Ambetter Health EPO Evidence of Coverage — Adult Vision + Adult Dental
This document is an Evidence of Coverage (EOC) for an Ambetter Health Exclusive Provider Organization (EPO) product covering adult vision and adult dental benefits, governing member rights, benefits, plan administration, and how to access care for affected members.
Policy Summary
PayerCentene
PolicyAmbetter Health EPO Evidence of Coverage — Adult Vision + Adult Dental
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionObtain required prior authorization for services listed on the Schedule of Benefits before providing them to avoid reduced benefits.
No material clinical or coverage changes in this revision.
Part 11Doc partition
24/7Nurse Advice Line
8:00-8:00Member Services hours
60Premium grace period (days)
Nov–JanOpen enrollment
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.
No PA required
Emergency services PA
Coverage, Eligibility, and Benefit Rules
Network-based coverage with administrative requirements
Coverage is primarily through network providers under an EPO; members must designate a network PCP and generally use network providers except limited exceptions.
Members must use network providers to receive benefits except limited exceptions (prior authorized non-network care or balance-billing protected services).
See Provider Directory and Services from Non-Network Providers provisions.
Member must designate a network primary care physician (PCP) for each member to obtain benefits; change of PCP may be effective on the next business day.
Provider Directory guidance and PCP rules apply.
If services are obtained from a non-network provider because of inaccurate provider directory information and the services are otherwise covered, member cost sharing will be applied at network levels and the member should contact Member Services.
Member Services will respond within one business day for directory inquiries.
Schedule of Benefits, this policy, and any riders define covered services and member cost sharing; prior authorization requirements are specified in the Schedule of Benefits and policy sections.
See Introduction and Prior Authorization sections.
Member ID card indicates applicable copayments, deductibles, and out-of-pocket maximums that apply to covered services.
Cost sharing details appear on the Schedule of Benefits and member ID card.
Balance billing and emergency coverage criteria
Balance billing protections and eligible expense rules for covered services
Services protected from balance billing include: emergency services; non-emergency services provided at a network hospital or ambulatory surgical center unless the member gives notice and consent to be balance billed; and air ambulance services by a non-network provider.
Balance billing protections defined per federal law effective Jan 1, 2022 and Definitions.
When balance billing protections apply and provider has no negotiated fee, the eligible expense is reimbursement as determined by the plan and required by law; member pays the network-equivalent cost share based on the recognized amount per applicable law.
Eligible expense rules for network and non-network providers.
Emergency services are covered without prior authorization and include facility, physician services, supplies, and prescription drugs charged by the facility; member or physician must notify the plan within 48 hours or as soon as reasonably possible if admitted.
Emergency services prior authorization exemption and notice requirement.
Care provided once a member is stabilized is not considered emergency care; continuation of care beyond stabilization is not covered unless authorized and medically necessary.
Dependent & Member Coverage Criteria
Eligibility, effective dates, and termination provisions for dependent and member coverage.
Dependent members become eligible on the later of: the subscriber's effective date or the qualifying event date (marriage, newborn birth, adoption placement, foster placement, domestic partnership, etc.).
Dependent Member Eligibility.
Dependent members listed on the initial enrollment application are covered on the subscriber's effective date.
Effective Date for Initial Dependent Members.
Eligible newborns are covered from the time of birth until the 31st day after birth; additional premium is required to continue coverage beyond 31 days and coverage may terminate retroactively if timely notice is not received.
Coverage for a Newborn Child.
An adopted child legally placed for adoption is covered from date of placement until the 31st day after placement; additional premium required to continue beyond 31 days and must be added within 90 days to avoid retroactive termination.
Coverage for an Adopted Child.
Administrative coverage and authorization criteria
Key coverage and administrative criteria extracted from the provided sections.
Off-exchange enrollees may add dependents in writing or via enrollambetterhealth.com provided required premium is paid; written confirmation and ID cards will be sent.
Adding Other Dependent Members.
Subscriber and dependent coverage may terminate for reasons including moving outside service area, subscriber request, nonpayment of premiums, fraud/misrepresentation, or death.
For All Members termination rules.
Dependent coverage ends when the individual is no longer a dependent, upon divorce, or for eligible children on Dec 31 of the year they turn 26 unless incapacity/dependency exceptions are provided with proof.
Dependent termination and limiting age rules.
If member is inpatient on policy effective date and prior coverage continues to furnish benefits, this policy will not cover those hospitalization services until discharge or exhaustion of prior benefits; member must notify within two calendar days if prior coverage does not continue.
Network and Non-Network Coverage Rules
Network vs Non-Network coverage and balance billing rules
Non-network services are generally not covered unless prior authorized or balance billing protections apply.
Services from Non-Network Providers section.
Members may be balance-billed by non-network providers for the difference between the plan's allowed amount and the provider's billed amount unless balance billing protections apply; such difference may not count toward the member's out-of-pocket maximum.
Non-Network Liability and Balance Billing.
When receiving care at a network facility, some hospital-based providers may be non-network; members may be asked to provide notice and consent to waive balance billing protections, in which case they may be responsible for balance billing and those amounts will not apply to deductible or out-of-pocket limits.
Hospital Based Providers and Notice/Consent implications.
Continuity of Care / Transitional Care
Continuity of care when a provider leaves the network
If a member is a continuing care patient when a provider's network participation terminates, the plan will notify the member and provide an opportunity to elect transitional care for the course of treatment for up to 90 days from notice or until the member is no longer a continuing care patient.
Continuity of Care provision under No Surprises Act.
Cost Sharing Application
How cost sharing is applied to claims and out-of-pocket limits
Each claim within an episode of care is processed separately; cost sharing (deductible, copayment, coinsurance) applies per claim as outlined in the Schedule of Benefits.
Cost Sharing Features and claim adjudication per episode.
After an individual meets the individual maximum out-of-pocket amount shown in the Schedule of Benefits, the plan pays 100% of covered services; the family out-of-pocket maximum equals two times the individual maximum and may be met by combining members' eligible expenses.
Maximum Out-of-Pocket rules.
Selected coverage criteria and limitations
Coverage stance and specific criteria or limitations for selected services included in these document portions.
Emergency services while outside the service area are covered without prior authorization; members should call 911 (or 988 for behavioral health) and report the emergency within one business day.
Emergency Services Outside of Service Area.
Non-emergency air ambulance services require prior authorization and are limited to specified clinical situations (emergency to appropriate hospital, neonatal special care, authorized transfers, ordering authority when member cannot refuse, or required transfers to network providers); members should not be balance billed for covered air ambulance services.
Air Ambulance Service Benefits.
Emergency ground and water ambulance transportation does not require prior authorization; non-emergency ambulance transportation requires authorization and non-network ambulance services may result in balance billing unless protections apply.
Ground and Water Ambulance Service Benefits.
Autism spectrum disorder services are covered when prescribed by a physician or behavioral health practitioner and include evaluation, applied behavior analysis (no numeric limit), habilitation, speech/occupational/physical therapy, behavioral health services, and related medications; ABA services are subject to prior authorization for medical necessity.
Coverage and exclusion criteria (section-specific)
Coverage summaries and exclusions as stated in these chunks:
Dental (Adults 19+): Diagnostic/preventive (Class 1), basic (Class 2), and major (Class 3) dental services are covered; see Schedule of Benefits for cost sharing and annual maximums.
Dental Benefits Adults 19 years of age or older.
Dental exclusions include numerous services (cosmetic procedures, certain oral surgeries, implants, hospitalization charges, orthodontics, veneers, TMJ appliances/therapy, and more) as enumerated in the policy.
Dental exclusions list.
Diabetic care: medically necessary supplies, self-management equipment, routine foot care, orthotics/diabetic shoes, lab testing, education and training, and related services are covered; insulin cost limits subject to state/federal mandates.
Diabetic Care covered services.
Dialysis: acute and chronic hemodialysis and peritoneal dialysis in facility or home, related supplies and equipment, and training are covered; rental versus purchase determined by cost comparison; prior authorization may apply for certain equipment.
Family Planning and Contraception Coverage
Family planning and contraception benefits are covered under preventive care without cost sharing when provided by a network provider and legal under applicable law; coverage aligns with HRSA-supported guidelines.
Coverage includes the full range of FDA-identified contraceptives (e.g., sterilization surgery, implantable rods, intrauterine devices, injectable contraceptives, oral contraceptives, patch, ring, diaphragms, condoms, emergency contraception) and related care (screening, education, provision, counseling, follow-up) when provided by a network provider.
Family Planning services covered as preventive care without cost sharing.
Services integral to furnishing contraceptive care (e.g., anesthesia for sterilization surgery) are included under preventive care even if billed separately.
Scope includes ancillary services integral to contraception provision.
Fertility Preservation Coverage
Fertility preservation services and supplies for standard treatments are covered when cancer treatment may cause iatrogenic infertility; prior authorization may be required.
Medically necessary fertility preservation services and supplies are covered when cancer treatment may directly or indirectly cause iatrogenic infertility.
Iatrogenic infertility definition and coverage trigger.
Prior authorization may be required for fertility preservation services per policy prior authorization rules.
Refer to Prior Authorization notes for process and timelines.
Rehabilitation and Home Health Coverage
Habilitation, rehabilitation, skilled nursing facility, and home health benefits are covered when medically necessary, subject to limitations and prior authorization; exclusions include respite, custodial, and educational care for home health.
Habilitation and rehabilitation services are covered when medically necessary and limited to services specified in the provision; rehabilitation care ceases to be covered when maximum therapeutic benefit is reached, no measurable progress is seen, care is custodial, or further treatment cannot restore function.
Habilitation and Rehabilitation criteria and limitations.
Skilled nursing facility and related facility services are covered when medically necessary, limited to charges made by an approved facility for room/board, nursing, diagnostic testing, drugs and professional services as described.
Skilled Nursing Facility coverage conditions.
Home health care services are covered when physician indicates the member cannot travel to medical appointments; covered services include skilled nursing, therapy, IV medications, necessary supplies and rental of medically necessary DME; home health benefits are subject to prior authorization.
Home Health Care Service Expense Benefits and exclusions (no respite/custodial/educational care).
Hospice Coverage
Hospice care services (inpatient, home, outpatient) for terminally ill members are covered when medically necessary; certain exclusions/limitations to medical necessity and other persons' expenses are noted.
Hospice benefits are available to terminally ill members receiving medically necessary care under a hospice program and include inpatient room and board, occupational/speech therapy, rental of medical equipment, palliative and supportive care, counseling, and bereavement counseling; benefits are subject to prior authorization and Schedule of Benefits limits.
Hospice Care Service Expense Benefits.
Exclusions and limitations: hospice medical necessity rules apply and benefits for expenses of other persons are limited as described in the policy.
Exclusions and limitations for hospice benefits.
Hospital and Medical/Surgical Coverage
Hospital and medical/surgical services are covered subject to policy terms, including limits on room and board, ICU, operating room usage, diagnostic and pre/post surgical testing, and a wide range of diagnostic services.
Hospital services covered include daily room and board (not exceeding most common semi-private room rate), private room when medically necessary, ICU stays, inpatient and outpatient operating room use, and routine inpatient services and supplies; coverage is subject to deductible and cost sharing provisions.
Hospital Benefits provisions.
Medical and surgical services covered include surgery in office/facility, pre/post surgical testing, imaging and laboratory services, chemotherapy (including oral), infusion and radiation therapies, anesthesia and related supplies, reconstructive surgeries (including post-mastectomy reconstruction), and medically necessary implants and grafts as listed.
Medical and Surgical Expense Benefits.
Long Term Acute Care (LTACH) Coverage
LTACH care is covered when medically necessary and approved; examples of qualifying conditions and detailed criteria for ventilation and clinical complexity are provided.
LTACH level of care may be considered medically necessary for clinically complex patients requiring extended hospital-level care (complex wound care, infectious disease management, medical complexity with comorbidities, rehabilitation needs, mechanical ventilator support, etc.).
LTACH common conditions and criteria.
Mechanical ventilation criteria for LTACH consideration include failed weaning attempts, mechanical ventilation for 21 consecutive days for 6+ hours/day, ventilator management at least every 4 hours, PEEP ≤10 cm H2O and FiO2 ≤60% with SpO2 ≥90%, hemodynamic stability and weaning potential; LTACH benefits are subject to prior authorization.
Ventilator management and clinical parameters for LTACH.
Mammography Coverage
Mammography (screening and diagnostic), tomosynthesis, MRI, ultrasound, and pathology evaluations are covered in alignment with USPSTF A and B guidelines and applicable laws.
Screening and diagnostic mammography services (including digital breast tomosynthesis, MRI, ultrasound, and pathology evaluations) are covered consistent with USPSTF A/B recommendations and applicable law; coverage applies when services are prescribed by a licensed practitioner.
Mammography coverage alignment with USPSTF and laws.
Maternity and Newborn Coverage
Maternity and newborn coverage includes minimum inpatient stay protections under federal law, newborn immediate coverage for medically necessary services, and specific provisions regarding surrogacy reporting and exclusions.
Minimum inpatient stay protections: a minimum of 48 hours following a vaginal delivery and 96 hours following a cesarean delivery are covered; attending provider and mother may agree on earlier discharge.
Newborns' and Mothers' Health Protection Act Statement of Rights.
Medically necessary services for a newborn child are covered immediately after birth for treatment of injury, sickness, congenital defects, and birth abnormalities; cost sharing for newborn services is applied separately per the Schedule of Benefits.
Newborn Charges and Coverage for a Newborn Child.
Certain maternity-related services may require prior authorization (e.g., specified outpatient/inpatient pre/postpartum services); delivery itself does not require prior authorization.
Maternity Care provisions and prior authorization exceptions.
Coverage Criteria and Service Categories
Summary of covered services and coverage conditions included in these sections.
Medical and surgical services: office, inpatient, outpatient surgery, pre/post surgical testing, imaging, chemotherapy, reconstructive surgery, implants, DME, anesthesia and related supplies are covered when medically necessary and subject to policy terms and cost sharing.
Medical/Surgical summary.
Medically necessary dental-related surgery and dental anesthesia for members <19 or those with disabilities are covered when indicated; includes cleft lip/palate treatment, orthognathic surgery, and other medically necessary oral surgeries.
Medical Dental Services provisions.
Medical vision services cover diagnosis and treatment of disease or injury; routine pediatric vision benefits for children under 19 include exams, frames, lenses, contact lenses and low vision aids; certain services (LASIK, visual therapy) are excluded.
Medical Vision and Pediatric Routine Vision Benefits.
Behavioral health and SUD services are covered inpatient and outpatient when medically necessary; Utilization Management uses InterQual for mental health and ASAM for SUD; some services require prior authorization but emergent inpatient withdrawal management and emergent inpatient treatment do not require prior authorization.
Prescription drug coverage criteria and exclusions
Coverage stance and notable exclusions, supply rules, and related pharmacy services.
Prescription drugs are covered under the prescription drug benefit; coverage includes prescribed drugs, oral anticancer medications, and certain off-label uses recognized by standard reference compendia when criteria are met.
Prescription Drug Expense Benefits scope.
Non-covered prescription drug items include erectile dysfunction drugs unless on formulary, immunizations not required by ACA, drugs administered at dispensing site, inpatient institution-dispensed meds, refills >12 months from order, drugs exceeding managed limits, OTC equivalents except formulary-listed OTCs, investigational drugs, and others as enumerated.
Non-Covered Services and Exclusions (drugs).
Operational pharmacy rules: refills prohibited until member has ≤15 days' supply on hand; split-fill program limits to 15-day supplies for first 90 days for certain new therapies with cost share pro-rated; mail-order and select pharmacies may provide up to 90-day supplies for maintenance medications.
Split-Fill Dispensing Program and Extended Days' Supply.
Coverage criteria (selected)
Coverage and required conditions summarized for specific service categories in this section.
Radiology and diagnostic testing: medically necessary imaging and diagnostic tests are covered; prior authorization may be required; technical and professional components may be billed separately and are subject to applicable cost sharing.
Radiology, Imaging and Other Diagnostic Testing.
Second medical opinion: available for minor surgical procedure recommendations, serious injury/illness, or unsatisfactory response to treatment; network second-opinion providers require only applicable cost sharing while non-network second opinions require authorization to be considered an eligible expense.
Second Medical Opinion provision.
Sleep studies are covered when medically necessary and can be performed at home or in a facility; authorization may be required.
Sleep Studies provision.
Transplant services are covered when the member is accepted as a transplant candidate and pre-authorized through a Center of Excellence or approved facility; coverage includes pre-transplant evaluation, LVAD as bridge when authorized, transplant procedure (including acquisition cost when authorized), and post-transplant follow-up; prior authorization required.
General exclusions
General non-covered services and exclusions listed in this section.
One of: Surrogacy-related services are excluded (including prenatal/postpartum care for surrogates, donor gamete/embryo expenses, storage, preimplantation genetic diagnosis, and services to any child birthed by a surrogate unless the child has an active policy at birth).
General Non-Covered Services and Exclusions.
Medicinal and recreational cannabis/marijuana use is excluded.
General Non-Covered Services and Exclusions.
Private duty nursing is excluded.
General Non-Covered Services and Exclusions.
Vehicle installations or modifications (e.g., adapted seats, lifting devices) are excluded.
General Non-Covered Services and Exclusions.
Termination and reinstatement
Policy termination and reinstatement rules.
Policy terminates for non-payment of premiums (subject to grace period), upon subscriber request, upon insurer declination to renew, when a dependent reaches limiting age (with possible continuation for incapacity), upon death (for individual policy), or other eligibility cessation as described in Eligibility and Enrollment.
Termination events and dependent limiting age rules.
Reinstatement: if renewal premium not paid before grace period ends, policy lapses; later acceptance of premium may reinstate policy without application or with application per insurer's process; if reinstated after conditional receipt, coverage may be effective on approval date or 45th day after conditional receipt; reinstated coverage limits apply (e.g., injury/sickness waiting periods) and premiums will not be applied to periods more than 60 days before reinstatement.
Reinstatement conditions and effective dates.
Right of reimbursement and cooperation
Right of reimbursement and cooperation provisions when third-party recovery exists.
If benefits are provided for injuries where a third party may be responsible, the insurer retains the right to recover the full cost of benefits provided from any third-party recoveries, uninsured/underinsured motorist payments, workers' compensation, medical payments coverage, or other compensatory sources.
Right of Recovery and Reimbursement provisions.
Member obligations: members must cooperate with insurer by providing information, notifying insurer of any claims or lawsuits, including insurer's benefits in third-party claims, signing documents to protect insurer's rights, and not taking actions that prejudice insurer's reimbursement rights; insurer may assert a first-priority lien on recoveries.
Cooperation Provision and member obligations.
Enforcement: insurer may intervene or assert reimbursement independently, will not pay member attorney fees for third-party claims, and may require disputed amounts to be escrowed until resolution; failure to cooperate may result in member responsibility for benefits plus insurer costs and fees.
Enforcement and remedies for non-cooperation.
Claims, payment, and beneficiary provisions
Claims handling, timelines, payments, beneficiary and travel-related provisions.
Notice and proof timelines: notice of claim required within 30 calendar days of loss and written proof of loss within 90 calendar days (or as soon as reasonably possible); insurer will furnish claim forms within 15 days of notice.
Notice of Claim and Proof of Loss provisions.
Claims processing times: for non-No Surprises Act services clean paper claims processed within 40 business days and clean electronic claims within 20 business days; No Surprises Act protected services processed within 30 calendar days; requests for additional information issued within 20 business days (electronic) or 40 business days (paper) and processing completes within 30 calendar days after receipt of all requested information.
Time for Payment of Claims and processing timelines.
Payment and assignment: benefits are payable to the member unless assignment to provider is in writing and approved by insurer; accrued benefits at death may be paid to beneficiary or estate and insurer may pay up to $1,000 to a relative if beneficiary is minor or incompetent.
Payment of Claims and Assignment.
Administrative and Appeal Criteria Set
Procedural coverage-related rules and member remedies described in these sections.
Emergency services while traveling outside the United States are covered up to 90 consecutive days; if travel exceeds 90 days no emergency coverage applies for the entire travel period.
Claims Incurred for Emergency Services While Traveling Outside the United States.
Claimants have 180 calendar days to file an internal appeal from the date of an adverse benefit determination; the plan will acknowledge and request needed information within five calendar days of receipt.
Filing an Appeal and internal appeal timing.
Standard appeal decision timeframes: pre-service appeals decided no later than 30 calendar days after receipt; post-service appeals no later than 60 calendar days; plan may extend by up to 14 calendar days if additional information is required.
Standard appeal decision timing.
Expedited appeals: decided within 72 hours for pre-service adverse determinations involving imminent jeopardy to life/health or ability to regain function; claimant may file by phone or in writing and provide clinical documentation.
Appeals, External Review, and Grievance Criteria
Procedures and criteria for appeals, external review, and grievances including eligibility, timelines, and outcomes.
External review eligibility: generally requires that the claimant was a covered person at time of service, the service would be covered but for the adverse benefit determination regarding medical necessity/experimental status/medical judgment/rescission, exhaustion of internal appeals unless exception applies, and all required information provided.
ExternalReviewEligibility criteria.
External review timing: standard request window is four months; preliminary review by plan within five business days (immediate for expedited); IRO decision timeline is 45 calendar days for standard and 72 hours for expedited reviews.
ExternalReviewTiming summary.
Plan responsibilities to IRO: plan must provide documents and information considered in making the adverse benefit determination to the IRO within five business days of assignment (immediately for expedited via electronic/telephone/fax); failure to timely provide documents may allow IRO to terminate review and reverse the determination.
IOResponsibility to provide documents.
Billing, Codes, and Key Numeric Thresholds
Eligible Expense / Reimbursementmixed
For network providers: eligible expense is the contracted fee. For non-network providers when balance billing protections apply: eligible expense is the negotiated fee if any, or reimbursement as determined by the plan as required by applicable law. For other non-network covered services with needed authorization: eligible expense is reimbursement as determined by the plan as required by applicable law.
mixed
mixed
mixed
No codes listed
mixed
Procedures and Preventive Services (no specific billing codes listed)mixed
Family planning/contraception methods, mammography screening/diagnostic including tomosynthesis, MRI, ultrasound, and a wide range of medical and surgical procedures are described but no specific billing codes are listed in these sections.
Pharmacy and Drug Coverage NotesmixedCovered
Prescription drugs dispensed by licensed pharmacies are covered; includes prescribed oral anticancer medications and certain off-label drugs recognized in standard reference compendia; cost-sharing and coupon rules apply (use of coupons may affect deductible/OOP accumulation).
Self-Injectable DrugsmixedCovered
Self-injectable drugs are covered under the prescription drug benefits; they are drugs delivered into muscle or under the skin and may be administered by the patient or caregiver after instruction; prescription drug cost share applies.
Radiology Billing Componentsmixed
Technical and professional components of radiology/imaging may be billed separately (two bills: technical component and professional component); prior authorization may be performed. Non-network providers should not balance bill beyond member cost sharing where balance billing protections apply.
Appeal Response Coding Disclosuremixed
Written appeal responses must include the diagnosis and procedure codes with meanings, or state that such codes are available upon request, along with claim/service/provider/date/amount and other appeal information.
inv-40: Member ID card shows
Shown on member ID cardMember name, member identification number, copayment amounts, applicable deductibles, and applicable out-of-pocket maximums (also accessible via member ID card/member portal)
Temporary cardTemporary member identification card available for download from AmbetterHealth.com until mailed card arrives
Delivery timingCard mailed after completed enrollment materials and initial premium payment
Prior Authorization, Claims, and Appeal Procedures
Prior Authorization
Prior Authorization Required
Ambetter Health reviews services to ensure the care you receive is appropriate and medically necessary. Utilization review includes pre-service (prior authorization), concurrent, and retrospective reviews. Prior authorization is required for certain medical and behavioral health services as indicated on the Schedule of Benefits and in this policy. Network providers must obtain authorization before providing services or supplies that require it. Examples when authorization is required include: services from a non-network provider, admission to a network facility initiated by a non-network provider, or services from a network provider resulting from a referral by a non-network provider.
Pre-service/prior authorization
Concurrent review (e.g., inpatient admissions)
Retrospective review (after service)
Prior Authorization
How to Obtain Prior Authorization
To obtain prior authorization or confirm that authorization has been obtained, contact Member Services at the telephone number on the member identification card, or submit requests via phone, fax, or provider portal per plan instructions. Timing requirements for submitting prior authorization requests include: elective inpatient admissions (at least 5 calendar days prior), initial organ transplant evaluation (at least 30 calendar days prior), clinical trial services (at least 30 calendar days prior), within 24 hours of any inpatient admission, and home health care start (at least 5 calendar days prior except post-hospital discharge). Ambetter will notify the member and provider of decisions within timeframes required by law and described below.
Definitions and Term Clarifications
inv-76: Policy / Definitions (intro)
Policy componentsThis Evidence of Coverage (policy), the Schedule of Benefits, and any amendments or riders together constitute the entire policy
Definitions usageTerms that have special meanings are italicized in the document and defined in the Definitions section
PurposeDocument describes how to access care, covered services, and member cost obligations; read entire policy for full understanding
inv-77: Acute rehabilitation
Acute rehabilitation definitionIntensive, multidisciplinary rehabilitation where services are performed 3+ hours/day, 5–7 days/week, medically managed by specially trained physicians
Typical therapies
Policy Summary
PayerCentene
PolicyAmbetter Health EPO Evidence of Coverage — Adult Vision + Adult Dental
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionObtain required prior authorization for services listed on the Schedule of Benefits before providing them to avoid reduced benefits.
Off-exchange enrollees may add dependents in writing or via enrollambetterhealth.com with required premium payment; Ambetter will send written confirmation and ID cards for added dependents.
Adding Other Dependent Members.
Member eligibility ceases upon events including subscriber moving outside the service area, subscriber request to terminate, nonpayment of premiums, fraud/misrepresentation, or member death; termination timing rules apply (e.g., last day of requested month no more than 60 days in advance).
For All Members termination rules.
Prior Coverage coordination for inpatients.
Open enrollment periods and special enrollment periods apply per policy; qualified individuals generally have 60 days to report qualifying events (up to 90 days after loss of Medicaid/CHIP).
Open and Special Enrollment rules.
Premiums are due on or before their due date; initial premium due prior to effective date; Ambetter may apply My Health rewards to unpaid premiums.
Premium Payment and application of rewards.
There is a 60-calendar-day grace period for premium payment; account moves to suspended status if payment not received by day 30; policy remains in force during grace period though claims may pend.
Grace Period operational detail.
Only specified third parties may pay premiums on a member's behalf (e.g., Ryan White program, tribes, government programs, certain tax-exempt organizations, family, qualifying foundations); other third-party payments may be rejected.
Third-Party Payment of Premiums rules.
Some medical and behavioral health services require prior authorization; network providers generally must obtain authorization prior to providing listed services as shown on the Schedule of Benefits. Timeframes for submission and decision vary by request type (urgent, non-urgent, concurrent, retrospective).
Prior Authorization requirements and timelines.
Emergency services and certain obstetrical/gynecological access are exempt from prior authorization; failure to obtain required prior authorization may result in reduced benefits, and provider billing protections apply as stated.
Prior Authorization exemptions and consequences of failure.
Authorization or authorization decisions do not guarantee payment or the amount of benefits; denials can be appealed per Appeals and Grievances Procedures.
Prior Authorization does not guarantee benefits.
Autism Spectrum Disorder Benefits.
Routine patient care costs for eligible clinical trials are covered when the trial meets listed funding/approval and phase requirements; investigational items and items for data collection are excluded; participation is subject to authorization requirements.
Clinical Trial Coverage requirements and exclusions.
Medically necessary acquired brain injury services (cognitive rehabilitation, neuropsych testing, neurofeedback, post-acute transition and community reintegration) are covered similar to other physical conditions; custodial and long-term nursing care are excluded.
Acquired Brain Injury Services.
Adult dental benefits for members 19+ cover diagnostic/preventive (Class 1), basic (Class 2), and major (Class 3) services as listed; an extensive list of dental exclusions applies and cost sharing and annual maximums are shown on the Schedule of Benefits.
Dental Benefits Adults 19+ and exclusions.
Dialysis Services and DME rules.
Durable Medical Equipment: rental or purchase of DME prescribed by a provider is covered when medically necessary; reimbursement limited to a standard item and repairs/replacements covered under conditions; prior authorization may apply.
Durable Medical Equipment provision.
Orthotic devices: initial purchase, fitting and repair of custom orthotics are covered; typically one pair of foot orthotics per year and replacement once per year when medically necessary; exceptions for members under 18 for growth or damage.
Orthotic Devices.
Prosthetics: purchase, fitting, adjustment, repairs and replacements of prosthetic devices are covered when medically necessary (includes certain implants and LVAD as bridge to transplant); some prosthetics excluded such as dentures and dental appliances.
Prosthetics coverage.
Emergency services are covered 24/7; members should call 911 or 988 for behavioral health emergencies; balance billing protections apply for non-network emergency providers.
Emergency Services provision.
Family planning and contraception: FDA-approved contraceptives, sterilization surgery, counseling and follow-up are covered under preventive care without cost sharing when provided by a network provider per HRSA guidelines.
Family Planning and Contraception coverage.
Fertility preservation: medically necessary services and supplies for fertility preservation when cancer treatment may directly or indirectly cause iatrogenic infertility are covered; prior authorization may be required.
Fertility Preservation provision.
Mental Health and Substance Use Disorder Benefits.
Prescription drug benefits cover medications dispensed by licensed pharmacies including certain off-label drugs recognized by standard compendia; cost-sharing and coupon rules affect deductible and out-of-pocket accumulation.
Prescription Drug Expense Benefits.
Medical foods and low-protein products for inherited metabolic diseases (e.g., PKU) and outpatient TPN are covered when medically necessary with a prescriber order; other dietary formulas and prepared meals are excluded.
Medical Foods and Low-Protein Food Products coverage.
Lock-in program may restrict members to a single designated pharmacy; medication refills prohibited until member has ≤15 days' supply on hand; self-injectable drugs covered under prescription drug benefit with applicable cost sharing.
Lock-in and refill rules and self-injectable drugs.
Members/providers may request standard exceptions for non-formulary drugs (decision within 72 hours) or expedited exceptions for exigent circumstances (decision within 24 hours); external IRO review timelines align with original request urgency.
Exception request and external review timelines.
Formulary is a guide and periodically updated; not all strengths/forms may be covered and plan design may restrict coverage despite formulary listing; OTC prescriptions listed on the formulary may be covered when ordered by a physician.
Formulary and OTC coverage notes.
Preventive services and medications required by ACA (USPSTF A/B, ACIP, HRSA) are covered without member cost share when obtained from a network provider; updates to recommendations become effective per plan start/anniversary rules.
Preventive Care Expense Benefits and timing.
Radiology/diagnostic services may require prior authorization; technical and professional components may be billed separately; balance billing protections apply where applicable to prevent billing beyond member cost share.
Radiology, Imaging and Other Diagnostic Testing.
Transplant Services and Center of Excellence requirements.
Center of Excellence transplant travel/lodging benefit: if required travel exceeds 60 miles, plan may pay transportation and lodging up to a maximum (e.g., $10,000 per transplant) for member, donor, and companions subject to receipt submission and timeline rules.
Ancillary Center of Excellence Service Benefits.
Urgent care: network urgent care centers covered; services needed after PCP hours are considered urgent care; Nurse Advice Line available 24/7 for guidance.
Urgent Care and Nurse Advice Line availability.
Adult vision benefits (19+): routine ophthalmological exam, refraction, dilation, frames, lenses, and contact lens fitting (in lieu of glasses) are covered per Schedule of Benefits; certain items (LASIK, visual therapy) excluded.
Vision Benefits Adults 19 years of age or older.
Wellness programs and offerings may be available at no additional cost; participation is optional and rewards may be applied to unpaid premiums per policy rules.
Wellness Programs and Other Offerings.
Health care services obtained at an urgent care facility that is a non-network provider are excluded.
General Non-Covered Services and Exclusions.
Needling-related services (e.g., dry needling) and specified alternative provider services (Naprapathic, Naturopathic) are excluded.
General Non-Covered Services and Exclusions.
Treatment of infertility is excluded except as expressly provided elsewhere in the policy (e.g., fertility preservation when related to cancer treatment).
Infertility treatment exclusion with noted exceptions.
Emergency services while traveling outside U.S.: covered up to 90 consecutive days; claims for such services must be submitted within 180 days with English documentation and proof of travel; reimbursement is sent to member who is responsible for paying the provider.
Claims Incurred for Emergency Services While Traveling Outside the United States.
Expedited Appeal provisions.
External review eligibility and process: external review available for medical judgment issues, surprise billing disputes, and rescissions after exhaustion of internal appeals (with exceptions for expedited reviews); standard external review requests must be filed within four months and IRO decision timelines are 45 calendar days (72 hours for expedited); plan performs preliminary review within five business days and provides documents to the IRO within five business days of assignment.
External Review Process and timelines.
Grievance scope and process: grievances (non-adverse benefit dissatisfaction) may be filed by phone or in writing; plan will acknowledge within five calendar days and resolve within 30 calendar days, with a possible 14-day extension with notice.
Grievance filing and processing timelines.
Authorized representatives: claimants may designate an authorized representative to act on their behalf with required written consent unless already legally authorized (parent, guardian, power of attorney); expedited appeals allow verbal authorization in limited cases.
AuthorizedRepresentative rules.
Therapy intensity requiredRehabilitation services must be performed for three or more hours per day, five to seven calendar days per week
SettingApplies while the covered person is confined as an inpatient in a hospital, rehabilitation facility, or skilled nursing facility
Multidisciplinary careTypically includes combinations of physical, occupational, and speech therapy under specially trained physicians' management
inv-42: Infertility duration
Definition timeframeInfertility is defined as inability to conceive after 12 consecutive months of unsuccessful attempts with regular exposure to viable sperm
Applies toDefinition used for coverage determinations where infertility criteria are relevant
Related termsIatrogenic infertility defined separately when caused by medical intervention
inv-43: Prior authorization lead times
Elective inpatient admissionsPrior authorization requests must be received at least five calendar days prior to an elective inpatient admission
Organ transplant evaluation & clinical trialsAt least 30 calendar days prior to the initial evaluation for organ transplant services and prior to receiving clinical trial services
Inpatient admission reportingPrior authorization must be submitted within 24 hours of any inpatient admission
inv-45: Benefit limits apply
ApplicabilitySome nonessential benefits are subject to lifetime or annual dollar maximums per policy terms
ReferenceSee Schedule of Benefits for detailed annual maximums and limits for specific services
Effect on paymentLimits may cap insurer payment for specified nonessential services even if medically necessary
inv-46: State/federal cost limits
Insulin cost capTotal amount required to pay for a covered insulin drug will not exceed applicable state and/or federal mandated limits
DME purchase vs rentalDME rental costs will not exceed purchase price; insurer may elect rental or purchase and prior authorization may apply
Related suppliesPayment for delivery/installation and medically fitting supplies covered when equipment is rented; separate payment rules when equipment owned by member
inv-47: Ventilator management parameters
Ventilator monitoring frequencyVentilator management required at least every 4 hours
PEEP and FiO2 thresholdsMaximum PEEP requirement 10 cm H2O and FiO2 60% or less with oxygen saturation at least 90%
LTACH ventilation durationPatient has received mechanical ventilation for 21 consecutive days for 6 or more hours per day as an example qualifying criterion
Refill prohibition thresholdMedication refills are prohibited until member's cumulative balance-on-hand is equal to or fewer than 15 calendar days' supply
Operational effectThis rule operates in addition to any medication quantity limits or refill guidelines
ScopeApplies to retail/mail refills per prescription drug benefit; exceptions may exist per formulary or prior authorization
inv-49: Refill and supply thresholds
Balance-on-hand refill ruleRefills prohibited until member has 15 days or fewer on hand
Standard supply limitsGenerally limited to a 30-day supply per dispense; some maintenance medications eligible for 90-day supply via mail order or select pharmacies
Split-fill and specialty rulesSplit-fill dispensing limits (e.g., 15 days for first 90 days for certain new therapies) and other managed drug limitations may apply
inv-50: Center of Excellence travel mileage threshold
Travel distance thresholdMember must travel more than 60 miles from their residence to the Center of Excellence for travel benefits to apply
Maximum reimbursementPlan pays up to $10,000 per transplant for transportation and lodging when travel threshold met (see member transplant guidelines)
DocumentationMileage reimbursement requires a mileage log and receipts submitted within 6 months of date of service
inv-51: Claim processing timelines
Clean electronic claimsProcessed within 20 business days for clean electronic claims (non-No Surprises Act)
Clean paper claimsProcessed within 40 business days for clean paper claims (non-No Surprises Act)
No Surprises Act claimsClean claims for services subject to federal No Surprises Act balance billing protections processed within 30 calendar days
Telephone number on member ID card
Phone/Fax/Provider Portal submission accepted
Elective inpatient admissions: ≥5 calendar days prior
Organ transplant initial evaluation: ≥30 calendar days prior
Clinical trials: ≥30 calendar days prior
Any inpatient admission: within 24 hours of admission
Home health start: ≥5 calendar days prior (except post-discharge)
Denial Risk
Failure to Obtain Prior Authorization
Failure to obtain required prior authorization may result in reduced benefits. Network providers may not balance-bill members for services when authorization was required but not obtained; however, benefits may be reduced except in cases of emergency services. For emergency services, prior authorization is not required, but the member or provider must contact the plan as soon as reasonably possible (or within 48 hours if admitted) to avoid financial responsibility for inpatient care deemed not medically necessary.
Benefits may be reduced if authorization requirements are not met
Emergency services are covered without prior authorization
Notify plan within 48 hours (or as soon as reasonably possible) after emergency admission
Note
Authorization Limits and Predeterminations
An authorization is a determination that a requested service is approved for medical necessity or appropriateness. Authorization does not guarantee payment or the amount of benefits — payment remains subject to all policy terms, member eligibility, and actual claims processing. Providers and members may request predeterminations of coverage, but predeterminations are not guarantees and may be reversed if based on incomplete or inaccurate information, if another party is responsible for payment, or if other facts change.
Authorization = approval of medical necessity/appropriateness
Authorization ≠ guarantee of payment
Predeterminations may be provided but can be reviewed and reversed
Denial Risk
Prior Authorization Denials
Prior authorization denials may be appealed. Refer to the Appeals and Grievances Procedures section for the internal and external appeal processes. If a prior authorization request is denied, members and providers have rights to appeal and to request additional review, including external independent review when eligibility criteria are met.
Denials may be appealed via internal appeals process
External review (IRO) available when criteria met
Prior Authorization
Non-Network and Out-of-Area Authorization
If a covered service cannot be obtained from a network provider within a reasonable distance, the plan may authorize services from a non-network provider at no greater cost to the member than if obtained from a network provider. Prior authorization must be obtained before receiving services from a non-network provider to be eligible for coverage. When traveling outside the service area, members may access Ambetter providers in other states; non-emergency services outside the service area may require authorization. Balance billing protections apply in certain situations (see No Surprises Act protections).
Non-network services may be authorized when network access is not reasonably available
Prior authorization required before obtaining non-network services to avoid member liability
Out-of-area Ambetter providers may require authorization for non-emergency care
Prior Authorization
Ambulance Authorization
Ambulance services: Emergency ground, water, and air ambulance transportation do not require prior authorization when the member is experiencing an emergency condition. Non-emergency ground, water, and air ambulance transportation requires prior authorization. Covered air ambulance transport includes transport to the nearest appropriate facility, neonatal special care units, transfers when authorized by the plan, and transport when required by the plan from a non-network to a network provider. Members should not be balance-billed for covered air ambulance services; nonemergency non-network ambulance services may be balance-billed unless protections apply.
Emergency ambulance services: no prior authorization required
Air ambulance coverage subject to plan authorization and limitations
Members should not be balance billed for covered air ambulance services
Prior Authorization
Clinical Trial Authorization
Clinical trial participation is subject to authorization requirements. To be eligible, the treating facility and personnel must have appropriate expertise, there must be adequate non-investigational alternatives, and available data must provide a reasonable expectation of benefit. Providers must obtain the patient’s informed consent consistent with legal and ethical standards. Routine patient care costs for members enrolled in eligible cancer clinical trials may be covered when authorized and otherwise covered under the policy.
Clinical trials require prior authorization
Treating facility and personnel must be qualified
Providers must obtain informed consent for clinical trial participation
Note
Appeal Review and Expedited Appeal Timelines
If a prior authorization is denied, members may file internal appeals (standard or expedited) and, if eligible, request an external review by an Independent Review Organization (IRO). Standard internal appeals: the plan will acknowledge receipt and notify the member of information needed within five calendar days. Expedited internal appeals are available for pre-service adverse determinations that could seriously jeopardize life, health, or ability to regain maximum function; decisions on expedited appeals will be made within 72 hours. For expedited appeals, claimants may submit clinical information by phone or in writing.
Standard appeal: plan acknowledges and requests needed information within 5 calendar days
Expedited internal appeal decisions made within 72 hours
Expedited appeals may be submitted by phone or in writing and must include clinical information
Note
External Review and IRO Procedures
External review process: Members have four months to request a standard external review (no time limit for expedited external review). The plan has five business days to complete a preliminary review (immediately for expedited) to determine eligibility. If complete, the Department assigns an IRO; the plan must provide documents to the IRO within timeframes described by law. The IRO will issue a decision within 45 calendar days for standard external reviews and within 72 hours for expedited external reviews. If the IRO reverses the adverse determination, the plan must approve the benefit.
4 months to request standard external review
Plan has 5 business days for preliminary review (immediate for expedited)
IRO decision timeframe: 45 calendar days (standard), 72 hours (expedited)
If IRO reverses, plan must approve the benefit
Includes combinations of physical, occupational, and speech therapy as needed
SettingProvided while the covered person is confined as an inpatient in a hospital, rehabilitation facility, or skilled nursing facility
inv-78: Balance billing protections
No Surprises Act protectionsBalance billing protections apply per federal law (effective Jan 1, 2022) for emergency services, certain non-emergency services at network facilities, and air ambulance services
Member cost share calculationWhen protections apply, member pays only network-equivalent cost share based on the recognized amount as defined in law
When balance billing may occurMember may be balance billed for non-network services that do not meet protection criteria unless prior notice and voluntary written consent provided
inv-79: Authorization
Authorization meaningAuthorization (authorized) means the plan's decision to approve the medical necessity or appropriateness of care
Types of reviewIncludes pre-service/prior authorization, concurrent, and retrospective utilization review processes
Provider responsibilitySome services require prior authorization; network providers generally must obtain authorization prior to providing listed services
inv-80: Medically necessary
Medically necessary criteriaService must be consistent with diagnosis, provided per accepted standards, not custodial, reasonably capable of improvement, not experimental, provided in most cost-effective setting, and not exceed needed scope/duration/intensity
Hospital confinementFor hospital confinement, means diagnosis and treatment cannot be safely provided as an outpatient
Coverage effectCharges for services not medically necessary are not eligible expenses
inv-81: Infertility
Infertility definitionInfertility means inability to conceive after 12 consecutive months of unsuccessful attempts despite regular exposure to viable sperm
Iatrogenic infertilityIatrogenic infertility is infertility caused by medical intervention (e.g., drugs or medical/surgical procedures) and is defined separately
Coverage noteTreatment of infertility is excluded except as expressly provided elsewhere in the policy (see fertility preservation for cancer-related iatrogenic infertility)
inv-82: Medically necessary
Medically necessary (repeat)A medically necessary service/item/treatment must diagnose or treat illness/injury consistent with diagnosis, meet accepted standards, not be custodial or experimental, and be the most cost-effective setting without exceeding needed scope/duration/intensity
Functional improvementMust demonstrate reasonable capability of improving functional ability
DocumentationDeterminations based on clinical information and applicable guidelines/policies
inv-83: Notice and consent
Notice and consent requirementsMember must receive written notice in required format and provide voluntary written consent to waive balance-billing protections; notice generally at least 72 hours before services (or 3 hours for services scheduled within 72 hours)
Consent contentsNotice must include good faith estimate of charges, any prior authorization requirements, and statement that consent is optional; consent must acknowledge understanding that billed amounts may not count toward deductible/OOP
ExclusionsNotice and consent do not apply to emergency services, air ambulance, unforeseen urgent needs, or ancillary services when no network provider available
inv-84: Terminally ill
Terminal illness definitionTerminally ill means a physician has given a prognosis that a member has six months or less to live
ImplicationUsed for determinations related to hospice and end-of-life benefits and expedited reviews
DocumentationPhysician prognosis required to substantiate terminal status
inv-85: Tobacco or nicotine use
Tobacco/nicotine use definitionUse means using tobacco or nicotine on average four or more times per week or use within six months prior to application; includes e-cigarettes/vaping (excluding ceremonial use)
Applies toUsed for underwriting, eligibility, or related program determinations where tobacco status is relevant
ExamplesIncludes cigarettes, cigars, e-cigarettes, and vaping devices
inv-86: Prior Authorization
Prior Authorization definedPrior authorization is a pre-service review to approve medical services as necessary; includes pre-service, concurrent, and retrospective reviews
Submission channelsRequests accepted by phone, fax, or provider portal per instructions
Timeframes for decisionsSpecific decision timeframes provided for urgent, non-urgent, concurrent, and retrospective reviews (see policy timelines)
inv-87: Special Enrollment Period
SEP general windowQualified individuals generally have 60 calendar days to report a qualifying event and request a Special Enrollment Period
Medicaid/CHIP lossIf loss of Medicaid/CHIP MEC, up to 90 calendar days to enroll following loss
Qualifying eventsIncludes marriage, birth, adoption, placement for adoption, move, and other listed events
Cost sharing componentsCost sharing includes deductible, copayments, and coinsurance; copayments are fixed amounts due at time of service and count toward maximum out-of-pocket but not the deductible
Deductible roleDeductible is amount members must pay before benefits apply for services subject to the deductible
Family OOPFamily maximum out-of-pocket equals two times the individual maximum; after individual OOP met, plan pays 100% for that member
inv-89: Health Savings Account (HSA)
HSA responsibilitiesMembers must satisfy federal HSA eligibility criteria; insurer is not trustee/custodian and does not provide tax advice; members responsible for HSA compliance
Plan checkRefer to Schedule of Benefits to confirm if enrolled plan is HSA-compatible
Tax adviceMembers should consult a professional tax advisor for HSA implications
inv-90: Primary Care Provider (PCP)
PCP requirementTo obtain benefits, members must designate a network Primary Care Provider (PCP) for each member; one will be assigned if not selected
PCP change frequencyMembers may change PCP no more than once per month; change effective no later than 30 calendar days after request
OB/GYN accessNo referral needed to access in-network obstetrical or gynecological care from a specialist
inv-91: CPC
CPC roleClinical Policy Committee (CPC) reviews requests for new technology coverage and advises benefit changes
One-time reviewIf CPC does not review, medical director may make a one-time determination subject to future CPC review
ScopeEvaluates new technology, procedures, drugs, devices, and new applications of existing technology
inv-92: Essential Health Benefits
EHB scopeEssential Health Benefits include categories such as ambulatory services, emergency services, hospitalization, maternity/newborn care, behavioral health, prescription drugs, rehabilitative services, laboratory, preventive services, chronic disease management, and pediatric services
Defined by lawAs defined by federal and state law and applicable regulations
ReferenceBenefits subject to policy terms and Schedule of Benefits for specifics
inv-93: iatrogenic infertility
Iatrogenic infertility definitionIatrogenic infertility is infertility caused by a medical intervention, including reactions from prescribed drugs or medical/surgical procedures (e.g., cancer treatment)
Related coverageFertility preservation services may be covered when cancer treatment may directly or indirectly cause iatrogenic infertility (prior authorization may be required)
DistinctionSeparate from general infertility definition (12 months) and used for preservation coverage determinations
inv-94: Durable Medical Equipment / Prosthetics
DME / prosthetics covered itemsDurable medical equipment and prosthetics include rental or purchase, fitting, repairs, replacements, and medically fitting supplies when medically necessary
Rental vs purchaseRental cost must not exceed purchase price; insurer may choose to rent or purchase; prior authorization may apply
Iatrogenic infertility (duplicate)Infertility caused by medical intervention (see fertility preservation coverage for cancer-related cases)
Use in policyTerm used to trigger fertility preservation coverage where expressly provided
DocumentationPrior authorization may be required to substantiate medical necessity for preservation services
inv-96: Self-Injectable Drugs
Self-injectable drugs definitionMedications delivered into muscle or under the skin by syringe/needle that patients or caregivers can administer after instruction
Benefit coverageCovered under the prescription drug benefit; prescription drug cost share applies
Refill rules impactSubject to medication balance-on-hand and supply limits (e.g., refills prohibited until ≤15 days on hand)
inv-97: Newborns' and Mothers' Health Protection Act
Federal maternity stay protectionUnder federal law, plans may not restrict hospital length of stay to less than 48 hours after vaginal delivery or less than 96 hours after cesarean delivery
Provider/mother optionProvider and mother may agree on earlier discharge and plan cannot require authorization for stays up to the federal minimum
ReferenceNewborns' and Mothers' Health Protection Act protections summarized in policy
inv-98: Self-injectable drugs (expanded)
Self-injectable drugs expandedSelf-injectable drugs are administered by syringe/needle into muscle or subcutaneous tissue and are covered under prescription benefits after initial instruction
Cost shareMembers subject to applicable prescription drug copay/coinsurance
Administration noteInitial medical supervision/instruction may be required before self-administration
inv-99: Exception request types
Standard exceptionStandard non-formulary or step therapy protocol exception decisions provided within 72 hours of request; if granted, coverage for duration of prescription/refills
Expedited exceptionExpedited exception determinations provided within 24 hours for exigent circumstances; if granted, coverage for duration of exigency
External IRO reviewAfter denial, members may request external exception review by an IRO with decision timelines that mirror original request urgency (72 hours for standard, 24 hours for expedited external reviews)
inv-100: Center of Excellence (transplant)
Center of Excellence definitionA designated facility for transplant services where special travel and lodging benefits apply when member must travel >60 miles
Travel/lodging benefitPlan will pay transportation and lodging up to $10,000 per transplant when Center of Excellence travel threshold met; receipts and logs required
Member responsibilitiesMember must arrange travel and provide receipts within 6 months for reimbursement; see member transplant guidelines and forms online
inv-101: Urgent care
Urgent care definitionUrgent care services are medically necessary services by network providers or network urgent care centers including facility costs and supplies; care needed after PCP hours considered urgent care
Nurse Advice Line24/7 Nurse Advice Line available to help determine appropriate care
Preventive benefit limitationZero-cost preventive benefits may not be used at a network urgent care center
inv-102: third-party
Third-party definition"Third-party" means any party that is, or may be, or is claimed to be responsible for injuries or illness to a member
ScopeIncludes parties potentially responsible for payment of expenses associated with third-party injuries
Plan rightsInsurer retains rights of recovery and reimbursement from third-party recoveries for benefits paid on behalf of the member
inv-103: Adverse benefit determination
Adverse benefit determinationA decision that admission, availability of care, continued stay, or other covered health care service does not meet plan requirements (medical necessity, appropriateness, level of care, experimental), resulting in denial, reduction, or termination
Appeal rightsMembers have rights to appeal adverse benefit determinations through internal appeals and, if eligible, external review processes
ReferenceSee Appeal and Grievance Procedures for filing timelines and process (180 days to file an internal appeal)
inv-104: External review / IRO
External review (IRO)External review is an independent review by an IRO assigned by the Department of Insurance after exhaustion of internal appeals; preliminary review and document transfer timelines described
Filing windowFour months to request a standard external review after internal decision; expedited external reviews have immediate preliminary handling
IRO timelinesIRO decision timelines: 45 calendar days standard, 72 hours for expedited (per policy summary) and plan must provide documents to IRO within five business days of assignment
inv-105: External review
External review summaryExternal review available for medical judgment issues, surprise billing cost-sharing disputes, and rescissions after internal appeals exhausted; Department assigns IRO
Eligibility checkPreliminary review within five business days to verify coverage at time of service, exhaustion of internal process, and completeness of request
Claimant rightsClaimant may submit additional information during review and will be notified of assignment to IRO
inv-106: Grievance
Grievance definitionGrievance is an expression of dissatisfaction about anything other than an adverse benefit determination (customer service, provider availability, quality of care/service)
Filing methodsFile by phone, in writing, or online; acknowledgment within 5 calendar days and resolution within 30 calendar days (plus possible 14-day extension)
Authorized representativeClaimant may designate an authorized representative; written consent required unless legally authorized (parent, guardian, power of attorney)
Adverse benefit determination (duplicate)Includes denials based on medical necessity, experimental/investigational status, medical judgment, rescissions, and similar decisions; subject to internal appeal and external review processes
Appeal timeline180 calendar days to file an internal appeal from date of adverse benefit determination; expedited appeals decided within 72 hours
RemediesClaimant entitled to submit evidence, request review by similarly qualified reviewer, and pursue external review if eligible