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 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 network facility, it is possible that some hospital-based providers (for example, assistant surgeons, hospitalists, and intensivists) may not be under contract with us as network providers. We encourage you to inquire about the providers who will be treating you before you begin your treatment, so that you can understand their network participation status with us.

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.

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) posted at ambetter.absolutetotalcare.com under “For Members,” “Forms and Materials,” “Forms”. Send all the documentation to us at the following address:

Ambetter from Absolute Total Care
Attn: Claims Department-Member Reimbursement
P.O. Box 5010
Farmington, MO 63640-5010

After receiving written proof of loss, Ambetter from Absolute Total Care will pay within 40 business days for clean claims filed on paper and within 20 business days for clean claims filed electronically all benefits then due during the calendar year [2023]. Benefits will be paid to you, or to the provider to whom you have assigned payment of benefits. "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 if it was submitted electronically and within 40 calendar days if it was submitted on paper. We 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 do not pay your premium by its due date, you will enter a grace period. This is the extra time we give you to pay.

During your grace period, you will still have coverage. However, if you do not 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 will not be eligible to enroll with us again until Open Enrollment or a Special Enrollment period.

If you receive a subsidy payment:

After you pay your first bill, you have a 90 calendar day 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 health care providers about the possibility of denied claims.

If you do not receive a subsidy payment:

After you pay your first bill, you have a grace period of 30 days. During this time, we will continue to cover your care, but we may hold your 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 received services from a provider or facility that is not in our network, terminate coverage with Ambetter, provide 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 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

Some covered services require prior authorization. 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 Schedule of Benefits, you must obtain authorization from us before the member:

1. Receives a service or supply from a non-network provider;
2. Is admitted into a network facility by a non-network provider; or
3. Receives a service or supply from a network provider to which the member was referred 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:

1. At least five calendar days prior to an elective admission as an inpatient in a hospital, skilled nursing or rehabilitation facility or hospice facility.
2. At least 30 calendar days prior to the initial evaluation for organ transplant services.
3. At least 30 calendar days prior to receiving clinical trial services.
4. Within 24 hours of any inpatient admission.
5. At least five 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:

1. For urgent concurrent review within one calendar day of receipt of the request.
2. For urgent pre-service requests, within three calendar days from date of receipt of request.
3. For non-urgent pre-service requests within two business days but no longer than 14 days of receipt of the request.
4. 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 or by sending a written request to the following address:

Ambetter Absolute Total Care
Attn: Member Services
PO Box 10341
Van Nuys, CA 91410

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 policy 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.

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 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.

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 (“IRO”). 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.

Non-formulary prescription drugs

Under the Affordable Care Act, you have the right to request coverage of prescription drugs that are not listed on the plan formulary (otherwise known as “non-formulary drugs”). To exercise this right, please contact your PCP or provider. Your PCP or provider can utilize the usual prior authorization request process. See “Prescription Drug Exception Process” for additional details.

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 EOB, please contact Member Services.

I) Coordination of Benefits

Coordination of Benefits exists when a member is covered by another plan besides Ambetter determines which plan pays first.  We coordinate benefits with other payers as required by any federal or state laws.  Medicaid is always the payer of last resort.