2026 Evidence of Coverage / Individual Member Contract
This document is the Ambetter Health Solutions Evidence of Coverage and individual member contract underwritten by Celtic Insurance Company, describing covered services, member rights/responsibilities, prior authorization requirements, and how to access care for enrolled members.
Policy Summary
PayerCentene
PolicyAmbetter Health Solutions Evidence of Coverage (Individual Member Contract)
Policy CodePolicy N/A
Change TypeNo material changes
Effective Date2026
Next Review DateN/A
Key ActionObtain prior authorization for services that the Schedule of Benefits or Prior Authorization section requires to avoid reduced benefits.
No material clinical or coverage changes in this revision.
1-833-543-3145Member Services phone
24/7Emergency services coverage
PA requiredPrior authorization noted
31 daysNewborn initial coverage
10Days to return contract for refund
Coverage, Exclusions, and Benefit Rules
Referenced Coverage Sections
The Table of Contents identifies major benefit sections, prior authorization, exclusions, and claims procedures; details are in the referenced sections.
Referenced sections include: Major Medical Expense Benefits; Prior Authorization; General Non-Covered Services and Exclusions; Claims and Coordination; Transplant Expense Benefits; Durable Medical Equipment; Prescription Drug Expense Benefits; Preventive Care; and Dependent Member Coverage (see Table of Contents).
Balance billing, emergency services, and related coverage rules
Balance billing protections and emergency services rules that apply to members.
Federal balance billing protections apply (effective Jan 1, 2022): non-network providers may not balance bill members for services subject to those protections; member is responsible only for network-level cost share based on the recognized amount.
If non-network care is received due to inaccurate provider directory information or incorrect network-status response, and services are covered, the member pays network cost sharing and will not be balance billed.
Emergency services are covered without prior authorization and include facility, physician services, supplies and prescription drugs charged by the facility; members must notify the insurer within 48 hours (or as soon as reasonably possible) of hospital admission resulting from an emergency when possible.
Authorizations approve medical necessity/appropriateness but do not guarantee payment; eligible expense and allowable reimbursement rules apply for non-network services as described in the contract.
Dependent, newborn, and adopted child coverage rules
Rules for dependent eligibility and initial coverage periods for newborns and adopted children.
Dependent members become eligible on the later of subscriber effective date or the qualifying event (e.g., marriage, birth, placement for adoption, foster placement, domestic partnership).
Eligible newborns are covered from time of birth until the 31st calendar day after birth; each service is subject to Schedule of Benefits cost sharing; additional premium is required to continue coverage beyond the 31st day. Notification within 31 days (or within 60 days, per provision) affects premium application and denial protections.
An eligible child placed for adoption is covered from the date of placement until the 31st calendar day after placement; the child is covered for injury and illness including preexisting conditions; additional premium and timely notification (within 60 days) and premium payment (within 90 days) are required to continue coverage beyond the 31st day.
Enrollment and coverage criteria
Effective date and special enrollment timing rules and related enrollment provisions.
Regular effective date: coverage is effective on the first of the month following plan selection, except as specified for special events.
Special effective dates: for birth, adoption, placement for adoption, or foster placement, coverage is effective on the date of the event; for marriage or loss of minimum essential coverage, effective the first of the following month (unless otherwise specified).
Qualified individuals generally have defined windows to report qualifying events (e.g., notification windows referenced elsewhere such as 31, 60, or 90 days) and certain enrollment triggers have specific effective-date rules described in the contract.
Premium payment and grace provisions apply (initial premium due prior to effective date; grace period referenced in Enrollment section).
Major medical and acquired brain injury coverage criteria
General coverage principles and scope of acquired brain injury (ABI) benefits.
Covered services must be medically necessary and not experimental or investigational; some services require prior authorization as noted in the contract.
Acquired brain injury benefits are provided on the same basis as treatment for other physical conditions and include cognitive rehabilitation, cognitive communication therapy, neurocognitive therapy and rehabilitation, neurobehavioral/neuropsychological testing and treatment, neurofeedback, remediation related to ABI, and post-acute transition and community reintegration services when necessary and related to the injury.
Custodial care and long-term nursing care are excluded from coverage under the ABI provision.
Acquired Brain Injury
Specific service categories and limits for acquired brain injury care.
Covered ABI services include: cognitive rehabilitation therapy; cognitive communication therapy; neurocognitive therapy and rehabilitation; neurobehavioral, neuropsychological, neurophysiological testing and treatment; neurofeedback therapy; remediation related to ABI; and post-acute transition and community reintegration services when medically necessary and provided in appropriate facilities (hospital, acute/post-acute rehab hospital, skilled nursing facility, or approved facility).
Coverage applies when services are medically necessary and aimed at maintaining function or preventing/ slowing deterioration; custodial and long-term nursing care are not covered.
Air Ambulance
Air ambulance coverage for emergency transport and requirements for non-emergency transport.
Air ambulance (fixed wing and rotary wing) is covered to the nearest appropriate facility for emergency conditions, to neonatal special care units when needed, and for authorized inter-hospital transfers; non-emergency air ambulance requires prior authorization.
Prior authorization is not required when the member is experiencing an emergency condition; non-emergency air ambulance without prior authorization is excluded. Note: air ambulance services outside the 50 U.S. states and D.C., international transports, or services provided for comfort/convenience are excluded.
Members should not be balance billed beyond applicable cost share for covered air ambulance services from non-network ambulance providers where protections apply.
Ambulance (Ground/Water)
Ground and water ambulance emergency coverage and prior authorization for non-emergency transport.
Ground and water ambulance transport to the nearest appropriate facility for an emergency condition is covered without prior authorization; transport to neonatal special care units and authorized inter-facility transfers are covered when authorized.
Non-emergency ambulance transportation requires prior authorization; ambulance services provided for comfort/convenience or covered by local governmental bodies (unless required by law) are excluded.
Members should not be balance billed for covered ground or water ambulance services when protections apply.
Autism Spectrum Disorder
Autism services coverage and prior authorization requirement for ABA.
Autism spectrum disorder services are covered when prescribed by an appropriate practitioner and include evaluation/assessment, applied behavior analysis (ABA), behavior training/management, speech therapy, habilitation, occupational therapy, physical therapy, psychiatric care, and medications/nutritional supplements.
No unit limits exist for applied behavior analysis services; ABA services are subject to prior authorization to determine medical necessity. If multiple providers render services the same day, separate cost sharing may apply per provider.
Clinical Trials
Clinical trial participation coverage for routine care costs and related services, with exclusions for investigational items and nonclinical expenses.
Coverage includes routine care costs for FDA-approved drugs/devices and medically necessary services to administer trial interventions; items/services otherwise generally available to qualified individuals; diagnosis/treatment of complications; and transportation essential to medical care for approved clinical trials.
Exclusions include investigational trial items/devices not approved by the FDA, items provided solely for data collection, housing/companion/nonclinical expenses, and items paid for by grants or sponsors.
Requirements: participation is subject to prior authorization; treating facility/personnel must have appropriate expertise; a qualified individual must have a referral or provide scientific justification; informed consent is required and must be available on request.
Diabetic Care
Diabetic care services and supplies covered when medically necessary; insulin cost cap applies.
Covered diabetic care includes examinations (including podiatric), routine foot care, lab/radiologic testing, self-management equipment and supplies (urine/ketone strips), blood glucose monitor supplies, syringes/needles, orthotics/diabetic shoes, urinary protein/microalbumin and lipid profiles, education/counseling, and eye exams/retinopathy screening as medically necessary and ordered by a practitioner.
Medically necessary diabetic supplies and blood glucose monitors are covered when ordered by a practitioner; the total amount a member pays for a covered insulin drug will not exceed applicable state and/or federal mandated limits.
Durable Medical Equipment and Supplies
Durable medical equipment (DME), supplies, orthotics, and prosthetics covered when medically necessary and subject to prior authorization and limits.
All types of durable medical equipment and supplies are subject to prior authorization; rental or purchase is at plan discretion but rental costs must not exceed purchase price and the plan will not pay rental longer than purchase cost.
Covered DME examples include hemodialysis equipment, crutches, pressure machines, glucometers, tracheotomy tubes, cardiac/neonatal/sleep apnea monitors, augmentative communication devices (with approval), rental of standard hospital bed/walker/non-motorized wheelchair/ventilator, one CPM machine post covered joint surgery, and medically necessary foot orthotics.
Repair, adjustment, and replacement are covered when medically necessary or when item is worn out/damaged and cannot be repaired; replacement frequency limits apply (e.g., orthotic devices may be replaced once per year when medically necessary with exceptions for growth or irreparable damage).
Exclusions include items such as air conditioners, raised toilet seats, treadmill exercisers, rental when facility provides equipment, and other listed non-covered items.
Coverage criteria and examples
Representative examples of covered services, limitations, and operational notes across multiple benefit areas.
Examples of covered items/services
Disposable medical supplies with a primary medical purpose are covered subject to reasonable quantity limits and member cost-sharing.
Medical and surgical non-durable supplies for disease management (e.g., allergy extracts, glucose test strips, ostomy supplies) are covered as described.
Prosthetics are covered for purchase, fitting, adjustments, repairs, and replacements when medically necessary; prosthetics should be purchased not rented; LVAD covered only as bridge to transplant.
Orthotic devices initial purchase, fitting and repair are covered; prior authorization may be required for corrective footwear; replacements allowed once per year when medically necessary with pediatric growth exceptions.
Hospice Benefits
Hospice benefit details, covered services, and prior authorization requirements.
Hospice care benefits apply to terminally ill members in a hospice program or at home; covered services include room and board (inpatient hospice), occupational/speech therapy, rental of medical equipment during hospice care, palliative and supportive care, counseling, and bereavement counseling.
Respite care is covered on an inpatient or home basis to provide temporary relief to family caregivers; respite days applied toward deductible and benefit limits per the Schedule of Benefits.
Hospice inpatient, home and outpatient care is subject to prior authorization as outlined in the contract.
Hospital/Medical/Surgical Coverage
Hospital, medical and surgical services covered when medically necessary and subject to contract terms and cost sharing.
Hospital services covered include daily room and board up to semiprivate rate, ICU room and board, inpatient/outpatient operating/treatment/recovery room use, emergency treatment, and private rooms when needed for isolation.
Medical and surgical services covered include surgery, pre/post-surgical testing, radiology, lab, genetic testing, chemotherapy (including oral), infusion, anesthesia, durable medical equipment and prosthetics, and related items as described; services are subject to prior authorization where required and to Schedule of Benefits cost sharing.
Medically necessary telehealth services are covered with the same cost sharing as comparable in-person services (unless provided under Virtual 24/7 Care which is treated separately).
Maternity/newborn rules include coverage for minimum inpatient stays (48 hours vaginal; 96 hours cesarean) and medically necessary newborn services provided immediately after birth; some maternity services may require prior authorization.
LTACH Coverage Criteria
LTACH admission criteria and mechanical ventilation threshold.
LTACH benefits are subject to prior authorization and are appropriate for members with clinically complex problems requiring extended hospital-level care (complex wound care, infectious disease requiring parenteral therapy, medical complexity with multiple comorbidities, rehabilitation needs not met in SNF/rehab, etc.).
Mechanical ventilator support criteria include failed weaning attempts, mechanical ventilation for 21 consecutive days for 6 hours or more per day, required ventilator management and stability parameters (hemodynamically stable, PEEP and FiO2 limits, oxygen saturation thresholds), and demonstrated weaning potential without untreatable progressive conditions.
Coverage criteria summary
Summary of selected covered services, preventive, pharmacy, mental health, and program rules.
Medical foods and formulas (including outpatient total parenteral nutrition, elemental formulas for malabsorption, PKU/inborn errors formulas, and medically necessary pasteurized donor human milk when prescribed) are covered as described.
Low-protein food products for specified inherited metabolic diseases (PKU, MSUD, MMA, IVA, propionic acidemia, glutaric acidemia, urea cycle defects, tyrosinemia) are covered when medically necessary and prescribed.
Preventive care services required by the ACA (USPSTF A/B, ACIP immunizations, HRSA pediatric and women’s recommendations) are covered without member cost share when obtained from a network provider; diagnostic reporting may change cost share if billed as diagnostic.
Mental health and SUD services are covered inpatient and outpatient; determinations use InterQual and ASAM criteria; many services require medical necessity and may require prior authorization except emergent inpatient withdrawal/treatment services. Covered services include PHP, IOP, detox, outpatient therapy, MAT, psychological testing, ABA, TMS, ECT, and telehealth services.
Coverage criteria and exclusions
Key coverage determinations, exceptions, exclusions, and transplant prerequisites.
Insulin cost cap: member payment for covered insulin will not exceed applicable state or federal mandated limits.
Exception process: standard exception determinations provided within 72 hours; expedited exception determinations within 24 hours; if granted, coverage provided for duration of prescription or exigency respectively; external exception review timelines mirror these timeframes.
Medication refill controls: medication balance-on-hand prohibits refills until member has ≤15 calendar days' supply on hand; supply limits generally limit retail to 30 days and maintenance drugs up to 90 days by mail order.
Transplant prerequisites: transplants covered when member is accepted as transplant candidate and prior authorization is obtained through Center of Excellence or approved facility before evaluation; medical criteria per Medical Management Policy apply; donor/recipient billing rules described.
Non-covered services: numerous explicit exclusions apply (see Non-Covered Services and Exclusions section), including experimental/ investigational items, many elective/cosmetic services, and other enumerated items.
Coverage Criteria and Exclusions (Transplant)
Transplant coverage conditions, covered services, donor handling, and ancillary benefits.
Transplant services are covered when the member is accepted as a transplant candidate and prior authorization is obtained through a Center of Excellence or approved facility prior to evaluation and related services; medical necessity per Medical Management Policy is required.
Covered transplant services include pre-transplant evaluation, organ harvesting, LVAD as bridge to transplant, outpatient services related to transplant (including pre-transplant treatment/stabilization), the transplant procedure (including acquisition cost when authorized), and post-transplant follow-up; donor search/acceptability testing included.
Donor billing rules
If both donor and recipient are covered by the same insurer, each has benefits paid by their own coverage program.
If donor is uninsured and recipient covered, donor benefits may be provided under the recipient's policy and charged against member benefits.
Non-covered services and exclusions
Contract-expressed non-covered services and explicit exclusions.
The contract lists numerous explicit exclusions to coverage including (but not limited to) services provided prior to effective date or after termination, services in excess of eligible expense, many cosmetic procedures, experimental or investigational treatments (subject to defined criteria), weight modification/bariatric surgery except as specifically covered, fertility/surrogacy-related services, custodial/residential care, many alternative therapies, certain prescription drug exclusions, and services received outside the U.S. except for limited emergency coverage. See the Non-Covered Services and Exclusions section for the full enumerated list.
Termination and refund provisions
Termination, refund, and discontinuance procedures for the contract.
Grounds for termination include nonpayment of premiums (subject to grace period), member request, reaching limiting age for dependents, insurer non-renewal or discontinuance, member death, or loss of eligibility as described elsewhere in the contract.
Upon cancellation or termination, unearned premium will be returned promptly to the original method of payment within 20 calendar days; cancellation becomes effective upon receipt of written notice or a later specified date.
If the insurer discontinues offering this form of contract for all residents of a state, specified notice periods (e.g., 90 or 180 calendar days depending on jurisdictional provision) apply and members will be offered other available coverage as described.
Subrogation and reimbursement
Subrogation, reimbursement, and member cooperation obligations when third parties are involved.
When a third-party causes injury or illness, the plan may pay benefits but reserves rights to reimbursement to the extent benefits were provided; the plan has lien and reimbursement rights and may require cooperation, execution of documents, and may intervene in suits to protect its subrogation interest.
Members must promptly notify the insurer of claims against third parties, include the insurer's benefit amounts in claims, not settle without notice, and reimburse the plan from any third-party recovery; the plan may delay future payments or offset benefits to enforce recovery rights.
If disputes arise over reimbursement amounts, the plan may require escrow of funds pending resolution; failure to cooperate may jeopardize claim handling per the contract provisions.
Claims submission and proof timelines
Claims notification, proof, and provider submission expectations and timelines.
Notice of claim must be provided within 30 calendar days of the date the loss began or as soon as reasonably possible; written proof of loss must be provided within 90 calendar days or as soon as reasonably possible (late proofs beyond one year generally not accepted unless incapacity existed).
Providers typically submit claims on members' behalf; if provider is non-contracted or member paid for covered services, members may submit reimbursement claims using the posted form and documentation to the insurer's Claims Department address provided in the contract.
Claims and Coordination Criteria
Standards for claim payment, clean claim definitions, emergency coverage abroad, assignment, coordination of benefits, and member cooperation.
Clean claim payment timelines: electronic clean claims paid within 25 calendar days and paper clean claims within 35 calendar days; resubmitted complete claims are processed within 20 calendar days. A clean claim is defined as a claim requiring no further information or adjustment.
Clean claim exclusions: duplicate claims filed within 30 days, fraudulent or materially misrepresented claims, claims requiring essential information for preexisting condition/COB/subrogation, and provider-submitted claims more than 30 days after date of service are not clean.
If claims are not denied within applicable timeframes, insurer pays interest on overdue benefits at specified rates and claimants may bring action to recover benefits and interest; bad faith can permit additional damages per law.
Emergency services while traveling outside the U.S. are covered for up to 90 consecutive days; claims for such services must be submitted within 180 days with required documentation and will be reimbursed to the member based on plan rules and exchange rates.
Secondary Payment and Appeals Interaction
How the plan handles payment when it is secondary and interactions with appeals/external review.
When this plan is secondary it may reduce benefits so that total benefits paid by all plans do not exceed total allowable expenses; the secondary plan must credit deductible amounts as if it were primary and calculate payments so combined payments equal what it would have paid as primary.
Timely filing: providers or members should submit claims to the secondary plan within that plan's claim filing time limit to avoid denial; contact the primary plan to verify status and coordination procedures.
Internal appeals generally must be exhausted before external review unless expedited external review is filed concurrently, waived, or the plan failed to follow appeal procedures; after exhausting internal review, claimant has four months to request external review from the State Insurance Department.
External Review and Appeal Criteria
External review eligibility, process steps, timelines, and IRO procedures.
External review is available for adverse determinations involving medical judgment (medical necessity, appropriateness, level of care, effectiveness), determinations that a treatment is experimental/investigational, surprise billing applicability/cost-sharing, and rescissions of coverage.
Exhaustion: claimants generally must exhaust internal appeals before requesting external review unless expedited external review is filed concurrently or a waiver/plan failure applies.
Preliminary review and IRO assignment: the plan has specified preliminary review timelines (five business days, immediate for expedited) and must notify claimant whether request is complete; State Insurance Department assigns an IRO within one business day of eligibility and claimant may submit additional information to the IRO within five business days.
Plan must provide documents to the IRO within five business days after assignment (immediately by electronic/expeditious means for expedited matters); if the plan fails to timely provide documents the IRO may terminate the external review and may decide to reverse the adverse determination.
Billing, Codes, and Key Numeric Limits
Acquired Brain Injury service categoriesmixedCovered
Cognitive rehabilitation therapy
Cognitive communication therapy
Neurocognitive therapy and rehabilitation
Neurobehavioral, neuropsychological, neurophysiological and psychophysiological testing and treatment
Neurofeedback therapy
Remediation required for and related to treatment of an acquired brain injury
Post-acute transition services and community reintegration services, including outpatient day treatment services and other post-acute treatment services
Miscellaneous coding notemixed
Placeholder entry: no specific code provided in this section of the source document.
DME and related itemsmixed
Rental (or at insurer option, purchase) of durable medical equipment prescribed by a provider; rental costs must not exceed purchase price; examples include hemodialysis equipment, crutches and replacement pads/tips, pressure machines, glucometer, tracheotomy tube, cardiac/neonatal/sleep apnea monitors, augmentative communication devices (when approved), rental of standard hospital bed, standard walker, standard non-motorized wheelchair, wheelchair cushion, ventilator, one Continuous Passive Motion (CPM) machine following covered joint surgery, and medically necessary foot orthotics.
Imaging and diagnostic servicesmixedCovered
Mammography screenings, diagnostic mammograms, digital breast tomosynthesis, MRI, ultrasound examinations, pathology evaluations
X-rays, MRI, CT scan, PET scan, ultrasound imaging and other diagnostic radiology services; technical and professional components may be billed separately; prior authorization may be required per Schedule of Benefits.
Drug benefit coding notemixed
Prescription drug benefit covers prescribed drugs dispensed by a licensed pharmacy; includes self-administered human growth hormones in specified cases and prescribed oral anti-cancer medications, which shall be covered no less favorably than IV/injectable cancer medications. Member payment for covered insulin will not exceed applicable state or federal mandated limits; exception/coverage determination processes available (standard 72-hour response).
Imaging prior authorization notemixed
Medically necessary radiology, imaging and diagnostic tests are covered; prior authorization may be required depending on the service and per the member's Schedule of Benefits. Note that technical and professional components may be billed separately.
Transplant-related servicesmixedCovered
Pre-transplant evaluation
Pre-transplant harvesting of the organ from the donor
Left Ventricular Assist Device (LVAD) when used as a bridge to heart transplant
Outpatient services related to transplant surgery, pre-transplant laboratory testing and treatment (e.g., high-dose chemotherapy, peripheral stem cell collection, immunosuppressive therapy)
Pre-transplant stabilization (inpatient stay to medically stabilize a member)
The transplant procedure itself, including acquisition cost for organ or bone marrow when authorized through Center of Excellence and performed at a participating facility
Post-transplant follow-up visits and treatments
Donor search and acceptability testing of potential live donors; donor and recipient cost-share rules as specified; ancillary travel/lodging reimbursement when travel >60 miles with maximum per transplant (see policy)
Billing/coding absencemixed
No specific billing or procedure codes provided in the General Non-Covered Services and Exclusions section; the section lists excluded services rather than CPT/HCPCS code sets.
Clean claim exclusionsmixed
Duplicate claims filed within 30 days, claims submitted fraudulently or based on material misrepresentations, claims requiring essential information for preexisting condition/COB/subrogation, and provider-submitted claims more than 30 calendar days after date of service are not considered clean claims; timelines for clean claims processing specified (electronic: 25 days; paper: 35 days; resubmitted complete claims: 20 days).
Appeal response coding disclosuremixed
Written appeal responses must include diagnosis and procedure codes with corresponding meanings or an explanation that such codes are available upon request; claimant entitled to copies of documents and records relevant to claim upon request.
Topics eligible for external reviewmixed
External review available for adverse determinations involving medical judgment (medical necessity, appropriateness, setting, level of care, effectiveness), determinations that a treatment is experimental or investigational, determinations of whether surprise billing protections apply and related member cost-sharing, and rescissions of coverage.
Insulin cost cap — member out-of-pocket cap
Insulin out-of-pocket capTotal amount a member will be required to pay for a covered insulin drug will not exceed any applicable state and/or federal mandated limits.
Reference sectionDiabetic Care Expense Benefits — insulin cost cap described.
ApplicabilityApplies to covered insulin drugs under the prescription drug benefit and described limits in the Schedule of Benefits/formulary.
rental vs purchase threshold — rental vs purchase
Prior Authorization, Provider Responsibilities, and Appeals
Prior Authorization
Prior Authorization — Overview and Where to Find Requirements
Some medical and behavioral health services require prior authorization. Prior authorization (also called authorization or approval) is our decision that a requested service, item, or course of treatment is medically necessary and appropriate for the member. Authorizations are not a guarantee of payment. Refer to your Schedule of Benefits for the complete list of services that require prior authorization and any applicable limits.
Prior authorization is required for certain non-emergency services rendered outside the service area, as noted in the provider directory and Schedule of Benefits.
Non-network services may require prior authorization when network care is not reasonably available; prior authorization for non-network care is granted to avoid additional member cost where network providers are unavailable.
Prior Authorization
Defined Terms and Glossary
Definitions (see Definitions section)
Definitions section referenceTerms used in this contract have special meanings and are defined in the Definitions section; refer to Definitions for authoritative meanings of italicized terms.
PurposeDefinitions provide contract-specific meanings for terms used throughout the Evidence of Coverage and are binding for interpretation of benefits and procedures.
LocationSee the Definitions section of the contract (early in the document) for the full list of defined terms.
Member notification of enrollment changes
Member obligation to notify life eventsMembers must notify Ambetter Health or the enrolling entity of enrollment-related changes that affect the contract (birth, adoption, marriage, divorce, adding/removing dependents, address changes, incarceration).
Decision Timelines and Appeal Processes
Policy Summary
PayerCentene
PolicyAmbetter Health Solutions Evidence of Coverage (Individual Member Contract)
Policy CodePolicy N/A
Change TypeNo material changes
Effective Date2026
Next Review DateN/A
Key ActionObtain prior authorization for services that the Schedule of Benefits or Prior Authorization section requires to avoid reduced benefits.
For home health related DME: rental of medically necessary DME at plan discretion is covered; plan may authorize purchase if purchase is projected to be cheaper than rental (purchase must be authorized before purchase).
Home health services covered when physician indicates patient cannot travel; includes skilled nursing, therapy professional fees, necessary supplies, hemodialysis, rental of DME at plan discretion, and IV medications; purchase of equipment may be authorized if cheaper than rental.
Hospice services include room and board, therapies, rental of equipment while in hospice, palliative/supportive care, counseling and bereavement services; hospice inpatient/home/outpatient care is subject to prior authorization.
Operational notes: prior authorization requirements apply for many services (DME, ABA, clinical trials, hospice, LTACH, certain imaging and transplants); authorizations must be obtained via the channels described in the Prior Authorization section and do not guarantee payment.
Pharmacy programs: split-fill for certain new therapies limits initial supply to 15 days for the first 90 days (members pay pro rata cost share); lock-in program may restrict members to a single network pharmacy; standard and expedited exception processes available (72 hours standard; 24 hours expedited); medication balance-on-hand rule prohibits refills until ≤15 days supply on hand.
Formulary rules, supply limits (generally 30-day retail; maintenance up to 90-day mail order; specialty limited to 30 days) and exclusions apply as described in the Prescription Drug section.
If donor has other coverage, donor should use that coverage (recipient policy is secondary to donor's own coverage when applicable).
Assignment: members may assign benefits to licensed providers for one year from assignment date; otherwise assignments are not recognized except as specified.
Coordination of benefits/order of benefit determination rules apply when member covered by multiple plans; primary plan pays first and secondary plan may reduce payments so total does not exceed allowable expense; specific rules for children of separated/divorced parents are detailed.
Members and their representatives must cooperate with insurer requests for authorizations, records, and information; failure to cooperate may lead to claim closure or denial until information is provided.
Decision timing: IRO must issue decision within 45 calendar days for standard external review (72 hours for expedited); if the IRO reverses the adverse determination, the plan must approve the covered service and provide notice.
Rental vs. purchase ruleThe plan will not pay rental for a longer period than it would cost to purchase the durable medical equipment; purchase may be authorized in lieu of rental if projected rental price exceeds purchase price.
Plan discretionRental (or at plan's option, purchase) is determined by the plan and must be from an authorized/provider approved source when purchase is authorized.
Delivery/installationDelivery and installation costs are covered when equipment is provided per DME rules.
Mechanical ventilation LTACH criterionPatient has received mechanical ventilation for 21 consecutive days for 6 hours or more per day — criterion for LTACH level-of-care consideration.
Additional ventilator requirementsVentilator management required at least every 4 hours; patient should exhibit weaning potential and be hemodynamically stable (no vasopressor dependence) with specified PEEP/FiO2/SpO2 thresholds.
ContextListed under Long Term Acute Care (LTACH) coverage criteria for medically necessary extended acute care.
Insulin cost cap — applicability (restatement)
Insulin out-of-pocket cap (restatement)The total amount you will be required to pay for a covered insulin drug will not exceed any state and/or federal mandated limits.
Where describedDefined in the Insulin subsection of Diabetic Care Expense Benefits and subject to applicable law.
ScopeApplies to covered insulin drugs under the prescription drug benefit; refer to Schedule of Benefits for cost-share details.
medication supply thresholds — refill and supply limits
Balance-on-hand refill prohibitionMedication refills are prohibited until a member's cumulative balance-on-hand is equal to or fewer than 15 calendar days' supply.
Retail supply limitStandard retail/short-term fills generally limited to a 30-day supply unless otherwise specified for specialty medications.
Mail-order/maintenance supplyMaintenance drugs may be dispensed up to a 90-day supply via mail order or participating extended-day supply pharmacies.
Maximum ancillary reimbursement per transplant
Maximum ancillary reimbursement per transplantThe plan will pay up to a maximum of $10,000 per transplant service for authorized transportation, lodging and related ancillary costs when using a Center of Excellence.
Documentation requirementReimbursement requires paid receipts and compliance with member transplant reimbursement guidelines; claims must be submitted per guidelines (within 6 months as noted in travel guidelines).
Applies whenMember obtains a medically necessary transplant at a designated Center of Excellence and travel distance qualifies.
Travel distance threshold for ancillary benefits
Travel distance threshold for ancillary benefitsAncillary travel and lodging benefits are payable when the member is required to travel more than 60 miles from residence to a designated Center of Excellence.
Center of Excellence definitionA Center of Excellence is a hospital that specializes in specific transplant types and meets agreed quality and cost-efficiency criteria.
Interaction with ancillary capMembers meeting the >60-mile threshold may be eligible for reimbursement up to the ancillary maximum per transplant service (see transplant reimbursement rules).
Note(No label provided in source) Placeholder entry retained for miscellaneous coding/value note.
Clean claim processing timelines
Electronic clean claim processingElectronic clean claims will be paid within 25 calendar days after receipt of a clean electronic claim.
Paper clean claim processingPaper clean claims will be paid within 35 calendar days after receipt of a clean paper claim.
Resubmitted complete claimsA claim resubmitted with previously identified deficiencies corrected (a clean resubmission) will be processed within 20 calendar days after receipt.
External notification timeframe — plan contact and external review initiation
External notification timeframeIf the plan is contacted by a member regarding a potential external review trigger, the plan must be notified and preliminary review procedures commence; claimant may perfect an external review request and the plan must respond per external review process timelines — notify within one business day after preliminary review whether request is complete; generally the plan must provide documents to IRO within five business days of assignment.
30-calendar-day referenceThe policy notes timeframes for notices to regulators and parties in other sections; members should follow external review and grievance filing deadlines (4 months to request external review after internal response).
How to notifyExternal review requests originate via the State Insurance Department after exhaustion of internal appeals unless expedited; claimant may request expedited external review concurrently with internal expedited appeal.
Standard grievance and appeal timeframes
Standard grievance resolution timeframeStandard (pre-service) grievance and appeals are resolved within 30 calendar days; standard post-service appeals are resolved within 60 calendar days.
Acknowledgement periodAcknowledgement of receipt for standard grievances/appeals is 5 calendar days.
Expedited appealsExpedited appeals are resolved as expeditiously as the claimant's health requires but no more than 72 hours after receipt.
How to Obtain Prior Authorization and Submission Requirements
Prior authorization requests (medical and behavioral health) must be submitted by telephone, fax, or via the provider portal as specified by the plan. Specific submission timing requirements include: at least 30 calendar days prior to an initial organ transplant evaluation or clinical trial services; within 24 hours of any inpatient admission (including emergent admissions); at least five calendar days prior to the start of home health care except post-hospital discharge; and other timeframes shown in the Schedule of Benefits. After receipt, we will notify the provider and member of our decision per applicable law.
To confirm whether a network provider has already obtained authorization, contact Member Services using the phone number on the member ID card.
Failure to obtain required prior authorization may result in reduced benefits; network providers may not bill members for services when the provider failed to obtain required prior authorization.
Emergency services are not subject to prior authorization, but you must contact us as soon as reasonably possible after the emergency to report the services.
Prior Authorization
Autism / ABA Prior Authorization
Applied Behavior Analysis (ABA) services for Autism Spectrum Disorder are covered when prescribed by a physician or behavioral health practitioner. ABA services (including evaluation, assessment, therapy, and behavior management) are subject to prior authorization to establish medical necessity. There is no per‑se numeric limitation for ABA in the benefit language, but services must be prior authorized and medically necessary.
If multiple providers deliver services on the same day, separate cost sharing may apply to each provider.
Providers should submit clinical documentation supporting medical necessity with the prior authorization request for ABA/ABA‑related services.
Prior Authorization
Home Health, Fertility Preservation, Sleep Studies, and Home Equipment
Home health services, fertility preservation services related to iatrogenic infertility, certain sleep studies, and some home equipment may require prior authorization. Home health care is covered when the physician indicates the member cannot travel to appointments; authorization timing rules (e.g., at least five calendar days prior to start except post‑hospital discharge) apply.
Home health: authorization may be required except when initiated immediately after hospital discharge; rental or purchase of DME for home use may require prior authorization.
Fertility preservation when medically necessary for potential iatrogenic infertility requires prior authorization.
Sleep studies may require prior authorization and can be performed at home or in a facility.
Note
Prior Authorization, Exception Requests, and External Review
Exception and authorization decision processes for medical services and drugs are available when a requested service, device, or drug is non‑formulary, subject to step therapy, or otherwise denied. Members, authorized representatives, or prescribing providers may request standard or expedited exceptions for drugs and may seek internal appeals and external review if exceptions or authorizations are denied.
Standard exception requests for non‑formulary drugs or step‑therapy protocol exceptions: decision provided within 72 hours of receipt.
Expedited exception requests for exigent circumstances: decision provided within 24 hours of receipt.
If an exception or authorization is denied, the member or their authorized representative may pursue the internal appeal process and, if eligible or after exhaustion, request external review by the State Insurance Department and assignment to an Independent Review Organization (IRO).
Note
Authorization Decision Timelines
Authorization decision timelines depend on review type. Urgent pre‑service reviews: within 48 hours of receipt. Non‑urgent pre‑service reviews: within 7 calendar days of receipt. Urgent concurrent reviews: within 48 hours from receipt of all information necessary (no more than 72 hours total); other concurrent timings as specified. Post‑service or retrospective reviews: within 30 calendar days of receipt.
If additional information is needed, statutory timeframes may be extended in accordance with applicable law.
For transplant and some other services specific advance timing requirements apply (e.g., ≥30 calendar days prior to initial transplant evaluation).
Prior Authorization
Non‑Network Provider Prior Authorization
If covered services cannot be obtained from a network provider within a reasonable distance, prior authorization may be provided to obtain services from a non‑network provider at no greater cost to the member than network care. When prior authorization for non‑network care is required, the member or PCP must request authorization before receiving services; otherwise the member may be responsible for charges incurred.
When prior authorization is granted for non‑network care due to network inadequacy, reimbursement and member cost share will be no greater than if services were obtained from a network provider.
Providers and members should contact Member Services for prior authorization and any travel reimbursement eligibility.
Documentation Required
Coordination and Timely Filing
Coordination of benefits and timely filing: when a member has multiple coverages, providers and members must submit claims to the appropriate primary and secondary plans within each plan's timely claim filing limits. Failure to submit to a secondary plan within that plan's filing limit may result in denial. Always report changes in coverage promptly to avoid processing delays.
If you have paid for covered services and the plan agreed to reimburse, submit the member reimbursement claim form available at AmbetterHealth.com along with documentation.
Providers typically submit claims on the member's behalf; when providers are non‑contracted, members may need to submit claims themselves.
Newborn/adoption interplay
Notification of newborns and adopted children within specified windows (31/60/90 days depending on provision) affects coverage and premium application; see Newborn/Adopted Child coverage rules for details.
How to notifyContact Member Services using the number or channels provided on the member identification card or as set out in the contract to report enrollment changes.
Provider Directory — access and availability
Provider directory accessA listing of network providers is available online at AmbetterHealth.com via the 'Find a Doctor' tool; printed copies are available on request at no charge.
Search capabilitiesOnline directory search can be filtered by specialty, zip code, gender, languages spoken, and accepting new patients status; directory entries show name, address, phone, office hours, specialty and board certifications.
Member assistanceMembers may call Member Services to request a printed directory or assistance in selecting a PCP or scheduling appointments.
Member Identification Card — issuance and presentation
Issuance timingMember identification cards are mailed after Ambetter receives completed enrollment materials and the initial premium payment.
Required presentationMembers must present their member identification card at each service; the card shows name, member ID, and copayment amounts required at time of service.
ReplacementIf a member does not receive a card within a few weeks of enrollment, they should call Member Services to request a replacement card.
Balance billing protections — No Surprises Act and non-network billing
No Surprises / balance-billing protectionsUnder federal law (No Surprises Act), non-network providers are prohibited from balance billing members for services subject to balance billing protections; members are responsible only for network-level cost sharing based on the recognized amount.
Notice & consent restrictionsNotice and consent procedures (written notice and signed consent provided at least 72 hours prior or 3 hours for near-term services) are required to waive balance billing protections in limited non-emergency circumstances; notice and consent does not apply to emergency/ancillary/no-network-availability services in most cases.
Directory error remediationIf non-network services were received due to inaccurate Provider Directory information, and services are covered, the member will pay network cost sharing and will not be balance billed.
Contract Definitions (selected)
Adverse benefit determinationAn adverse benefit determination is our decision that denies, reduces, or fails to provide payment or coverage, or finds a service not medically necessary, investigational, or not covered (see Definitions).
Authorization (prior authorization)Authorization means our decision to approve the medical necessity or appropriateness of care; authorizations are not guarantees of payment.
Appeal/External reviewAppeal means a grievance requesting reconsideration of an adverse benefit determination; external review is available for medical-judgment issues, surprise-billing determinations, and rescissions as defined.
Allowed/Eligible expenseAllowed or eligible expense definitions describe how network and non-network eligible expenses are determined for payment purposes.
Hospice — definition and certification
Hospice definitionHospice services are provided to terminally ill members in a hospice inpatient program or at home as certified by a network physician.
Respite careRespite care is covered on an inpatient or home basis to provide temporary relief to family caregivers; respite days applied toward deductible and benefit limits as described in Schedule of Benefits.
Prior authorizationHospice inpatient, home and outpatient care are subject to prior authorization per the contract.
Hospital — definition and minimum capabilities
Hospital definitionA hospital operates pursuant to law, provides inpatient care with 24-hour nursing, staff availability, organized diagnostic and treatment facilities, and is not primarily a long-term care facility.
Minimum capabilitiesHospitals must have organized diagnostic/treatment facilities, staff of providers available at all times, and must provide acute medical/surgical/mental condition treatment; exclusions apply for facilities primarily providing custodial or long-term care.
Service contextsHospital services include inpatient, emergency, surgical, radiology, lab, and related hospital charges subject to medical necessity and prior authorization where required.
Medically necessary — definition overview
Medically necessary definitionMedically necessary means consistent with symptoms/diagnosis, provided according to accepted medical practice, not custodial, not solely for convenience, not experimental/investigational, and provided in the most cost-effective setting; for hospital confinement it means care cannot be safely provided outpatient.
ConsequencesCharges for treatment not medically necessary are not eligible expenses under the contract.
ApplicationMedically necessary standard is applied to coverage determinations, prior authorization, and appeals.
Network — definition and cost-sharing impact
Network definitionNetwork is the group of contracted providers and facilities who have agreed to provide services to members for agreed fees; members receive most services through the network and network eligible expense is the contracted fee.
Impact on cost-sharingWhen balance billing protections apply for non-network emergency or certain services, member cost sharing is calculated as if services were received from a network provider and based on the recognized/eligible amount as required by law.
Non-network exceptionsServices from non-network providers may be covered in specified circumstances (emergency, non-network at network facility, authorized non-network care) as defined in the contract.
Notice and consent — non-network notice timing and good-faith estimate
Notice and consent timingTo waive balance billing protections, a non-network provider must provide written notice at least 72 hours before services (or at least 3 hours for services scheduled within 72 hours) and obtain the member's written consent in the required format.
Good-faith estimate requirementNotice must include a good-faith estimate of non-network charges and disclosure that non-network care may not accrue toward deductible/OOP; member must sign voluntary consent acknowledging understanding and receipt of notice.
LimitationsNotice and consent does not apply to emergency services, air ambulance, services furnished due to unforeseen urgent needs, or when no network provider is available for ancillary services; post-stabilization consent has additional conditions.
Dependent member eligibility — timing and qualifiers
Dependent eligibility timingDependents become eligible on the later of the subscriber effective date or the qualifying event date (marriage, birth, adoption placement, foster placement, domestic partnership), per the Definitions section.
Newborn/adopted child automatic coverage periodNewborns and eligible adopted children are covered from birth or placement until the 31st calendar day after birth/placement without additional premium if timely notified.
Notification windows to avoid denialNotifying the plan within specified windows (31/60 days depending on provision) affects premium charges and prevents denial for failure to notify; additional premium payment deadlines (e.g., within 90 days for adoption) apply to continue coverage beyond 31 days.
Newborn and adopted child coverage — automatic coverage and notification windows
Automatic newborn/adopted child coverage periodAn eligible newborn or adopted child is covered from birth or placement until the 31st calendar day after birth/placement.
Avoiding denial — notification windowsIf notice is given within 60 calendar days of birth or placement, the plan will not deny coverage due to failure to notify; additional premium rules apply for continuation beyond 31 days.
Premium deadline for adoption continuationFor an adopted child, additional premium required to continue coverage beyond 31 days must be received within 90 calendar days of placement per the adoption provision.
Skilled nursing facility (SNF) — definition and certification
SNF definitionA skilled nursing facility is one that meets regulatory certification requirements and provides inpatient skilled nursing and related services requiring daily skilled nursing or rehabilitation staff involvement; it is distinct from hospital-level care.
Examples of SNF careExamples include IV injections and physical therapy provided as inpatient skilled services.
Certification requirementFacilities must meet specific regulatory certification criteria to qualify as SNFs under the contract.
Cost sharing definitionCost sharing means the member's participation through deductibles, copayments, and coinsurance as listed in the Schedule of Benefits.
Deductible definitionDeductible is the amount of covered service expenses a member must pay before benefits are payable; copayments and coinsurance are not included in the deductible.
Maximum out-of-pocketMaximum out-of-pocket is the total of copays, coinsurance, and deductibles a member must pay; family OOP equals two times the individual OOP.
Coinsurance amount — definition and treatment
Coinsurance amount treatmentCoinsurance is the member's share of the cost of a service; coinsurance does not apply toward the deductible but does count toward the maximum out-of-pocket amount.
Post-OOPAfter the annual maximum out-of-pocket is met for an individual, the plan will pay 100% of covered service expenses.
Schedule of BenefitsSpecific coinsurance percentages and applicability are listed in the member's Schedule of Benefits.
Coinsurance — alternate entry
Coinsurance definition (alternate)Coinsurance is the member's share of the cost of a service expressed as a percentage and counts toward the maximum out-of-pocket but not toward the deductible.
ApplicationCoinsurance amounts apply per service as listed in the Schedule of Benefits.
Impact when OOP metWhen OOP is met, coinsurance no longer applies and plan pays 100% of covered services.
Deductible — definition and counting rules
Deductible definitionThe deductible amount is the covered expenses members must pay in a calendar year before benefits are payable; copayments and coinsurance are not included in the deductible.
Family deductibleFor family coverage, there is a family deductible equal to two times the individual deductible; individual and family satisfaction rules described in Definitions.
Schedule referenceSee the Schedule of Benefits for deductible amounts and exceptions for specific services.
Copayment — definition and OOP treatment
Copayment definitionA copayment is a fixed dollar amount due at the time of service; copayments do not count toward the deductible but do apply toward the maximum out-of-pocket.
TimingCopayments are due at the time services are performed as shown in the Schedule of Benefits.
Non-covered servicesPayment of a copayment does not preclude potential billing for non-covered services by the provider.
Maximum Out-of-Pocket — definition and family relationship
Maximum Out-of-Pocket (OOP)Maximum out-of-pocket is the total amount a member must pay in copayments, coinsurance and deductibles until the OOP is reached; after that, plan pays 100% of covered services.
Family OOP relationshipFamily maximum out-of-pocket equals two times the individual maximum out-of-pocket amount.
ApplicationRefer to the Schedule of Benefits for numeric OOP amounts and service-specific limits.
Durable medical equipment — definition
DME definitionDurable medical equipment (DME) are items that can withstand repeated use, are primarily for medical purposes, not useful absent illness/injury, and appropriate for home use.
Rental vs purchase ruleRental costs must not exceed purchase price; the plan will not pay rental longer than it would cost to purchase the equipment.
Prior authorizationDME may require prior authorization per the contract.
Emergency condition (ambulance) — definition
Emergency condition (ambulance)An emergency condition is a situation with acute symptoms of sufficient severity that a prudent layperson would reasonably expect absence of immediate attention to jeopardize health, bodily functions, or organs; in such cases air ambulance prior authorization is not required to nearest appropriate hospital.
Ambulance contextAir and ground ambulance emergency transport covered without prior authorization to the nearest appropriate facility.
Balance billing noteMembers should not be balance billed for air ambulance emergency services beyond cost share where protections apply.
Durable medical equipment (DME) — duplicate entry
Durable medical equipment (duplicate)DME defined as equipment that can withstand repeated use, used for medical purpose, not useful absent illness/injury, appropriate for home use; rental/purchase rules apply.
Repair/maintenanceRepair of DME is a covered service when medically necessary; related supplies covered in rental or when equipment owned by member.
ExamplesExamples include standard hospital beds, walkers, wheelchairs, ventilators, CPM machine rental after joint surgery, glucometers, cardiac monitors, augmentative communication devices when approved.
Home health care — definition and medical necessity
Home health care definitionHome health care is medically necessary network care provided at the member's home when the physician indicates the member cannot travel to medical appointments; includes skilled nursing, therapy services, necessary supplies, and rental of DME at plan discretion.
Prior authorization and limitsSleep studies and certain home equipment may require authorization; purchases in lieu of rental may be authorized if rental cost projected to exceed purchase price and authorized provider approves.
Service componentsCovered components include home health aide (with skilled nursing), skilled nursing services, professional therapy fees, hemodialysis, IV medications as described.
LTACH — definition and scope
LTACH definitionLong-term acute care hospitals (LTACHs) provide extended medical and rehabilitative care to individuals with clinically complex problems requiring hospital-level care for extended periods.
ScopeLTACH services include care for complex wound management, infectious disease requiring parenteral therapy, medical complexity with multiple comorbidities, rehabilitation needs not met in SNF/rehab, and prolonged mechanical ventilation per specified criteria.
Prior authorizationLTACH benefits are subject to prior authorization requirements per the contract.
Respite care (hospice) — definition and counting
Respite care (hospice)Respite care provides temporary relief to family caregivers for a terminally ill member; available inpatient or at home and counts toward hospice benefit limits and applicable deductible/benefit calculations.
ApplicationRespite days applied toward the member's deductible amount are considered benefits provided and shall apply against any maximum benefit limit for these services.
CertificationHospice services and respite require certification by a network physician as described in hospice provisions.
Low-protein food products — definition
Low-protein food products definitionLow-protein food products are specially formulated foods intended for dietary treatment of inherited metabolic diseases and are defined by protein content per serving; they exclude natural foods that are naturally low in protein.
Use caseCovered when prescribed under direction of a physician for specified inherited metabolic diseases (PKU, MSUD, MMA, IVA, propionic acidemia, glutaric acidemia, urea cycle defects, tyrosinemia).
LimitationsBenefits are limited to the listed inherited metabolic diseases and subject to contract limits.
Self-injectable drugs — definition and administration
Self-injectable drugs definitionSelf-injectable drugs are medications delivered into muscle or subcutaneously that patients or caregivers can administer after initial instruction; they are covered under the prescription drug benefit and subject to prescription cost-share.
Exception/coverage processCoverage and cost share follow the prescription drug benefit and formulary/exception processes (standard/expedited exception requests available).
Related timelinesStandard exception determinations for non-formulary drugs are provided within 72 hours; expedited exceptions within 24 hours.
Standard and expedited exception — definitions and timelines
Standard exception definitionA standard exception is a request by a member/authorized representative/provider to cover a non-formulary drug or request a protocol (step-therapy) exception; determinations provided within 72 hours of receipt.
Expedited exception definitionAn expedited exception may be requested for exigent circumstances that may seriously jeopardize life, health, or ability to regain maximum function or when member is currently on a non-formulary drug; determinations within 24 hours.
External exception reviewIf denied, the member may request external review by an independent review organization with 72-hour (standard) or 24-hour (expedited) decision timelines; if reversed coverage provided for duration specified.
Balance-On-Hand definitionBalance-On-Hand is the member's cumulative on-hand supply used to determine refill eligibility; refills are prohibited until the member has equal to or fewer than 15 calendar days' supply on hand.
Operational effectThis provision operates in addition to any applicable medication quantity limits or refill guidelines (e.g., 30/90-day supply rules).
ApplicabilityApplies to medications under the prescription drug benefit; refer to formulary and Schedule of Benefits for additional supply limits and exceptions.
Pre-transplant stabilization and Center of Excellence — definitions and ancillary summary
Pre-transplant stabilization definitionPre-transplant stabilization is an inpatient stay to medically stabilize a member to prepare for a later transplant, whether or not the transplant occurs.
Center of Excellence definitionA Center of Excellence is a hospital designated to provide certain transplant services and ancillary benefits and that meets agreed quality and cost-efficiency criteria.
Ancillary benefits summaryWhen transplant is performed at a Center of Excellence and member travels >60 miles, ancillary travel and lodging benefits may be provided (subject to maximum reimbursement rules).
Subrogation — definition and right of reimbursement
Subrogation definitionSubrogation and right of reimbursement means the plan may seek repayment from third-party recoveries for benefits paid on behalf of a member and may place a lien or intervene in recovery actions.
Member cooperationMembers must cooperate in preservation of subrogation rights, provide information, and not settle claims without providing notice to the plan (at least 30 days prior to settlement as specified).
Offset consequencesThe plan may delay processing future claims or offset future benefits until reimbursement rights are satisfied; written reimbursement agreements may be required.
Cooperation Provision — member obligations
Cooperation provisionMembers or persons acting on their behalf must cooperate fully with the plan by signing authorizations, providing records, answering questions under oath, and furnishing other requested assistance to protect the plan's rights.
Consequences of non-cooperationFailure to provide requested information or take requested actions may result in claim closure or denial until such information or action is provided.
ScopeCooperation obligations apply to subrogation, claims investigation, and other administrative processes as described in the contract.
Allowable Expense — definition
Allowable Expense definitionAllowable Expense is a health care expense covered by any plan (including deductibles, coinsurance, copayments) and excludes expenses not covered by any plan.
Examples of non-allowable expensesExamples include the difference between semi-private and private room costs unless covered, and amounts in excess of the highest usual-and-customary or negotiated fee across plans.
Coordination effectWhen multiple plans apply, allowable expense determines how benefits are coordinated to avoid payments exceeding 100% of allowable expense.
Closed Panel Plan — definition
Closed Panel Plan definitionA Closed Panel Plan provides benefits through a panel of providers primarily employed by the plan and excludes coverage for services provided by other providers except in emergencies or by referral from a panel member.
ImplicationMembers generally must use panel providers to receive benefits except as specified for emergencies or authorized referrals.
ExceptionsEmergency services and specific referral-authorized services may be provided outside the closed panel per contract rules.
Custodial Parent — definition
Custodial Parent definitionCustodial Parent is the parent awarded custody by court decree or, absent decree, the parent with whom the child resides more than half the calendar year (excluding temporary visitation).
Use in COBCustodial parent status figures into order of benefit determination and coordination rules when children are covered by multiple plans.
DocumentationChanges in custodial status should be reported to Member Services to ensure correct coordination of benefits handling.
Primary and Secondary plan — definitions and interaction
Primary plan definitionPrimary plan is the plan that pays benefits first without regard to other plans when a person is covered by more than one plan; order of benefit determination rules establish which plan is primary.
Secondary plan definitionSecondary plan determines benefits after the primary plan and may reduce benefits so total payments do not exceed allowable expense; it must credit deductible amounts as though it were primary.
Medicare interactionMedicare primary/secondary payer guidelines govern status when a member is Medicare-eligible; when Medicare is primary, this plan pays secondary up to the Medicare allowable amount but not more than it would have paid as primary.
Appeal/Grievance and External Review — definitions and scope
Appeal/Grievance definitionAn appeal (grievance) is a request to reconsider, reverse, or modify an adverse benefit determination; claimants may file in writing or by phone and submit supporting documents.
Expedited appeal/external reviewExpedited processes exist for cases where standard timeframes would jeopardize life/health/function; expedited appeal resolved within 72 hours and expedited external review within 72 hours per timelines.