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2024 Transparency Notice
A) Non-network liability and balance billing
If you receive services from a non-network provider, you may have to pay more for services you receive. Non-network providers may be permitted to bill you for the difference between what we agreed to pay, and the full billed amount charged for a service. This is known as balance billing. This amount is likely more than network costs for the same service and might not count toward your annual maximum out-of-pocket amount limit. However, you will not be balance billed when balance billing protections apply to covered services.
B) Enrollee Claim Submission
Providers will typically submit claims on your behalf, but sometimes you may need to submit claims yourself for covered services. This may happen if your provider is not contracted with us.
We must receive written proof of loss within 90 calendar days of the loss or as soon as is reasonably possible. Proof of loss furnished more than one year late will not be accepted unless you or your covered dependent member had no legal capacity to submit such proof during that year.
If you have paid for services we agreed to cover, you can request reimbursement for the amount you paid. We can adjust your deductible, copayment or cost sharing to reimburse you. We must receive notice of claim within 30 days of the date the loss began or as soon as reasonably possible.
To request reimbursement for a covered service, you need a copy of the detailed claim from your provider. You also need to submit a copy of the member reimbursement claim form (PDF) at posted at ambetterofoklahoma.com under “Member Resources”.
Send all the documentation to us at the following address:
Ambetter of Oklahoma
Attn.: Claims Department
PO Box 5010
Farmington, MO 63640-5010
Benefits will be paid within 30 calendar days for clean claims filed electronically or on paper. "Clean claims" means a claim submitted by you or a provider that has no defect, impropriety, or particular circumstance requiring special treatment preventing payment. If we have not received the information, we need to process a claim, we will ask for the additional information necessary to complete the claim. You will receive a copy of that request for additional information. In those cases, we cannot complete the processing of the claim until the additional information requested has been received. We will make our request for additional information within 20 calendar days of our initial receipt of the claim and will complete our processing of the claim within 30 calendar days after our receipt of all requested information
C) Grace Periods and Claims Pending
If you don’t pay your premium by its due date, you’ll enter a grace period. This is the extra time we give you to pay (we understand that stuff happens sometimes).
During your grace period, you will still have coverage. However, if you don’t pay before a grace period ends, you run the risk of losing your coverage. During a grace period, we may hold — or pend — your claim payment.
If your coverage is terminated for not paying your premium, you won’t be eligible to enroll with us again until Open Enrollment or a Special Enrollment period. So make sure you pay your bills on time!
If you receive a subsidy payment
After you pay your first bill, you have a three months grace period. During the first month of your grace period, we will keep paying claims for covered services you receive. If you continue to receive services during the second and third months of your grace period, we may hold these claims. If your coverage is in the second or third month of a grace period, we will notify you and your healthcare providers about the possibility of denied claims.
If you don’t receive a subsidy payment
After you pay your first bill, you have a grace period of 30 calendar days. During this time, we will continue to cover your care, but we may hold your claims. We will notify you and your providers about this non-payment and the possibility of denied claims.
D) Retroactive Denials
"Retroactive denial of a previously paid claim" or "retroactive denial of payment" means any attempt by a carrier retroactively to collect payments already made to a provider with respect to a claim by reducing other payments currently owed to the provider, by withholding or setting off against future payments, or in any other manner reducing or affecting the future claim payments to the provider.
There are instances where claims may be denied retroactively if you: terminate coverage with Ambetter; provide late notification of other coverage due to new coverage; or have a change in circumstance, such as divorce or marriage. This causes Ambetter to request recoupment of payment from the provider.
You can avoid retroactive denials by paying your premiums on time and in full, and making sure you talk to your provider about whether the service performed is a covered benefit.
If you believe the denial is in error, you are encouraged to contact the Member Services Department by calling the number on your ID card.
E) Recoupment of Overpayments
Members may call in to request a refund of overpaid premium. Refunds are processed by two methods, electronically or by a manual check. The type of refund that is issued is dependent on the method of payment. Payments made with a debit/credit card via e-Cashiering, interactive voice response (IVR) system, auto pay, member portal as well as credit card payments sent to our lockbox vendor will be refunded via e-Cashiering. Payments made via e-Check will also be refunded electronically. Payments made by check to our lockbox vendor and payments that were processed in-house at our Little Rock location must be refunded manually via paper check.
F) Medical Necessity and Prior Authorization
Services are only covered if they are medically necessary. Medically necessary services are those that:
- Are the most appropriate level of service for the member considering potential benefits and harm
- Are known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes
Prior Authorization Required
Some covered service expenses require prior authorization. Network providers must obtain authorization from us prior to providing a service or supply to a member. However, there are some network eligible service expenses for which you must obtain the prior authorization.
For services or supplies that require prior authorization, as shown on the Schedule of Benefits, you must obtain authorization from us before the member:
- Receives a service or supply from a non-network provider; or
- Are admitted into a network facility by a non-network provider; or
- Receive a service or supply from a network provider to which you or your dependent member were referred to by a non-network provider.
Pursuant to the federal No Surprises Act, emergency services received from a non-network provider are covered services without prior authorization.
Prior Authorization requests must be received by phone/e-fax/Provider portal as follows:
- At least 5 calendar days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, hospice, or residential treatment facility.
- At least 30 calendar days prior to the initial evaluation for organ transplant services.
- At least 30 calendar days prior to receiving clinical trial services.
- Within 24 hours of any inpatient admission, including emergent inpatient admissions.
- At least 5 calendar days prior to the start of home health care except those members needing home health care after hospital discharge.
After prior authorization has been requested and all required or applicable documentation has been submitted, we will notify you and your provider if the request has been approved as follows:
- For urgent concurrent reviews, within 1 calendar day of receipt of the request.
- For urgent pre-service reviews, 3 calendar days from the date of receipt of request.
- For non-urgent pre-service reviews, within 15 days of receipt of the request.
- For post-service or retrospective reviews, within 30 calendar days of receipt of the request.
You do not need to obtain prior authorization from us or from any other person (including your PCP) in order to obtain access to obstetrical or gynecological care from a medical practitioner in our network who specializes in obstetrics or gynecology. The medical practitioner, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan or procedures for making referrals. For a list of participating medical practitioners who specialize in obstetrics or gynecology, contact Member Services.
Failure to Obtain Prior Authorization
Failure to comply with the prior authorization requirements will result in benefits being reduced.
Network providers cannot bill you for services for which they fail to obtain prior authorization as required.
Benefits will not be reduced for failure to comply with prior authorization requirements prior to receiving emergency services. However, you must contact us as soon as reasonably possible after you receive emergency services.
G) Drug Exceptions Timeframes and Enrollee Responsibilities
Prescription Drug Exception Process
Sometimes members need access to drugs that are not listed on the formulary. Members or provider can submit a drug exception request to us by contacting Member Services at 1-833-492-0679 (TDD/TTY: 711) or by sending a written request to the following address:
Ambetter of Oklahoma
Attn: Member Services
14000 Quail Springs Parkway, Suite 650
Oklahoma City, OK 73134
Standard exception request
A member, a member’s authorized representative or a member’s prescribing physician may request a standard review of a decision that a drug is not covered by the plan. The request can be made in writing or via telephone. Within 72 hours of the request being received, we will provide the member, the member’s authorized representative or the member’s prescribing physician with our coverage determination. Should the standard exception request be granted, we will provide coverage of the non-formulary drug for the duration of the prescription, including refills.
Expedited exception request
A member, a member’s authorized representative or a member’s prescribing physician may request an expedited review based on exigent circumstances. Exigent circumstances exist when a member is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug. Within 24 hours of the request being received, we will provide the member, the member’s authorized representative or the member’s prescribing physician with our coverage determination. Should the expedited exception request be granted, we will provide coverage of the non-formulary drug for the duration of the exigency .
External exception request review
If we deny a request for a standard exception or for an expedited exception, the member, the member’s authorized representative or the member’s prescribing physician may request that the original exception request and subsequent denial of such request be reviewed by an independent review organization. We will make our determination on the external exception request and notify the member, the member’s authorized representative or the member’s prescribing physician of our coverage determination no later than 72 hours following receipt of the request, if the original request was a standard exception, and no later than 24 hours following its receipt of the request if the original request was an expedited exception.
If we grant an external exception review of a standard exception request, we will provide coverage of the non-formulary drug for the duration of the prescription. If we grant an external exception review of an expedited exception request, we will provide coverage of the non-formulary drug for the duration of the exigency..
H) Information on Explanations of Benefits
An Explanation of Benefits (EOB) is a statement that we send to members to explain what medical treatments and/or services we paid for on behalf of a member. This shows the amount billed by the provider, the issuer’s payment, and the enrollee’s financial responsibility pursuant to the terms of the policy. We will send an EOB to you after we receive and adjudicate a claim on your behalf from a provider. If you need assistance interpreting your Explanation of Benefits, please contact Member Services at 1-833-492-0679 (TDD/TTY: 711).
I) Coordination of Benefits
Ambetter of Oklahoma coordinates benefits with other payers when a member is covered by two or more group health benefit plans. Coordination of Benefits (COB) is the industry standard practice used to share the cost of care between two or more carriers when a member is covered by more than one health benefit plan.
It is a contractual provision of a majority of health benefit contracts. Ambetter of Oklahoma complies with Federal and state regulations for COB and follows COB guidelines published by National Association of Insurance Commissioners (NAIC).
Under COB, the benefits of one plan are determined to be primary and are first applied to the cost of care. After considering what has been covered by the primary plan, the secondary plan may cover the cost of care up to the fully allowed expense according to the plan’s payment guidelines. Ambetter of Oklahoma Claims COB and Recovery Unit procedures are designed to avoid payment in excess of allowable expense while also making sure claims are processed both accurately and timely.