2024 Transparency Notice 

A) Out-of-network liability and balance billing

The Ambetter network is the group of providers, including but not limited to physicians, hospitals, pharmacies, other facilities and health care professionals, we contract with to provide care for you. If a provider is in our network, services are covered by your health insurance plan. Network providers may not bill you for covered expenses beyond your applicable cost sharing amounts (e.g., copayment, coinsurance, and/or a deductible).

If you receive services from a non-participating provider, you may have to pay more for services you receive. Non-participating 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.

When receiving care at a participating hospital it is possible that some hospital-based providers may not be participating providers. If you provide notice and consent to waive balance billing protections, you may be responsible for payment of all or part of the balance bill.  Any amount you are obligated to pay to the non-participating provider in excess of the eligible expense will not apply to your deductible amount or maximum out-of-pocket amount.

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.

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 calendar days after the occurrence or commencement of any loss 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 will need to submit Member Reimbursement Claim Form(PDF) posted at Ambetter.WesternSkyCommunityCare.com under “For Members,” “Forms and Materials,” “Forms.” Send all the documentation to us at the following address:

Ambetter from Western Sky Community Care
Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-5010

After getting your claim, we will let you know we have received it, begin an investigation and request all items necessary to resolve the claim. Benefits will be processed immediately for clean claims.

We will accept or reject your claim no later than 30 days after we receive it. If we reject your claim, the notice will state the reason why. If we agree to pay all or part of your claim, we will pay it no later than the fifth business day after the notice has been made.

C) Grace Periods and Claims Pending

Each premium is to be paid on or before its due date. The initial premium must be paid prior to the coverage effective date, although an extension may be provided during the annual Open Enrollment period.

When a member is receiving a premium subsidy:

After the first premium is paid, a grace period of three months from the premium due date is given for the payment of premium. Coverage will remain in force during the grace period. If full payment of premium is not received within the grace period, coverage will be terminated as of the last day of the first month during the grace period, if advance premium tax credits are received.

We will continue to pay all appropriate claims for covered services rendered to the member during the first month of the grace period, and may pend claims for covered services rendered to the member in the second and third month of the grace period. We will continue to collect advance premium tax credits on behalf of the member from the U.S. Department of the Treasury, and will return the advance premium tax credits on behalf of the member for the second and third month of the grace period if the member exhausts their grace period as described above. A member is not eligible to re-enroll once terminated, unless a member has a special enrollment circumstance, such as a marriage or birth in the family or during annual open enrollment periods.

When a member is not receiving a premium subsidy:

Premium payments are due in advance, on a calendar month basis. Monthly payments are due on or before the first day of each month for coverage effective during such month. There is a 31 day grace period. This provision means that if any required premium is not paid on or before the date it is due, it may be paid during the grace period. During the grace period, the policy will stay in force; however, claims may pend for covered services rendered to the member during the grace period.

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 received services from a provider or facility that is not in our network, 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 service. You can also avoid retroactive denials by obtaining your medical services from a network provider.

If you believe the denial is in error, you are encouraged to contact Member Services by calling the number on the back of your member identification 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), auto pay, or 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 live check.

F) Medical Necessity and Prior Authorization

Services are only covered if they are medically necessary. 

Medically necessary services are health care services that are determined by a provider, in consultation with the health insurance carrier, to be appropriate or necessary, according to:

1. Any applicable generally accepted principles and practices of good medical care;
2. Practice guidelines developed by the federal government, national or professional medical societies, boards and associations; or
3. Any applicable clinical protocols or practice guidelines developed by the health insurance carrier consistent with such federal, national and professional practice guidelines. These standards shall be applied to decisions related to the diagnosis or direct care and treatment of a physical or behavioral health condition, illness, injury or disease.

Prior Authorization Required

Some covered services require prior authorization. In general, participating providers must obtain authorization from us prior to providing a service or supply to a member. However, there are some network eligible expenses for which you must obtain the prior authorization.

For services or supplies that require prior authorization, as shown on the Summary of Benefits and Coverage (SBC), you must obtain authorization from us before you or your dependent member:

• Receive a service or supply from a non-participating provider; or
• Are admitted into a network facility by a non-participating provider, or
• Receive a service or supply from a participating provider to which you or your dependent member were referred to by a non-participating provider.

Prior authorization must be obtained for services or supplies after you or a dependent member are admitted into a network facility by a non-participating provider once emergency room transfer or urgent care stabilization has occurred.

Prior authorization requests must be received by phone/e-fax/provider portal as follows:

1. At least seven days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility or hospice facility.
2. At least seven days prior to the initial evaluation for organ transplant services.
3. At least seven days prior to receiving clinical trial services.
4. Within one business day of an admission for an inpatient admission, including for mental health or substance abuse treatment.
5. At least seven days prior to the start of home health care.

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:

1. For urgent concurrent reviews within one calendar day of receipt of the request.
2. For urgent pre-service reviews, within 24 hours from date of receipt of request.
3. For non-urgent pre-service reviews within seven calendar days of receipt of the request.
4. For post-service or retrospective reviews, within 30 calendar days of receipt of the request.

Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements may result in denial of payment.

Participating 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 an emergency. However, you must contact us as soon as reasonably possible after the emergency occurs.

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 or by sending a written request to the following address:

Ambetter from Western Sky Community Care
Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-5010

1. 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 or a protocol exception for step therapy. 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 or step therapy protocol exception request be granted, we will provide coverage of the non-formulary drug for the duration of the prescription, including refills, or of the drug that is the subject of the protocol exception. 

2. 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 member's life, health, or ability to regain maximum function or when a member 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 standard exception or step therapy protocol exception request be granted, we will provide coverage of the non-formulary drug or the drug that is the subject of the protocol exception for the duration of the exigency.

3. 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 or step therapy protocol exception request, we will provide coverage of the non-formulary drug or the drug that is the subject of the protocol exception 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 or the drug that is the subject of the protocol exception 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 member’s financial responsibility pursuant to the terms of the policy. We will send an EOB to a member 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.

I) Coordination of Benefits

Ambetter 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 policies. Ambetter 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 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.