Centene Ambetter Evidence of Coverage Prior Auth

Coverage Criteria and Benefit Rules

General coverage framework

The contract, Schedule of Benefits, and enrollment application together govern covered services, subject to definitions, provisions, limitations, and exclusions.

This Evidence of Coverage, together with the Schedule of Benefits and your enrollment application, constitutes the contract governing benefits and covered services.

Coverage of services is subject to the contract's defined terms, provisions, limitations, exclusions, and any applicable laws or regulations.

Authorizations, cost sharing, benefit levels, and applicable prior authorization requirements are as specified in the Schedule of Benefits and the relevant provisions of the contract.

Network provider access and balance billing protection

Network provider requirement and protections when directory information is inaccurate.

A Provider Directory of contracted network providers is available online and on request; members may designate a network primary care physician (PCP).

Member Services will respond to inquiries about a provider's network status within one business day.

If a member receives services from a non-network provider because of inaccurate Provider Directory information or following a network-status inquiry, and the services are otherwise covered, the member's cost sharing will be applied at network levels and the member should not be balance billed; contact Member Services immediately if balance billed.

Network vs. Non-network services and balance billing

Guidance on provider network status, member protections and how eligible expense and cost sharing are determined.

Network providers: allowed amount equals the contracted fee and member cost sharing is measured per the Schedule of Benefits.

Non-network providers: eligible expense and allowed amount are determined per the contract; when federal/state balance-billing protections apply, member cost share is calculated as if services were rendered by a network provider and the member is protected from balance billing.

When balance-billing protections apply (federal No Surprises Act effective Jan 1, 2022), non-network providers/facilities are prohibited from balance billing for protected services; member pays cost share based on the recognized amount under law.

Emergency services are covered without prior authorization; the member (or provider) must notify the plan within 48 hours (or as soon as reasonably possible) after an inpatient admission resulting from an emergency to avoid potential financial responsibility for care determined not medically necessary.

Dependent and new dependent coverage rules

Rules governing when dependent members become eligible and the automatic coverage periods for newborns and adopted children.

Dependent members become eligible on specified events: subscriber effective date, marriage to add a spouse, birth of an eligible newborn, date an adopted child is placed for adoption, foster child placement, or establishment of a domestic partnership.

A newly eligible dependent must be enrolled as required by the enrollment provisions and Schedule of Benefits to continue coverage beyond initial automatic periods.

Newborn and Adopted Dependent Coverage

Dependent newborns and adopted children coverage rules

Newborns: an eligible child born to you or a covered family member is covered from the time of birth until the 31st calendar day after birth; each newborn's services are subject to the Schedule of Benefits cost sharing. Additional premium is required to continue coverage beyond 31 days and the required premium is calculated from the child's date of birth.

Adopted children: an eligible child legally placed for adoption is covered from the date of placement until the 31st calendar day after placement; the child is covered for injury or illness including conditions existing prior to placement. Additional premium is required to continue coverage beyond 31 days and must be received within 90 calendar days of placement to continue coverage; 'placement' is the earlier of physical custody or entry of an order granting custody for adoption.

Enrollment Periods and Qualifying Events

Enrollment periods and qualifying events

Open enrollment occurs annually (specified period in Schedule of Benefits); enrollments on or before the stated cutoff have the listed effective date.

Special and limited enrollment periods: generally a qualified individual has 60 calendar days to report a qualifying event to request special enrollment; loss of Medicaid/CHIP may extend this to 90 days.

Qualifying events include

Loss of minimum essential coverage or non-calendar year group/individual coverage.
Gaining or becoming a dependent through marriage, birth, adoption, placement for adoption, foster care, or court order.
Unintentional enrollment errors by HHS agents, permanent move gaining access to new plans, domestic abuse/spousal abandonment, changes in APTC/CSR eligibility, or other events listed in the contract.

Premiums, Grace Periods, Third-Party Payments, and Misstatements

Premium payment, grace, acceptable payors, and misstatement handling

Premiums are due on or before the due date; initial premium must be paid prior to coverage effective date; Ambetter may apply earned rewards to unpaid premiums as allowed.

Grace period: when not receiving a premium subsidy, there is a 60-calendar-day grace period during which the contract remains in force but claims may pend and providers will be notified of possible denials.

Third-party premium payors are restricted per CMS guidance; acceptable payors include specified public programs, tribal organizations, certain tax-exempt organizations, family members, certain employer HRA arrangements, and qualifying private foundations; unacceptable third-party payments will be rejected and the premium remains due.

Misstatements: premium adjustments may be made for misstated age or tobacco/nicotine use; members must notify changes of residence within 60 days which may affect premium and trigger special enrollment eligibility.

Cost Sharing and Out-of-Pocket Limits

Application of copays, coinsurance, deductibles and OOP limits.

Cost sharing consists of deductible, copayments, and coinsurance as specified in the Schedule of Benefits; each claim is adjudicated separately and coverage applies only to eligible expenses.

Deductible: amounts that must be paid by members before benefits are payable; copayments do not count toward the deductible; see Schedule of Benefits for amounts and service applicability.

Copayments: fixed-dollar amounts due at time of service; do not count toward the deductible but do count toward the maximum out-of-pocket; providers may bill for non-covered services.

Coinsurance: member's share of cost; applies toward the maximum out-of-pocket but not the deductible; plan pays 100% of allowed amounts after individual OOP met.

Maximum out-of-pocket: member pays applicable copayments, coinsurance, and deductibles until the individual OOP is met; family OOP equals two times the individual OOP; specific benefit limits and non-network reductions may apply.

Coverage stance and specific benefit notes

Covered services are subject to medical necessity, benefit limits, and prior authorization where specified. Essential health benefits are covered without lifetime or annual dollar maximums; certain non-essential benefits may have limits.

All covered services must be medically necessary, not experimental or investigational, and are subject to the contract's conditions, exclusions, and any applicable prior authorization requirements.

Essential health benefits (ambulatory, emergency, hospitalization, maternity/newborn, MH/SUD, prescription drugs, rehabilitative/habilitative services, lab, preventive, pediatric services including oral/vision) are included and are not subject to lifetime or annual dollar maximums under this contract.

Benefit implications include

Some services require prior authorization; failure to obtain required authorization may result in denial and potential balance billing for non-network providers.
Certain non-essential benefits may be subject to lifetime or annual limits as stated in the contract.

Ancillary & DME coverage criteria

Covered services, limits, and notable coverage positions extracted from the document portion:

Acupuncture: covered on outpatient basis when provided by a network provider; see Schedule of Benefits for limits.

Autism Spectrum Disorder: covers evaluation, ABA (no numeric limit stated), behavior management, habilitation, speech/OT/PT, psychiatric care and medications; ABA is subject to prior authorization for medical necessity; same-day services by multiple providers may carry separate cost sharing.

Ambulance (air, ground, water): emergency transport covered without prior authorization; non-emergency air/ground requires prior authorization; covered air ambulance services should not result in balance billing when covered.

Clinical trials: routine patient care costs for qualifying trials may be covered if trial meets approval criteria; investigational items and those solely for data collection are excluded; participation may require prior authorization.

Colorectal cancer screening: covered per USPSTF guidelines, beginning at age 45 for average-risk members or earlier for high-risk members.

Prosthetics coverage criteria

Prosthetics coverage and limitations:

Prosthetic devices: covered when medically necessary to replace missing body parts or function of permanently useless or malfunctioning parts; purchase preferred over rental; taxes, shipping and handling covered.

Examples of covered prosthetics include internal heart valves, pacemakers, vascular replacements, fracture fixation devices, intraocular lenses, custom breast prostheses post-mastectomy (plus four surgical bras per benefit period), artificial eyes/larynx, cochlear implants, and other prosthetic implants as medically necessary.

Left Ventricular Assist Devices (LVAD) are covered only when used as a bridge to a heart transplant.

Exclusions/limits

Certain items are excluded or limited (e.g., dentures, dental appliances, non-rigid appliances, wigs purchased out-of-network, penile prosthesis when not medically necessary).

Family planning coverage criteria

Family planning and contraception (preventive care, no cost sharing when network and legal):

Contraceptives: the full range of FDA-identified contraceptives for adolescent and adult women per HRSA guidelines is covered when provided by a network provider and when legal under applicable law (includes sterilization, implants, IUDs, injectables, oral contraceptives, patches, rings, diaphragms, sponges, caps, condoms, spermicides, emergency contraception, and additional FDA-approved methods).

Support services: contraceptive-related screening, education, provision, counseling, follow-up (including removal/continuation/discontinuation) and anesthesia integral to sterilization procedures are included under preventive care without member cost share when rendered by a network provider.

Fertility preservation criteria

Fertility preservation:

Medically necessary standard fertility preservation services and supplies are covered when cancer treatment may cause iatrogenic infertility; prior authorization may be required.

Assisted reproductive technologies such as artificial insemination, IVF, embryo transfer, GIFT, and ZIFT are excluded under the infertility services provision (see Infertility coverage).

Rehab/home health/hospice/LTACH/hospital criteria

Rehabilitation, home health, hospice, LTACH and hospital services:

Rehabilitation and habilitation: covered when medically necessary and provided by appropriate facilities or licensed practitioners; outpatient PT/OT/ST and other therapies covered; care ceases when maximum therapeutic benefit reached or no measurable progress; prior authorization may be required.

Home health: covered when physician indicates inability to travel, includes home health aide as part of skilled program, private duty RN outpatient (subject to limits), therapy fees, IV meds, hemodialysis at home, necessary supplies and rental/purchase of DME at plan discretion; home health subject to prior authorization; respite/custodial/educational care excluded.

Hospice: covered for terminally ill members under a hospice program (inpatient or home); includes respite care, room and board up to common semi-private rate, therapies, equipment rental, palliative care, counseling and bereavement; subject to prior authorization and limits.

LTACH: long-term acute care hospitals covered when medically necessary and authorized for clinically complex problems (complex wound care, infectious disease management, mechanical ventilator support with specified parameters, medical complexity, rehabilitation needs); prior authorization required.

Infertility coverage criteria

Infertility services:

Covered services limited to medically necessary diagnostic tests to determine infertility and treatment of underlying medical causes (e.g., endometriosis, obstructed tubes, hormone deficiency).

Excluded: artificial insemination, IVF, embryo transplant, GIFT, and ZIFT are not covered.

Lymphedema criteria

Lymphedema benefit rules:

Lymphedema treatment is covered when rendered or prescribed by a licensed physician or provided in an authorized facility; coverage includes multilayer compression bandaging systems and custom or standard-fit gradient compression garments.

Mammography criteria

Mammography coverage rules:

Mammography screening and related imaging aligned with USPSTF A/B guidelines and applicable laws are covered; includes preventive and diagnostic mammograms, digital breast tomosynthesis, MRI, ultrasound and pathology; coverage available regardless of age when prescribed by a licensed practitioner.

Maternity/newborn/surrogacy criteria

Maternity, newborn, and surrogacy coverage rules and minimum stays:

Maternity inpatient stay: minimum covered stay of 48 hours after a vaginal delivery and 96 hours after a cesarean delivery; no prior authorization required for stays up to these minima though notification requirements apply for inpatient admissions.

Newborn care: medically necessary services for a newborn are provided immediately after birth; each newborn incurs separate cost sharing per the Schedule of Benefits; see Dependent Member Coverage for newborn/adopted child timing.

Surrogacy: services or supplies related to a member acting as a surrogate are not covered; members acting as surrogates must notify the plan within 30 calendar days of enrollment or agreement or face potential recoupment and fraud remedies.

Coverage criteria

Additional covered services and limitations (medical/surgical, behavioral health, newborn care, vision, dental anesthesia, medical foods, prescription drugs):

Medical and surgical benefits: broad coverage for surgery, pre/post operative testing, diagnostic imaging, lab tests, genetic/molecular cancer testing, chemotherapy (including oral), radiation, DME, reconstructive surgery, and listed implants and grafts when medically necessary and consistent with contract terms.

Behavioral health and SUD: inpatient and outpatient services covered (inpatient psych, detox, crisis stabilization, residential treatment, PHP, IOP, MAT, ECT, TMS, ABA, telehealth); determinations use InterQual (mental health) and ASAM (SUD); prior authorization may apply except for emergent inpatient withdrawal or emergent inpatient treatment.

Pediatric routine vision: vision benefits for members under 19 provided through plan year they turn 19; specified frames/lenses/contact lenses covered with listed exclusions.

Dental anesthesia and oral surgery: anesthesia and hospital charges for dental care covered for members under certain ages or with disability/medical conditions; clinical indications per AAPD guidance and may require prior authorization.

Prescription drug coverage criteria and limits

Prescription drug coverage, exceptions process, exclusions, specialty limits, extended day supply, lock-in and split-fill rules:

Formulary: generics preferred; formulary governs tiering and covered strengths/forms; non-formulary drugs may be requested via exception processes (standard or expedited).

Oral anticancer medications and self-injectable drugs: covered under prescription drug benefit with parity to IV/injectable cancer medications provided as medical benefits.

Exclusions: erectile dysfunction drugs, weight-loss drugs, drugs administered at dispensing site, institution-dispensed inpatient meds, refills >12 months from order, investigational drugs, foreign meds except emergencies, cosmetic meds, infertility drugs unless on formulary, compounds without an FDA-approved ingredient, most vitamins unless on formulary.

Day-supply limits: specialty drugs limited to 30-day supply; maintenance drugs up to 90-day supply via mail/extended network pharmacies; 90-day fills subject to discounted cost share as applicable.

Preventive care coverage

Preventive care coverage as required by the ACA and related provisions.

Preventive services rated A or B by USPSTF, ACIP immunizations, HRSA pediatric and women's guidelines are covered without member cost share when obtained from a network provider.

New recommendations/guidelines from USPSTF, CDC or HRSA become covered effective on plan start or anniversary date one year after issuance, consistent with law; the Preventive Care Guide is updated annually.

Service-specific: annual DRE and PSA testing covered when performed by a medical practitioner regardless of member age as medically necessary.

Diagnostic testing and second opinion rules

Diagnostic testing and second opinion procedural rules.

Radiology/imaging/diagnostic tests that are medically necessary are covered; prior authorization may be required; technical and professional components may be billed separately.

Balance-billing protections apply to radiology, imaging and diagnostic testing when statutory protections are in effect; non-network providers should not bill members beyond applicable cost sharing in those cases.

Second medical opinion: members entitled to a second opinion when surgery is recommended, a serious illness/injury exists, or unsatisfactory response to treatment; network consultants may be used with network cost sharing; non-network second opinions require prior authorization or member may be balance billed.

Radiology, Imaging, Diagnostic Testing

Imaging-specific coverage notes

Diagnostic imaging: medically necessary imaging (X-ray, MRI, CT, PET/SPECT, mammogram, ultrasound) is covered; prior authorization may be required per Schedule of Benefits, and balance-billing protections apply where statutory protections exist.

Sleep Studies

Sleep study coverage rules

Sleep studies are covered when medically necessary; prior authorization may be required; studies may be performed at home or in a facility as appropriate.

Transplant Benefits and Exclusions

Transplant coverage, Center of Excellence rules, travel reimbursement and exclusions.

Transplants are covered when a member is accepted as a transplant candidate and pre-authorized through a Center of Excellence, network facility, or approved non-network facility; authorization required before transplant evaluation and related services.

Covered transplant expenses include pre-transplant evaluation and harvesting, LVAD as bridge to transplant, the transplant procedure (including acquisition cost when authorized), post-transplant follow-up, donor search/testing, and related outpatient services when authorized.

Center of Excellence travel reimbursement: when required travel exceeds 60 miles, plan will reimburse transportation and lodging expenses up to a maximum per transplant service (maximum specified in member transplant reimbursement policy; example: up to $10,000 per transplant service) subject to documentation and timelines for submission.

Transplant exclusions include

Prophylactic harvests without transplant, animal-to-human transplants, acquisition cost when not authorized through Center of Excellence, transplants performed outside the U.S., and numerous ancillary expenses (alcohol/tobacco, vehicle maintenance, entertainment, pet care, upgrades, insurance premiums) are excluded from reimbursement.

Urgent Care Services

Urgent care coverage notes

Urgent care services provided by network providers and at urgent care centers are covered, including facility costs and supplies; zero-cost preventive benefits may not apply at network urgent care centers.

Members are encouraged to contact their PCP or the 24/7 Nurse Advice Line for guidance; Nurse Advice Line is available 24/7.

Wellness Programs and Other Offerings

Available wellness programs and optional offerings

Ambetter may offer wellness programs and other services to members at no additional cost (e.g., My Health Pays rewards, Ambetter Perks discounts); participation is optional and programs may be modified or discontinued.

Rewards may be convertible to monetary value and plan reserves the right to apply such rewards to unpaid premiums; program availability and tools vary by market and may require verification for medical inability to participate.

Prior Authorization and Non-Network Services

Prior authorization mechanics and rules for non-network services

Prior authorization required for certain medical and behavioral health services; network providers generally must obtain authorization prior to providing listed services per the Schedule of Benefits.

Timing and submission: requests accepted by phone, fax or provider web portal; specific timing requirements apply (e.g., ≥5 calendar days for elective inpatient admissions, ≥30 days prior to initial transplant evaluation and clinical trial services, within 24 hours for inpatient admissions).

Failure to obtain required prior authorization may result in denial of benefits; non-network providers may balance bill members when authorization is not obtained or when services are not authorized; network providers may not bill members for their failure to obtain required authorizations.

Services from non-network providers are not normally covered unless prior authorization is obtained when network providers are not reasonably available; otherwise member responsible for charges.

General non-covered services and exclusions

Enumerated non-covered services and general exclusions; services not covered unless expressly provided elsewhere in the contract.

General exclusions include (non-exhaustive):

Services provided without cost to the member absent insurance; provider-imposed fees that are provider responsibility; services by immediate family members; services not identified as covered.
Services where other coverage is primary, non-medically necessary court-ordered care, services outside contract effective dates, and charges exceeding eligible expense.
Weight modification and bariatric surgery (except if specifically covered), weight loss programs, reversal of sterilization, most abortions, and many dental services except as provided under medical benefits.
Experimental/investigational services, injectable medications not self-administered unless on formulary, certain infertility treatments (IVF, artificial insemination), surrogacy-related services, and medicinal/recreational cannabis.

Termination and related administrative rules

Termination, refunds, reinstatement, and discontinuance provisions.

Coverage ceases upon contract termination for reasons including non-payment (subject to grace period), member request, insurer non-renewal or death (individual plans), and loss of eligibility; dependent child coverage ends at age limits noted in the contract.

Refund upon cancellation: unearned premium will be returned within 20 calendar days to the original payor; cancellation effective on receipt or later date specified in notice.

Reinstatement: contracts erroneously terminated may be reinstated resulting in restoration of enrollment with no break in coverage when applicable.

Discontinuance: insurer will provide 90- or 180-day written notice depending on scope of discontinuance and offer other individual market coverage options on a guaranteed-issue basis as required by law.

Right of reimbursement and subrogation

Subrogation and right of reimbursement when member recovers from third parties.

Ambetter retains the right of subrogation and reimbursement for the full cost of benefits paid when a third party is or may be responsible for the member's injuries; Ambetter is subrogated to the member's recovery rights to the extent of benefits paid.

Members must cooperate fully, notify the insurer of claims or lawsuits, include amounts paid by Ambetter in third-party claims, and preserve Ambetter's first-priority lien on recovery proceeds to reimburse benefits paid.

Ambetter may intervene in legal actions, assert liens, demand repayment, and seek recovery without regard to member fault; failure to cooperate may make the member liable for benefits plus insurer costs and attorney fees incurred by Ambetter in recovery efforts.

Coordination of Benefits and order of benefit determination

Coordination of Benefits (COB) policy, definitions, and order of benefit determination when member has multiple plans.

Ambetter coordinates benefits with other payers in accordance with NAIC guidelines and applicable federal/state law; the 'Plan' definition identifies which coverages are included or excluded from COB rules.

Allowable expense is the necessary, reasonable and customary cost for covered items when covered under any involved plans; when Medicare is primary, Medicare's allowable expense governs for secondary determinations.

Primary plan pays benefits without regard to other plans; secondary plans may consider primary payments when calculating their liability and will not pay more than they would have as primary.

Order of Benefit Determination

Order of benefit determination rules when covered by multiple plans.

When covered by multiple plans, the order of benefit determination follows the contract rules: non-dependent vs dependent status, birthday rule for parents, court decree rules for separated/divorced parents, active vs retired employee rules, COBRA/state continuation rules, and length of coverage; if none apply, allowable expenses are shared equally and no plan pays more than it would as primary.

Key rules include

Non-dependent plan is primary to dependent plan.
For children covered by both parents, the plan of the parent with the earlier birthday in the year is primary (or longest-covered if birthdays the same), with court orders/custody rules superseding as specified.
Active employee coverage is primary to retired/laid-off employee coverage; COBRA/state continuation is secondary to active employee coverage.

Secondary Plan Effects

Effects when this plan is secondary.

When Ambetter is secondary, benefits will be reduced so that total payments from the primary plan and Ambetter do not exceed Ambetter's maximum allowable benefit for each covered service; Ambetter will not pay more than it would have paid if it were primary.

Ambetter determines its obligation based on all claims submitted during the claim determination period and adjusts payment accordingly, including consideration of Medicare allowable amounts when Medicare is primary.

Claims and Payment Procedures

Claims submission, proof, processing, and payment rules.

Notice of claim must be provided within 30 calendar days of the loss or as soon as reasonably possible; claim forms will be furnished within 15 days after notice.

Written proof of loss must be submitted within 90 calendar days of the loss or as soon as reasonably possible; proofs more than one year late accepted only if legal incapacity prevented timely submission.

Clean claims processed within 30 days electronically or 45 days paper; No Surprises Act claims processed within 30 days regardless of submission method; if additional information is requested, Ambetter will request it within 30 days and complete processing within 15 days after receipt of that information.

Benefits are payable to the member unless assignment is authorized in writing and approved; Ambetter may pay providers directly and may deduct overpayments from future benefits.

Cooperation and Claim Denial

Member and representative cooperation requirements and consequences.

Members and their representatives must cooperate fully with Ambetter: sign authorizations, provide records, answer questions, and assist in communications; failure to cooperate may result in claim closure or denial.

Failure to provide requested information or take required actions may lead to denial of the claim and cessation of further action until compliance occurs.

Foreign Emergency Services

Emergency services while traveling outside the United States.

Emergency medical services are covered for up to 90 consecutive days while traveling outside the U.S.; if travel exceeds 90 consecutive days, no coverage is provided for the entire travel period.

Claims for emergency services incurred outside the U.S. must be submitted within 180 days with clinical documentation in English (or translated at member expense) and proof of travel dates; reimbursement is based on the member's benefit plan and paid to the member.

Legal Actions

Timing rules for bringing legal action.

No suit may be brought sooner than 60 calendar days after the required proof of loss is given; no suit may be brought more than three years after the date proof of loss is required.

Appeals, Grievances, and External Review Criteria

Timelines and procedures for appeals, expedited appeals, external review, and grievances.

Members may appeal adverse benefit determinations (denials, reductions, terminations); appeals may be filed in writing or orally and members have 180 calendar days to file an appeal from the adverse determination date.

Standard internal appeal: acknowledgement within 5 business days; resolution within 30 calendar days (allowable extension 14 calendar days); expedited internal appeal resolved within 48 hours when health/life/function is seriously jeopardized.

Grievances: standard grievance acknowledgement within 5 business days and resolution within 20 business days (allowable extension 10 business days); timely filing for grievances is 180 calendar days.

External review: if dissatisfied with final internal appeal for issues involving medical judgment, experimental/investigational determinations, surprise billing applicability, or rescissions, members may request an external review by an IRO; IRO decision is binding and costs are covered by the plan; external review resolution timeframe is typically 15 business days (72 hours for expedited external review as applicable).

Prior Authorization, Claims and Provider Responsibilities

Prior Authorization

Prior Authorization Required

This contract contains prior authorization requirements. Benefits may be reduced or not covered if the requirements are not met. See the PRIOR AUTHORIZATION section for details and the Schedule of Benefits for services that require prior authorization.

Network providers must obtain authorization prior to providing services or supplies that require prior authorization.
Failure to obtain required prior authorization may result in denial of benefits; network providers may not balance bill members for authorization failures, but non-network providers can.

Note

Emergency Services Authorization Exception

Emergency services are covered without prior authorization. If you are admitted to a hospital as a result of an emergency, you or your provider must notify us within 48 hours or as soon as reasonably possible. When notified, we will review and notify whether the inpatient setting and number of days are medically necessary. Care beyond stabilization requires authorization to remain covered.

Benefits for emergency services include facility, physician services, supplies and prescription drugs charged by the facility.
If a provider is non‑contracted, you may be financially responsible for care we determine not medically necessary.

Prior Authorization

Notification/Authorization on Prior Inpatient Coverage

If a member is inpatient at the time coverage becomes effective, you must notify us within two calendar days of the effective date so we can review and authorize any medically necessary inpatient services. If services occur at a non‑contracted hospital, claims will be paid at the allowable amount and the member may be billed for amounts above the allowable.

Notify Ambetter Health within two calendar days of your effective date for any ongoing inpatient stay that began prior to coverage taking effect.
Ambetter will review and authorize medically necessary stay days; non‑contracted facility billing may result in balance billing to the member for amounts above the allowable.

Prior Authorization

Ground/Water Ambulance Prior Authorization

Non‑emergency ground or water ambulance transports require prior authorization. Emergency ground or water ambulance transport does not require prior authorization.

Non‑emergency ambulance transportation (ground or water) requires prior authorization.
You should not be balance billed for covered ground or water ambulance services when protections apply.

Prior Authorization

Hospice Prior Authorization

Hospice benefits (inpatient, home and outpatient) are subject to prior authorization. Covered hospice services include room and board, therapies, rental of medical equipment, palliative and supportive care, counseling, and bereavement services; respite care is available and may apply to deductible/limits.

Prior authorization is required for hospice inpatient, home and outpatient care as outlined in this contract.
See the Schedule of Benefits for coverage limits and any applicable prior authorization timelines.

Prior Authorization

LTACH Prior Authorization

Long‑term acute care hospital (LTACH) benefits are subject to authorization requirements. LTACHs provide extended hospital‑level care for clinically complex patients when medically necessary and approved by us.

Authorization is required for LTACH level of care and coverage is limited to medically necessary services approved by Ambetter.
Common conditions/services considered for LTACH care are evaluated case‑by‑case and require prior authorization.

Prior Authorization

Formulary Exception Requests

Members, authorized representatives, or prescribing physicians may request formulary exceptions. Standard exception requests will be decided within 72 hours; expedited (urgent/exigent) requests will be decided within 24 hours.

Standard exception: decision within 72 hours of receipt; if granted, coverage will be provided for the duration of the prescription.
Expedited exception: decision within 24 hours when exigent circumstances exist; if granted, coverage provided for duration of the exigency.

Prior Authorization

External Exception Review

If we deny a standard or expedited formulary/step‑therapy exception request, the member, designee, or prescribing physician may request an external exception review by an independent review organization (IRO). External exception reviews have expedited timelines based on the original request type.

For a standard exception external review, we will notify the requester of the determination within three business days of receipt.
For an expedited exception external review, we will notify the requester of the determination within one business day of receipt.
If the external exception review is granted, coverage will be provided for the duration of the prescription or the exigency as applicable.

Prior Authorization

Non‑Network Provider Prior Authorization

Prior authorization is required to obtain covered services from a non‑network provider when equivalent network providers are not reasonably available. You or your PCP must request prior authorization and provide required documentation; otherwise charges will be your responsibility and non‑network providers may balance bill.

Request prior authorization before receiving services from a non‑network provider; otherwise you may be responsible for all charges.
Network availability and reasonable distance are considerations for approving non‑network authorization.
Documentation and justification must accompany the prior authorization request for non‑network services.

Denial Risk

Authorization Denial Appeal

If a prior authorization request is denied, members have the right to appeal under the GRIEVANCE AND APPEAL PROCEDURES. Appeals may be submitted in writing or orally and must be filed within 180 calendar days of the adverse benefit determination. We will acknowledge within five business days and decide within 30 calendar days (with a possible 14‑day extension with consent).

Appeals should be sent to Ambetter Health Appeals and Grievances Department as instructed in the contract.
Members may designate a representative; the appeal will be reviewed by an independent reviewer with appropriate clinical expertise.
Decisions include written notice with explanation, criteria used, reviewers' titles/qualifications, and further appeal rights including external review.

Denial Risk

Rescission and Repayment for Fraud

Coverage may be rescinded and benefits recovered for intentional misrepresentation or fraud. Rescission will be applied retroactively only if the misrepresented fact is in a signed written enrollment application, was provided to the member, and was intentional and material. During the first two years of coverage, if a member commits fraud or knowingly provides false information about eligibility or claims, we may demand repayment of benefits paid.

Rescission: coverage may be voided and claims denied when intentional, material misrepresentation exists in a signed enrollment application.
Repayment: within the first two years of coverage, Ambetter has the right to recover benefits paid if a member commits fraud, misrepresentation, or knowingly provides false information related to eligibility or claims.

Key Definitions and Terms

Definitions (general note)

Defined terms importanceMany words used in this contract have special meanings in the health care context and are italicized and defined in the DEFINITIONS section.

Where to find definitionsRefer to the DEFINITIONS section of the contract for term-specific meanings used throughout the document.

Reading guidanceBecause provisions are interrelated, read definitions along with the Schedule of Benefits and applicable sections to interpret coverage correctly.

Contract parties terminology

Member terminologyThe terms 'you' or 'your' refer to the member or any dependent members enrolled in the contract.

Payer terminologyThe terms 'we', 'our', or 'us' refer to Ambetter Health (Celtic Insurance Company), the plan issuing the contract.

Document contextReferences to Celtic Insurance Company and Ambetter Health are used interchangeably to identify the plan entity under this contract.

Acute rehabilitation

Core definitionAcute rehabilitation is an intensive, multidisciplinary rehabilitation program where patients normally receive physical, occupational, and speech therapies three or more hours per day, five to seven days per week while confined as an inpatient in a hospital, rehabilitation facility, or extended care facility.

Setting and managementServices are provided to medically managed patients by specially trained physicians in an inpatient hospital, rehabilitation facility, or extended care facility.

Relation to other rehab levelsAcute rehabilitation is distinct from sub-acute or intensive day rehabilitation, defined by therapy hours and inpatient confinement criteria.

Allowed amount

Allowed amount meaningAllowed amount (also see Eligible expense) is the maximum amount the plan will pay a provider for a covered service; for network providers this is the amount the provider agreed to accept as payment for that service.

Cost sharing applicationThe allowed amount is subject to member cost sharing (deductible, coinsurance, copayment) per the member's Schedule of Benefits.

Non-network implicationsIf services are received from a non-network provider, the member may be balance billed for amounts exceeding the allowed amount unless balance billing protections apply.

Authorization

Authorization definitionAuthorization (authorized) means the plan's decision to approve the medical necessity or appropriateness of care for a member by the member's PCP or provider; authorizations are not a guarantee of payment.

ScopeAuthorizations apply to specialty or other medically necessary care and may be required pre-service, concurrently, or retrospectively as part of utilization review.

ConsequencesObtaining authorization does not guarantee benefits or payment; failure to obtain required authorization may result in denied benefits or member financial responsibility, particularly for non-network services.

Balance billing protections

No Surprises Act protectionsBalance billing protections derive from the federal No Surprises Act and prohibit non-network providers from balance billing members for certain covered services (e.g., emergency services, certain non-emergency services at network facilities, and air ambulance).

Member cost-share calculationWhen balance billing protections apply, the member's cost share is calculated as if services were received from a network provider based on the recognized amount under law.

Notice and consent limitsNotice and consent procedures may permit waiver of protections for certain non-emergency services at network facilities if legal notice/consent requirements and timing are met; protections do not apply to emergency services and specified ancillary services.

Behavioral health

Behavioral health definitionBehavioral health includes both mental health disorders and substance use disorders and encompasses prevention, intervention, treatment, and recovery support services.

Service scopeCovered behavioral health services include inpatient psychiatric hospitalization, detoxification, crisis stabilization, residential treatment, PHP, IOP, medication management, therapy, ABA where applicable, and other clinically indicated services.

Utilization criteriaDeterminations for behavioral health and SUD services use clinical criteria such as InterQual for mental health and ASAM for SUD; prior authorization may be required except for certain emergent inpatient services.

Experimental or investigational

Experimental or investigational definedExperimental or investigational describes services, treatments, devices, or drugs that are under study, unproven, lack FDA approval for the indication, or are used outside accepted off-label uses as determined by the plan; routine clinical trial costs may be covered if otherwise covered.

Clinical trial exceptionPhase III or IV FDA clinical trials' routine patient care costs may be covered if the trial meets listed approval criteria; investigational items themselves and items solely for data collection are excluded.

Decision basisCoverage determinations consider FDA status, inclusion in authoritative compendia, and peer-reviewed clinical evidence for off-label uses.

Home health care agency / Hospice / Hospice care program

Home health care agency definitionA home health care agency operates pursuant to law, provides home health care under RN supervision, maintains daily medical records, and provides a planned program of physician-ordered observation and treatment; Medicare-approved agencies are deemed acceptable.

Hospice and hospice programHospice services are for terminally ill members in inpatient or home settings, provided by certified hospice care programs supervised by a network physician to manage palliative needs and support families.

Operational requirementsHospice programs must be licensed and provide coordinated interdisciplinary services prescribed and supervised by a provider to meet the special needs of terminally ill members and their immediate families.

Hospital / Inpatient / Intensive care unit

Hospital definitionA hospital is an institution operating pursuant to law for reception, care, and treatment of inpatients; provides 24-hour RN nursing services and physician availability, organized diagnostic and treatment facilities, and is not primarily a long-term care facility.

Inpatient definitionInpatient services are those received by an overnight resident patient charged for room and board.

Intensive care unitAn intensive care unit is a hospital unit meeting Joint Commission standards for Special Care Units (ICU).

Medically necessary

Medically necessary criteriaMedically necessary services/items/supplies are consistent with symptoms/diagnosis, provided per generally accepted medical practice, not custodial, capable of improving functional ability, not solely for convenience, not experimental, provided in the most cost-effective setting, and not excessive in scope/duration/intensity.

Hospital confinement criterionFor inpatient hospital confinement, medical necessity requires that diagnosis and treatment cannot safely be provided as an outpatient.

Payment implicationCharges for services not medically necessary are not eligible expenses under the contract.

Network / Network provider / Network eligible expense

Network definitionNetwork means a group of providers or facilities contracted with Ambetter Health (directly or indirectly) to provide services to members for an agreed fee.

Network providerA network provider is any licensed person or entity that has entered into a contract with Ambetter Health to provide covered services, including hospitals, physicians, pharmacies, and labs.

Network eligible expenseNetwork eligible expense is the eligible expense for services or supplies provided by a network provider; includes emergency services even if provided by a non-network provider.

Notice and consent / Balance billing

Notice and consent purposeNotice and consent permits a member to waive balance-billing protections for certain non-emergency services provided by a non-network provider at a network facility if statutory notice, timing, and written voluntary consent requirements are met.

Timing requirementsRequired notice must be provided at least 72 hours before services (or at least 3 hours before if scheduled within 72 hours), with a copy of notice and consent provided to the member.

LimitsNotice and consent does not waive protections for emergency services, air ambulance, unforeseen urgent needs, ancillary services, or when no network provider is available for an ancillary service.

Prior authorization

Prior authorization definitionPrior authorization is a decision to approve specialty or other medically necessary care for a member by the member's PCP or provider group prior to the member receiving services.

Utilization review typesPrior authorization may be part of pre-service (prior authorization), concurrent, or retrospective utilization review processes.

Effect of not obtainingFailure to obtain required prior authorization may result in denial of benefits and potential member liability, especially for non-network services; authorizations do not guarantee payment.

Dependent member / Newborn coverage / Adopted child coverage

Dependent eligibility eventsDependent members become eligible on events such as the subscriber's coverage effective date, marriage, birth of an eligible newborn, placement for adoption, foster placement, or as otherwise specified in enrollment rules.

Newborn automatic coverage periodAn eligible newborn is covered from time of birth until the 31st calendar day after birth unless the insurer has received notice; additional premium required to continue coverage beyond 31 days.

Adopted child coverage periodAn eligible child placed for adoption is covered from the date of placement until the 31st calendar day after placement; additional premium required to continue coverage beyond 31 days with specified timeframes for premium payment.

Cost sharing

Cost sharing overviewCost sharing includes deductible, copayments, and coinsurance; members pay these amounts per the Schedule of Benefits for covered services until maximum out-of-pocket is met.

DeductibleDeductible is the amount of covered services a member must pay before benefits are payable; copayments do not count toward the deductible.

Maximum out-of-pocketMaximum out-of-pocket is the cap on member-paid copayments, coinsurance, and deductibles; family OOP equals two times the individual OOP.

Deductible

Deductible definitionDeductible is the amount of covered services that must be paid by each member before benefits are provided; it does not include copayments or coinsurance; not all services are subject to the deductible (see Schedule of Benefits).

ApplicationSpecific deductible amounts and applicable services are listed in the member's Schedule of Benefits.

Interaction with other cost shareCopayments do not count toward the deductible but do apply toward the maximum out-of-pocket amount.

Copayment

Copayment definitionA copayment is a fixed dollar amount due at the time of service; copayments do not count toward the deductible but do count toward the maximum out-of-pocket amount.

Provider billingPayment of a copayment does not prevent a provider from billing for non-covered services.

Schedule referenceCopayment amounts for specific services are shown in the Schedule of Benefits.

Coinsurance

Coinsurance definitionCoinsurance is the member's share of the cost of a service, payable in addition to any applicable deductible; coinsurance applies toward the maximum out-of-pocket but not the deductible.

Plan payment after OOPAfter the annual out-of-pocket maximum is met, the plan pays 100% of allowed amounts for covered services.

Application detailsCoinsurance amounts and applicability are specified in the Schedule of Benefits.

Maximum out-of-pocket

Maximum out-of-pocket definitionMaximum out-of-pocket is the total amount a member must pay in copayments, coinsurance, and deductibles in a year; after this amount is met the plan pays 100% of allowed amounts for covered services.

Family OOPFamily maximum out-of-pocket equals two times the individual maximum out-of-pocket; once an individual meets their individual OOP, remaining family OOP can be met by other members' eligible expenses.

LimitationsApplicable specific benefit limits and eligible expense determinations may affect OOP calculations as described in the Schedule of Benefits and contract.

Coinsurance Amount

Coinsurance amount restatedCoinsurance amount is the member's share of the cost of a service required in addition to any applicable deductible and counts toward the maximum out-of-pocket but not the deductible.

ApplicationCoinsurance specifics are listed in the Schedule of Benefits and applied per claim adjudication rules.

Effect of meeting OOPOnce maximum out-of-pocket is met, coinsurance no longer applies and plan pays 100% of allowed amounts for covered services.

Maximum Out-of-Pocket

Maximum Out-of-Pocket (restated)The maximum out-of-pocket is the total amount a member must pay in copayments, coinsurance, and deductibles in a plan year after which the plan pays 100% of allowed amounts for covered services.

Family calculationFamily OOP equals two times the individual OOP; combination of members' eligible expenses can satisfy family OOP once an individual reaches individual OOP.

Schedule referenceRefer to the Schedule of Benefits for the numeric OOP amounts applicable to the member's plan.

Balance Billing / Non-Network Liability

Balance billing definitionBalance billing occurs when a non-network provider bills the member for the difference between the provider's charge and the amount the plan agreed to pay (allowed amount).

Member exposureMembers may be responsible for balance billing unless federal balance billing protections apply (e.g., emergency services, certain non-emergency services at network facilities, air ambulance), in which case cost share is calculated as if services were from a network provider.

ActionIf balance billed in protected situations, members should contact Member Services immediately using number on member ID card.

Durable medical equipment

DME definitionDurable medical equipment (DME) is equipment that can withstand repeated use, is primarily for medical purposes, is appropriate for home use, and may be rented or purchased per policy rules; rental costs must not exceed purchase price and plan may elect purchase over rental.

Covered examplesExamples include standard hospital bed, standard walker, non-motorized wheelchair, ventilator, infusion pumps, glucometers, neonatal and sleep apnea monitors, and other physician-prescribed items.

Prior authorizationAll types of durable medical equipment and supplies are subject to prior authorization as outlined by this contract.

Emergency condition

Emergency conditionAn emergency condition exists when a member is experiencing an emergency that requires transport to the nearest hospital that can provide appropriate services; emergency air or ground ambulance does not require prior authorization when an emergency condition exists.

Notification timingMembers or providers must notify the plan within 48 hours (or as soon as reasonably possible) after an emergency hospital admission to avoid potential financial responsibility for non-medically necessary inpatient care.

Ambulance exceptionNon-emergency air ambulance services require prior authorization; emergency air ambulance services do not when the member is experiencing an emergency condition.

Iatrogenic infertility

Iatrogenic infertility definitionIatrogenic infertility is infertility caused by a medical intervention, including reactions from prescribed drugs or medical/surgical procedures provided for cancer treatment.

Coverage contextMedically necessary fertility preservation services for patients at risk of iatrogenic infertility (e.g., due to cancer treatment) may be covered; prior authorization may be required.

Related exclusionsAssisted reproductive technologies (IVF, artificial insemination) are excluded unless otherwise specified elsewhere in the contract.

Prosthetic devices

Prosthetic devices definitionProsthetic devices are artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes; purchases are preferred over rentals and devices must be medically necessary.

Examples and requirementsCovered prosthetics include internal heart valves, pacemakers, vascular replacements, fracture fixation devices, custom breast prostheses post-mastectomy, intraocular lenses, artificial eyes/larynx, and others when medically necessary.

Purchase vs rentalPlan may elect purchase over rental; repair and replacement are covered when medically justified; certain exclusions (e.g., dentures, non-rigid appliances) apply.

Medical foods

Medical foods coverageMedical foods and formulas are covered for outpatient total parenteral nutrition therapy (TPN), outpatient elemental formulas for malabsorption, and dietary formulas when medically necessary for Phenylketonuria (PKU) and specified inborn errors of metabolism.

Donor human milkMedically necessary pasteurized donor human milk is covered when prescribed by an infant's pediatrician stating the infant cannot receive maternal milk or the mother cannot produce sufficient milk.

ExclusionsOther dietary formulas, oral nutritional supplements, special diets, prepared meals, and formula for access problems are excluded unless specified.

Formulary

Formulary roleThe formulary or prescription drug list is a guide to available generic and brand drugs approved by the FDA and covered under the prescription drug benefit; it is not a complete list and is periodically reviewed and updated.

Coverage nuancesSpecific plan designs may exclude certain products or categories despite formulary appearance; dosage forms or strengths may not all be covered.

Access to current listFor the most current Ambetter Health Formulary or Prescription Drug List, members should visit AmbetterHealth.com or call Member Services.

Standard Reference Compendia

Standard Reference CompendiaStandard Reference Compendia refers to American Hospital Formulary Service Drug Information; American Medical Association Drug Evaluation; or United States Pharmacopoeia-Drug Information.

Use for off-label coverageOff-label drugs may be covered if recognized for the indication in at least one standard reference compendium or supported by peer-reviewed clinical studies per contract criteria.

Where referencedReferenced in the Prescription Drug Benefits section when determining coverage for off-label drug uses.

Self-injectable drugs

Self-injectable drugs definitionSelf-injectable drugs are prescription drugs delivered into muscle or under the skin with a syringe and needle that members or caregivers can administer; they are covered under the prescription drug benefits and subject to prescription drug cost share.

Coverage paritySelf-injectable and oral anticancer medications are covered under the prescription benefit and are treated no less favorably than IV/injectable cancer medications covered under medical benefits.

Formulary guidanceSelf-injectable drugs are included on the formulary where applicable; cost-sharing and supply limits apply as set forth in the drug benefits section.

Utilization review

Utilization review typesUtilization review includes pre-service (prior authorization), concurrent review (e.g., inpatient stay), and retrospective review after services have been provided.

Prior authorization mechanicsSome medical and behavioral health services require prior authorization; network providers generally must obtain authorization prior to providing listed services; timing and procedures are specified in the Prior Authorization section.

ConsequencesFailure to obtain required authorization may result in denials and member financial responsibility; authorizations do not guarantee payment.

Second medical opinion

Second medical opinion entitlementMembers are entitled to a second medical opinion when a surgical procedure is recommended, a serious illness or injury exists, or the member is not responding satisfactorily to current treatment.

Provider choice and cost shareIf a member selects a network provider for the second opinion, only applicable network cost sharing applies; non-network second opinions require prior authorization or the member may be balance billed.

ProcedureMembers may choose a physician of their choice and should follow the prior authorization rules if selecting a non-network consultant.

Allowable expense / Plan (COB)

Allowable expense (COB)Allowable expense is the necessary, reasonable, and customary item of expense for health care when covered under any of the plans involved; used to determine coordination of benefits payments.

Plan definition'Plan' for COB purposes is a form of coverage written on an expense-incurred basis with which coordination is allowed and includes group/non-group contracts, Medicare components as permitted, and other listed coverages.

Order rulesUnder COB, the primary plan pays first; the secondary plan may cover remaining costs up to allowable expense following NAIC guidelines and federal/state law.

Primary/Secondary plan and Order of Benefits

Primary vs Secondary planPrimary plan is one whose benefits are determined without considering other plans; secondary plan is not primary and pays after the primary per order of benefit determination rules.

Order determination principlesOrder of benefits rules include non-dependent vs dependent, birthday rule for parents' plans, court decree rules for separated/divorced parents, active vs retired employee status, and other regulatory rules.

When plan is secondaryWhen this plan is secondary, its benefits are reduced so that total paid by the primary and this plan do not exceed the plan's maximum allowable benefit; Ambetter will not pay more than it would if it were primary.

Appeal and External Review

Appeal filing timeframeMembers have 180 calendar days to file an internal appeal of an adverse benefit determination from the date the determination is issued.

Expedited appealExpedited appeals are available when a requested service would seriously jeopardize life, health, or ability to regain maximum function and will be resolved within 48 hours.

External reviewIf dissatisfied with the final internal appeal outcome on certain issues, members may request an external review by an Independent Review Organization (IRO); the IRO decision is binding and plan covers associated costs.

Rescission / Repayment for Fraud

Rescission definition and conditionsRescission voids coverage retroactively when there is an intentional, material misrepresentation in a signed written enrollment application and a copy of the application was provided to the member; rescission means the coverage was never in effect.

Time limits on defensesAfter two years from the policy issue date, misstatements (except fraudulent misstatements) cannot be used to void the contract or deny claims for losses after that period.

Repayment for fraudDuring the first two years of coverage, if a member commits fraud or knowingly provides false information relating to eligibility or claims, the plan may demand repayment of benefits provided during the coverage period.

Personal Health Information (PHI)

PHI definitionPersonal Health Information (PHI) includes oral, written, and electronic health information protected under HIPAA and the plan's Notice of Privacy Practices.

Privacy obligationsAmbetter Health follows HIPAA requirements and has policies and procedures to protect PHI; members are notified annually of privacy practices and can request the full Notice of Privacy Practices.

Member accessMembers can review how their PHI is used and disclosed per the Notice of Privacy Practices and contact the plan for additional information.

OpenPayer

Ambetter Health — Individual Evidence of Coverage (member contract)

Coverage Criteria and Benefit Rules

Coding, Codes and Quick Reference

Prior Authorization, Claims and Provider Responsibilities

Key Definitions and Terms