Balance billing occurs when a provider bills you for the difference between the charged amount and the maximum out-of-network allowable amount. For example, if the provider’s charge is $100 and the maximum allowed amount is $70, the provider may bill you for the remaining $30. You can’t be balance billed by an in-network provider.
COB is available to you and allows you to manage your benefits when you and other members of your plan are covered by more than one health insurance plan. If COB applies, the order of benefit determination rules shall be looked at first. The rules explain whether the benefits of your Network Health plan are determined before or after those of another plan. This would include group insurance or coverage under a governmental plan that is required or provided by law (excluding Medicaid and Medicare).
If your prescribed medication is not covered or partially covered, you or your prescriber can ask us to cover it. This is considered an exception.
Exceptions can be handled both externally and internally. Exceptions usually require a supporting statement from your prescriber explaining why alternative medications are not sufficient.
Express Scripts will make a decision on your exception within three business days of receiving all the necessary information–including the supporting prescriber statement. You can request an expedited decision if you or your doctor feel your health could be harmed by a three-day waiting period. If your expedited request is granted, Network Health will provide a decision within 24 hours of receiving your doctor’s supporting statement.
An EOB is a statement sent to you listing health care services you received, the amount billed and payment made. An EOB is sent to you shortly after Network Health receives information from your provider and processes a claim. It is important to review your EOBs and compare them to any provider bills you receive. The amount you owe for an item or service will be shown in the “Your Responsibility” section.
Network Health sends EOBs on an ongoing basis as claims are processed. You may opt to receive electronic delivery of your EOBs by changing your communication preferences in your online member portal.
After you have paid your first month’s premium, there is a grace period before Network Health can terminate your coverage if you do not pay your future premiums by the due date.
There are two separate grace periods.The grace period doesn’t apply if your policy terminates for any reason other than not paying your premium.
Health care services or supplies are considered reasonable, medically necessary and/or appropriate when:
Except for emergency health and urgent care services, you must get prior authorization from Network Health for services performed by an out-of-network provider to be covered. A maximum out-of-network allowable amount may be applied when services are received from provider who is out-of-network.
In some cases, Network Health needs to give approval for you to receive coverage for certain services. This is called a prior authorization (or prior approval). Network Health participating providers will submit a request on your behalf for authorization. If you wish to receive coverage for services from a non-participating provider or a non-participating practitioner in our service area, you must obtain prior authorization from Network Health, except for emergency health services. Failure to do so will result in a denial of benefits.
Network Health will review prior authorization request and make the decision to approve or deny the service based on whether the service is medically necessary and appropriate. Network Health will review the request within 14 days (72 hours for pre-service urgent requests and 24 hours for concurrent urgent requests) and send you a decision letter.
If you have an authorization request or questions about the prior authorization process, call our care management department at 800-236-0208 or TTY 800-947-3529. For mental health and substance abuse services, please contact Network Health’s Care Management Behavioral Health Department at 800-555-3616.
If you feel you are entitled to a refund of premium, submit your request to Network Health in one of the following ways.
A retroactive denial is a reversal of a previously paid claim.
To avoid retroactive denials, you should pay premium your no later than 31 days after the due date.
Claims may be reprocessed retroactively up to 15 months from the date the provider was paid. Reprocessing may occur if you and/or the provider were overpaid or underpaid. The provider is responsible for reimbursing you if the new claim entitles you to a credit.
Notification will be sent to you if the reversal is because of an error in the setup of a benefit and claims need to be reprocessed or new Summary of Member Responsibility Tables (SOMRs) needs to be sent.
If the reversal is due to an error in the provider contract or provider configuration, claims are required to be reprocessed. If necessary, the provider will be notified. You have one year from the proof of loss date to request review. Claims will be reprocessed regardless of the impact of your liability.
Network Health processes claims according to state and federal time frames. Providers will file most claims, but if a member files a claim, he or she must provide all reasonably necessary information in order for the claim to process. Providing all the necessary information will allow Network Health to process the claim more quickly. If you have questions about benefits, eligibility or claims payment please call 855-275-1400.
When submitting a claim, please follow these guidelines.
Network Health does not require a form to submit a claim. To arrange for reimbursement, send itemized bills and proof of payment within 90 days to Network Health.