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
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
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
Retroactive denials
responsible for payment.
- You may be denied retroactively, even after you receive services from a provider
- Preventing retroactive denials
Overpayments
Refund of a premium overpayment due to over-billing
- To receive a refund of premium overpayment
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
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
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
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
