within one year (365 days) from the date of service. If your Provider does not file a claim for You, You are responsible for filing the claim within the one-year deadline. Claims submitted after the deadline are not eligible for benefit payment or reimbursement. If a claim is returned to You because We need additional information, You must resubmit it with the information requested within 90 days of receipt of the request. Claims can be submitted to Us at:
Bright Health Insurance Company P.O. Box 16275 Reading, PA 19612
A grace period is a designated period of time immediately following the due date of your monthly premium. If your premium is paid during the grace period, coverage will remain in effect. If your premium is not paid during the grace period, coverage will terminate. A Grace Period of 3 months for individuals receiving federal insurance subsidies will be allowed for the payment of all outstanding premiums. If the full balance of outstanding premium is not paid within Your grace period, coverage will end on the last day of the first calendar month of the grace period. For non-subsidized Members, a 31-day grace period will be allowed for the payment of all outstanding premiums. If the full balance of outstanding premium is not paid within Your grace period, coverage will end on the last day for which You have paid Your premium. We will provide You notice of Your nonpayment before cancelling Your Policy. We will not pay for any services received on or after the date Your coverage ends.
A pending claim is a claim that remains in a “hold” or “pending” status. This means the claim will not be paid or denied until specific action is taken.
A retroactive denial is the reversal of a previously paid claim, through which the enrollee then becomes responsible for payment. Claims may be denied retroactively, even after the enrollee has obtained services from the provider. Ways to prevent retroactive denials, when possible:
What to do if your claim is retroactively denied:
If you overpaid your insurance premium you may qualify for a refund. If you think you overpaid, We can help you. Please call the number on the back of your ID card with questions about your premium payment and a possible refund.
Pre-authorization is the process of reviewing a request for health care services for Medical Necessity and network affiliation prior to You receiving those services.
If You are receiving care from a Network Provider, the Network Provider is responsible for obtaining Pre-authorization before they provide these services to You. If the Provider fails to obtain Pre-authorization and the service is denied, he or she may not balance bill You.
If You are receiving care outside of Your Service Area, or care from a Non-Network Provider, You are responsible for making sure that Pre-authorization is obtained. Information regarding services can come from the Non-Network Provider or from You.
The Pre-authorization review process requires the full cooperation of the requesting Physician in order for Us to evaluate all of the pertinent information and make a coverage determination. We must make Our decision within 15 days business days of receiving the Prior Authorization request and Physician’s statement. You can request an expedited exception if you or your Physician believe that your health could be seriously harmed by waiting 15 business days for a decision. If your request to expedite is granted, We must give you a decision no later than 72 hours after We get the supporting statement from your Physician.
Exceptions to above may be granted in certain circumstances or for emergency or special situations. Your prescriber or doctor and pharmacy staff will need to provide certain information in order for us to review an exception request. There is a process to appeal decisions, and You will receive that information if You are denied a claim.
If the plan does not cover Your medication or has restrictions or limits on Your medication that You don’t think will work for You, You can do one of these things:
Examples of exceptions are:
The medication must be in a class of medications that is covered.
For standard exception requests, We must make a determination and notify You and the prescribing physician no later than 72 hours following Our receipt of the request for exception. If We grant a standard exception request, We must provide coverage of the non-formulary drug for the duration of the prescription, including refills.
For expedited exception requests, We must make a determination and notify You and the prescribing physician no later than 24 hours following Our receipt of the request for exception.
Expedited exception requests are appropriate for exigent circumstances, which means the person for whom the request is being made is suffering from a health condition that may seriously jeopardize his or her life, health, ability to regain maximum function, or the person is undergoing a current course of treatment using a non-formulary drug. If We grant an exception based on exigent circumstances, We must provide coverage for the non-formulary drug for the duration of the exigency.
For additional information about the prescription drug exceptions processes for drugs not included on Your Plan’s Formulary, please contact the Pharmacy Customer Services number on Your ID Card.
An EOB is a statement an issuer sends the enrollee to explain what medical treatments and/or services it paid for on an enrollee’s behalf, the issuer’s payment, and the enrollee’s financial responsibility pursuant to the terms of the policy.
Your doctor's office submits a claim for payment to Us after you receive care. If your provider is not submitting a claim on your behalf, you must send a completed claim form and an itemized bill to the address listed on your ID card.
After the claim is processed, We will provide an Explanation of Benefits (EOB) to you. We send this statement to explain what medical treatments and/or services were paid. It tells you how your claim was paid, including the amount that was paid and to whom it was paid. It’s simple and clear, so you can see what was submitted, what’s been paid and what you owe. EOBs are available for you to look at online at www.brighthealthplan.com.
When two plans cover the same service, they may coordinate benefits. This is so that neither plan duplicates the other plan's payment. Coordination of Benefits rules can vary from state to state. Please refer to your policy for more information.
If you are covered by more than one of Our qualified health plans, you will receive the benefits of only one plan. You may choose the plan under which you will be covered. We will refund any premium received under the other plan. Any claims payments made by us under the plan you choose to cancel will be deducted from any such refund of premium.