Claims and coverage

General information about your health plan


Out-of-network liability and balance billing

Balance billing occurs when an out-of-network provider bills you for charges other than copayments, coinsurance, or a remaining deductible.

  • Financial liability for out-of-network services
  • Exceptions to out-of-network liability, such as emergency services
  • Balance billing

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Submitting a claim directly

If you submit a claim requesting payment for services that have been received

  • How to submit a claim if the provider failed to submit the claim
  • Time limit to submit a claim

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Grace periods and claims pending during the grace period

About grace periods for payment and claims submitting during the grace period

  • What a grace period is
  • What claims pending is
  • Payment for services received during the grace period

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Retroactive denials

responsible for payment.

  • You may be denied retroactively, even after you receive services from a provider
  • Preventing retroactive denials

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Refund of a premium overpayment due to over-billing

  • To receive a refund of premium overpayment

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Medical necessity and prior authorization

Medical necessity describes care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. Prior authorization is pre-approval by Health Tradition for a covered service, before the service is received.

  • Some services may require prior authorization and/or be subject to review for medical necessity
  • If you don’t follow proper prior authorization procedures
  • The time frame for prior authorization requests

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Prescription drug claims

Requesting and getting access to drugs not listed on the plan’s formulary

  • How to obtain non-formulary drugs
  • The time frame for a decision based on a standard review or expedited review due
  • How to complete the application

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Information on Explanations of Benefits (EOBs)

An EOB is a statement an insurance company sends to explain what medical treatments and/or services it paid for on an enrollee’s behalf, the company’s payment, and your financial responsibility.

  • What an EOB is
  • Sent when we receive or decide on a claim
  • How to read and understand an EOB

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Coordination of benefits (COB)

Coordination of benefits exists when you are is also covered by another plan and determines which plan pays first.

  • How benefits are coordinated

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