Claims Payment Policies & Other Information
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Governs claims submission, out-of-network liability/balance billing, prior authorization and medical necessity timeframes, drug formulary exception processes, grace periods, EOB explanations, coordination of benefits, and related member responsibilities for Presbyterian Health Plan members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Member Responsibilities
Coverage criteria and member responsibilities
Covered stance and member financial responsibility notes:
ALL of the following
Balance billing and out-of-network treatment
- Out-of-network providers may balance bill members for charges beyond copayments, coinsurance, or deductible; providers may require payment in full at time of service and ask the member to submit the claim to Presbyterian.
[[see citations]]
- Non-urgent or non-emergent services received from an out-of-network provider may require prior authorization before the service is received.
[[see citations]]
- HMO members: out-of-network services are not covered except for emergency services; members may be billed for those services.
[[see citations]]
Claims submission and processing
- Providers are generally responsible for submitting claims; members may submit claims in certain situations (e.g., required by provider), and required submission windows apply (in-network 90 days; out-of-network 1 year).
Claims are processed within 30 days of receipt.
- Explanation of Benefits (EOB) will detail amounts allowed, amounts paid, member responsibility, and codes used.
Prior authorization and medical necessity
- Some services may require prior authorization and/or be subject to review for medical necessity.
Medical necessity is care that is reasonable, necessary, and/or appropriate based on evidence-based clinical standards of care.
- If proper prior authorization procedures are not followed before receiving the service, the service may be denied and the member may be financially responsible, except for emergency services.
- A prior authorization will specify the length of time it is valid, not to exceed 24 months; the member may revoke an authorization at any time.<= 24 months
Drug formulary exceptions
- Members or appointed representatives may request a formulary exception; the member's physician must complete the Drug Prior Authorization Request Form and explain medical reason for the exception.
Requests can be faxed to (505) 923-5540 or mailed to Pharmacy Department P.O. Box 27489 Albuquerque, NM 87125-7489; customer service number on last page.
- Types of exceptions include: coverage of a non-formulary drug, or waiver of coverage restrictions or quantity limits if the plan allows.
- Decision timeframes: standard decisions completed no later than 5 working days after receiving the request; expedited decisions completed no later than 24 hours after receiving the request.Standard: 5 working days; Expedited: 24 hours
Grace period and pending claims
- During the grace period for certain members, appropriate claims may be paid during the first month; claims may be pended during the second and third months and processed if premiums are paid before the end of the grace period.3 months (for certain APTC recipients)
Recoupments and retroactive denials
- Overpayments (including premium overpayments) will be refunded when contacted; retroactive denials (reversal of a previously paid claim) may render the member responsible for payment.
ALL of the following
- Customer service contact numbers and pharmacy fax/address are provided for assistance with submissions and exception requests.
Fax: (505) 923-5540; Pharmacy Department P.O. Box 27489 Albuquerque, NM 87125-7489.
ALL of the following
- Prior authorization validity will not exceed twenty-four (24) months and may be revoked by the member at any time.<= 24 months
EOB Codes and Drug Exception Timeframes
| EOB includes explanation codes describing how the claim was processed; descriptions available on member portal or EOB. |
Prior Authorization, Drug Exceptions, and Out-of-Network Authorization
Prior authorization required; valid up to 24 months; member may revoke
Some services require prior authorization and/or may be reviewed for medical necessity. If proper prior authorization procedures are not followed before receiving the service, Presbyterian may deny payment and the member may be financially responsible (except for emergency services). A prior authorization will specify how long it is valid (not more than 24 months) and the member may revoke the authorization at any time.
- Prior authorization is required for certain services and is used to approve access to a covered benefit before service is received.
- Failure to follow prior authorization procedures can result in denial of payment and member financial responsibility, except for emergencies.
- Authorizations specify a validity period up to 24 months and may be revoked by the member at any time.
Out-of-network non-urgent services may need prior authorization
Non-urgent or non-emergent services from out-of-network providers may require prior authorization from Presbyterian before receiving the service. HMO members should note out-of-network services are not covered except for emergencies and they may be billed for those services.
- Obtain prior authorization before scheduling non-urgent/non-emergent out-of-network services when required.
- For HMO members, out-of-network services are generally not covered (except emergencies) and members may be financially liable.
Submit drug prior authorization / exception requests; decision timelines
Providers may submit drug formulary exception or prior authorization requests on behalf of members using the Drug Prior Authorization Request Form; standard decisions are completed within five working days and expedited decisions within 24 hours.
- Doctor can fax requests to (505) 923-5540 or mail to Pharmacy Department P.O. Box 27489 Albuquerque, NM 87125-7489; member or representative may call customer service.
- Provider must explain the medical reason for the exception on the Drug Prior Authorization Request Form.
- Standard decision timeframe: no later than 5 working days after receipt; expedited decision timeframe: no later than 24 hours after receipt.
Key Definitions
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