Transparency in Coverage

More details about your health care costs and payments

We want to help you understand how health care costs work when you have a health plan. We hope this info offers a little more clarity.

Costs for doctors and hospitals NOT in your plan (out-of-network), and balance billing

Your health plan has certain doctors and hospitals in it. With some plans, we’ll also pay for a portion of the cost of care received from those who are NOT in your plan. But those doctors and hospitals don’t have an agreement with us, so they can charge higher amounts if they want. Balance billing is when they send you a bill for some or all of their fees — which in most cases have to come out of your own pocket.

It’s always a good idea to look at the details of your plan or contact us to see if your plan covers care from doctors and hospitals not in your plan. Also, check whether you need your main doctor (also called your primary care physician or PCP) to refer you to other doctors for services to be covered.

You can avoid being balance billed by always going to doctors or hospitals in your plan. If you choose to go to one that isn’t, check with them first to see what they charge. And then call us for info on how much of that we may cover.

If you’re having an emergency, you need to get care right away. And you don’t need to be worrying about what it costs. That’s why when you receive emergency care, for example at the emergency room (ER), we cover it the same whether the hospital is in your plan or not.

An emergency is when a medical condition occurs with symptoms that are so severe that a normal person could reasonably expect that immediate medical attention is needed or the condition could result in placing the health of the individual (or, if pregnant, the health of the unborn child) in danger, or cause serious damage to bodily functions, parts or organs.

Reminder, going to the ER for care that is not an emergency is not a good idea, and will likely cost more than care from a non-emergency doctor. Also, if you’re admitted to the hospital from the ER — you need to make sure the hospital and the doctors treating you are in your plan. Some states, but not all, have laws that require the doctors and hospitals to tell you if they are not in your plan. Always, if it’s possible, call us or have someone with you call us to check and see if the doctors and hospital are in your plan.

Submitting claims timely to us for care you’ve received

One of the advantages of choosing a doctor or hospital that’s part of your plan is that they submit claims for you. So, if you go to one of the doctors or hospitals in your plan, you don’t have to worry about letting us know about it. We’ll find out about it from the doctor when they submit a claim. Then we can pay our portion. However, when you go to one that’s NOT in your plan, you’ll often need to fill out a claim form and send it to us.

To file a claim, follow these steps:

1. Complete a claim form by calling our Customer Service phone number 1-800-595-0619
2. Attach an itemized bill from the provider for the covered service.
3. Make a copy for your records.
4. Mail your claim to the address on the claim form or to the address provided below.

If you’re submitting a claim to us, it’s best if you do it as soon as possible. Most plans have time limits on how long you have to submit claims. You can refer to the claim submission details below. You can also check your specific plan’s claims filing time limit details to see what the limit is for your plan.

Enrollee medical claim submission and claim filing time limit information:

Enrollee dental claim submission and claim filing time limit information:

Grace period for monthly payments.

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

We’ll continue to pay claims for your care for the first month of this grace period. And then we’ll hold (also called “pend”) claims — meaning, we won’t pay them yet, but we’ll keep them and get ready to pay them.

If you’re able to pay all the missed monthly payments before your grace period is up, we will then go back and pay any claims for covered services we were holding (also called “pending”).

Reminder: Not all grace periods are three months — this is when you’re getting financial help from the government for your monthly payment.

If you don’t pay for all the missed months, we have to deny any claims that we were holding or pending. And you’ll be responsible to cover those costs.

It’s best to pay your monthly payment on time every month, to avoid any chance of getting into your grace period. Ask about setting up automatic payments if you think that can help you.

Retroactive denial

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’s not enough money in your account and we never get a new payment from you. We’d then go back and retroactively deny that claim, and we’d need to get the money back that we paid for it.

If a claim wasn’t paid yet, but we were just holding it (or pending it) as described in the previous section, Grace period for monthly payments — it can also be denied if you run out your grace period. But since we didn’t pay it yet, we wouldn’t call it a retroactive denial. It’s just called a denial.

One way you can avoid having your claims denied is by always paying your monthly payment on time. If you’re late, be sure to pay before your grace period runs out. Ask about setting up automatic payments if you think that can help you.

Getting money back if you pay us more than you owe

If you pay more than what you owe, we’ll either refund or credit the extra amount to you or your account. Our systems will notice any overpayment. But if you believe you’ve paid more than you needed to, please call the member service number on the back of your ID card or log in to your online account 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’ve overpaid.

Medical necessity and prior authorization

Medical necessity is a standard that doctors and health plans use to figure out if the care you’re 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”.

When you go to a doctor or hospital in your plan, they will work with us to see if any of the care you’re getting needs prior authorization. If you go to one 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’re 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 doesn’t get prior authorization for something that needs it, you could be responsible for more of the cost.

Prior authorization timeframes:

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’ll make a decision within 72 hours of getting the request. We will look at whether it’s 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’re suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or if you’re undergoing a current course of treatment using a drug not covered by your plan. In that case, we’ll 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.

An IRO review may be requested by a member, member’s representative, or prescribing provider by calling our member services team using the phone number provided on the back of the member’s identification card. A member can also submit a request for an IRO review digitally by completing a form that is available in our message center.

Explanation of Benefits (EOB)

An Explanation of Benefits (EOB) is a summary of services you’ve received during a specific period. It shows the charges, the date of your visit, and the name of the provider you visited. An EOB is not a bill. It’s available to help you understand the payments made for your covered services and to help you keep track of your expenses. EOBs are sent at least once a month after the Member receives services and the claim is received by Imperial Health Plan to be processed.

Coordination of Benefits (COB)

When you or anybody else on your plan, like your spouse or kids, is covered by two different health plans — both plans need to know about it. We’ll work together to make sure you’re 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 can delay claim payments. So be sure to let us know as soon as possible.