Claims Payment Policy and Practices
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Governs how Western Health Advantage members and providers file claims, request reimbursements, appeal or grieve decisions, and rules about premium payments, grace periods, balance billing, and related administrative processes. Affects WHA members, providers billing WHA, and Member Services handling claims and appeals.
No material clinical or coverage changes in this revision.
Coverage, Claims, and Member Billing Rules
COVERAGE CRITERIA
Operational coverage and member-billing rules — claim submission, reimbursement, appeals/grievances, continuation of coverage during appeals, premium grace periods, balance-billing protections, and related administrative timelines and contacts.
ALL of the following
ALL of the following
- Provider should obtain member ID card at time of service.
- If member paid out-of-pocket, member may request reimbursement using the Claim Reimbursement Form available at mywha.org (Request Reimbursement under MyTOOLs) or submit by mail to 2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833 Attention: Claims Department.
- Claims for reimbursement must be submitted to WHA within 180 days from the date of service.
ALL of the following
- Upon receipt of a reimbursement claim, WHA will notify the claimant regarding the outcome within 45 business days.
- Only services covered under the member's plan are eligible for reimbursement; applicable copayment/coinsurance and/or deductible will determine the reimbursed amount.
- Prescription-only reimbursement requests should be directed to OptumRx online at optumrx.com or by calling 1.800.356.3477.
ALL of the following
- Methods to submit an Appeal or Grievance: mail (Attn: Appeals and Grievances 2349 Gateway Oaks Drive Sacramento, CA 95833), secure fax 916.563.2207, call Member Services (916.563.2250 or 888.563.2250), secure email via mywha.org/securemessage, or complete the online Grievance Form at westernhealth.com/grievance-form.
- Timeframe to file: submit within 180 days of the incident or action that caused dissatisfaction; contact Member Services if unable to meet this period.
- Acknowledgement and resolution timelines: WHA sends an acknowledgement within 5 calendar days and resolves Appeals and Grievances within 30 days of receipt. Written notification of the disposition will be sent and will include contractual or clinical rationale.
- Expedited appeals: standard expedited resolution time is 72 hours when delay could seriously jeopardize health (e.g., severe pain or imminent serious threat).
- Member rights in appeals: opportunity to review the file and submit testimony; second review by a physician not involved in the initial review for clinical determinations.
- Continuation of coverage during appeal: If appealing a denial for services within an already-approved ongoing course of treatment, coverage for the approved services will continue while the Appeal is decided.
ALL of the following
Grace period types
- 30-day grace period applies to members not receiving premium tax credits: coverage continues during the 30-day period; member must pay past due premiums within the 30 days to avoid cancellation.
- 90-day (three-month) subsidized grace period applies to members receiving premium tax credits: month 1 claims are paid; claims for months 2 and 3 may be suspended until past due premiums are paid; coverage continues during the grace period.
- At the end of the grace period: coverage will end if WHA does not receive all premiums owed through the subsidized grace period; member remains responsible for unpaid premiums and for health care services received during months 2 and 3 (including emergency care). If coverage ends for nonpayment, the plan end date is the last day of the first month of the three-month subsidized grace period.
ALL of the following
- Non-participating hospitals and physicians are prohibited under state law from billing members more than their applicable copayment and/or deductible for emergency services.
- WHA will pay the reasonable and customary value for emergency services provided by non-participating providers; members are never responsible for more than the applicable copayment and/or deductible for emergency services.
- If billed more than the applicable copayment and/or deductible for emergency services from a non-participating provider, members may report the provider to the California Department of Managed Health Care (888.466.2219) and may contact Appeals and Grievances or Member Services for assistance.
ALL of the following
- For general claim filing information and Member Services contact: call 916.563.2250 or 888.563.2250 toll-free or TTY 888.877.5378; visit mywha.org/claim.
- Appeals and Grievances mailing and fax contacts: Attn: Appeals and Grievances 2349 Gateway Oaks Drive Sacramento, CA 95833; secure fax 916.563.2207.
- For assistance with premium billing, recoupment, or refunds contact Premium Billing (see premium billing contact info in document).
Coordination of Benefits criteria
Coordination of Benefits (COB) eligibility and member obligations.
ALL of the following
- COB is a process used to prevent duplicate payments when more than one insurer covers a member.
- Individual and family plans do not coordinate benefits with other individual or group health plans.
Potential COB eligibility
- Members who are also covered by Medicare may be eligible for COB.
- Members with more than one employer-sponsored group health plan may be eligible for COB.
ALL of the following
- Members are required to inform all of their health care providers if they or their dependents have any other coverage.
- Members must provide WHA with their Social Security Number and/or Medicare identification number to facilitate coordination of benefits.
ALL of the following
- Refer to the member's Evidence of Coverage (EOC) for additional COB limitations and details.
- An Explanation of Benefits (EOB) may be supplied or requested; an EOB explains claim payment and member responsibility and is not a bill.
Codes, EOBs, and Coverage Dates
| No codes listed |
Provider Responsibilities and Billing Requirements
Prior authorization required for non‑participating providers (exceptions: emergency/urgent outside service area)
Any coverage for services provided by a Physician or other health care provider who is not a Participating Provider requires written Prior Authorization before the service is obtained, except in Emergency Care situations and Urgent Care situations that arise outside WHA's Service Area. If services are received from a non‑Participating Provider without first obtaining Prior Authorization from WHA or the member's Medical Group, the member will be liable to pay the non‑Participating Provider for those services.
- Prior authorization must be obtained in writing prior to the service for non‑participating providers.
- Exceptions: Emergency Care and Urgent Care that arise outside WHA's Service Area.
- Without prior authorization the member is responsible for payment to the non‑participating provider.
Explanation of Benefits (EOB) availability — may be supplied or requested
An Explanation of Benefits (EOB) provides details about a processed medical insurance claim, showing what portion was paid to the provider and what portion, if any, is the patient's responsibility; the EOB is not a bill. Any EOB may be supplied or requested.
- EOB often arrives via mail and closely resembles a medical bill but is not a bill.
- Providers or members may supply or request an EOB as needed.
Member cooperation required for coordination of benefits (COB)
Members are required to cooperate and assist with WHA's coordination of benefits by informing all of their health care providers if they or their dependents have any other coverage and by providing WHA with their Social Security Number and/or Medicare identification number to facilitate COB.
- Tell all health care providers if the member or dependents have other coverage.
- Provide WHA with Social Security Number and/or Medicare ID to facilitate coordination.
- Refer to the Evidence of Coverage (EOC) for additional COB limitations and details.
Key Definitions
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