Transparency in coverage
Only applicable to Individual Health Coverage (IHC) members.
With the right information, you can make the best health-related decisions for yourself and your loved ones. This page will give you a brief overview of some of our business practices, as well as information here about claims, cost-sharing, and coverage. Much of this information is available in your member handbook or summary of benefits.
Member claims submission
A claim is a request for payment. You or your health care provider submits claims to your health insurer. The claims are for costs for health care services and/or supplies from a hospital, doctor, or other health care facility.
Certain medical services may require additional information. This could be notes from the provider, or payment or rejection notices from other insurance carriers. (Other insurance could be Workers’ Compensation, other health plans, Medicare, auto insurance, etc.). Other information also includes origin and destination points for ambulance transfers or accident information. Delays in submitting this special information, when required, may delay the claims from processing.
Generally, you do not need to submit claims for services received in-network. The situation changes if you choose to receive care from an out-of-network provider and/or your provider does not submit claims. In those cases, you must notify us of the claim as soon as possible after receiving covered services. You must notify us in writing or by calling Customer Service at 1-888-YOUR-AH1 (1-888-968-7241). When we receive a notice of your claim, we will send the necessary claim form. You must then send the completed claim form, with all itemized bills attached, within 90 days. Claim forms should be submitted to the following address:
AmeriHealth Insurance Company
P.O. Box 211184
Eagan, MN 55121
Please refer to the last section at the bottom of this page for more information.
Nonpayment of premium and grace periods for members receiving premium tax credits
Per regulation 45 CFR 156.270(d), members who receive advance payments of the premium tax credit and have previously paid at least one full month’s premium have a 90-day grace period when premium payments are not made on time. A grace period is additional time that a member is given to pay outstanding premium. During the grace period a member can make outstanding premium payments without losing coverage. If a member fails to make payment in full within 90 days, coverage will be terminated.
Claims received during the first 31 days of the grace period will be paid on schedule. Claims received during the remaining grace period may be pended as necessary, meaning we will neither pay nor deny the claim. If a member pays his or her outstanding premium in full during the 90-day grace period, claims will be paid accordingly. If the member fails to pay his or her outstanding premium, claims will be denied.
Per regulation 45 CFR 155.430(b)(2)(ii)(B), members who do not receive advance payments of the premium tax credit and have previously paid at least one full month’s premium will not have their claims paid during the 31-day grace period, but the claims will be pended. After the 31-day grace period has ended, if the member has not paid the premium, the claims that are pended will deny and the account will be retroactively terminated effective to the last paid-to-date.
Retroactive denial of claims
A retroactive denial is the reversal of a previously paid claim. This occurs after services are rendered, where you may become liable for payment. Claims may be retroactively denied in certain situations, including, but not limited to the following:
- If your coverage is retroactively terminated
- If we determine you have other health care coverage that should have been the primary payer
- If there was a provider billing error
Ways to prevent a retroactive denial include the following:
- Ensure that premium payments are made on time
- Do not sign up for Marketplace coverage when you are eligible for Medicare, Medicaid, or other insurance that qualifies as Minimum Essential Coverage
- Ensure that you are not intentionally misrepresenting any material facts when signing up for health care coverage
- Review and understand your benefits
- Review your Explanation of Benefits (EOB) thoroughly
If you have any questions about the payment of your claim you may contact Customer Service at 1-888-YOUR-AH1 (1-888-968-7241).
Member recoupment of overpayments
If you dispute a charge or payment, you may contact Customer Service for additional assistance by calling 1-800-313-9168.
Coordination of benefits
If you have more than one health insurance plan, those plans need to work together to make sure you’re getting the most out of your coverage. That process is referred to as Coordination of Benefits. Coordinating your benefits helps us process your claims faster and maximizes your benefits, which can lower your out-of-pocket costs. One plan becomes your primary plan and pays your claims first. Then the second plan pays toward the remaining cost.
Please refer to the last section at the bottom of this page for additional information.
Liability for non-network coverage and balance billing
AmeriHealth offers Health Maintenance Organization (HMO) and Exclusive Provider Organization (EPO) plans in the Individual Health Care (Consumer) market. These plans do not include coverage for services provided outside of our provider network. Therefore, you would be responsible for the full cost of the service if you are receiving out-of-network care. However, there are two types of exceptions to this. Emergency care is covered no matter where the service is obtained. Also, you may be covered if you inadvertently receive care from an out-of-network provider while being treated at a network facility. In both cases, applicable network cost-share would apply. Please see your benefit booklet for additional details on your coverage level.
Explanation of Benefits
Your Explanation of Benefits (EOB) helps you understand your out-of-pocket costs for covered services. This includes how much your provider charged for the services, how much your health care plan paid, and what amount you owe. You will only receive an EOB if you are liable for any charges after the claim is adjudicated.
Find out how to read and understand your EOB. If you have any questions about your EOB, contact Customer Service at 1-888-YOUR-AH1 (1-888-968-7241).
Please refer to the last section at the bottom of this page for additional information.
Formulary Drug Exception Process
Sometimes our members need access to drugs that are not listed on the plan’s formulary (drug list). These medications are initially reviewed the pharmacy benefits manager for AmeriHealth through the formulary exception review process. The member or provider can submit the request to us by calling the pharmacy benefits manager at 1-888-678-7012. Providers can also submit a request electronically or send a fax to 1-888-678-5285. The exception request must describe your need for the drug. If the exception request is approved, we will cover the drug at the highest cost-share as listed in your benefits.
We will reply to requests within one business day. If you do not receive a reply within this timeframe, please call the pharmacy benefits manager at 1-888-678-7012.
Quantity limits and age limits still apply to exception requests. If your request is denied, we will send you and your doctor each a letter, which will provide notification of the denial decision and details regarding your right to appeal.
AmeriHealth New Jersey Appeals Unit
259 Prospect Plains Road, Bldg M
Cranbury, NJ 08512
Phone: 1-877-585-5731 prompt #2
Fax: 609-662-2480
Drug Exception Appeal Process
AmeriHealth (AH) offers an exception process which allows covered persons to request and gain access to drugs not listed on the plan’s formulary
An internal appeal may be requested by a covered person or an authorized representative by mailing, calling, or faxing the request to:
AmeriHealth
The Member Appeals Department
P.O. Box 41820
Philadelphia, PA 19101-1820
Phone: 1-888-671-5276
Fax: 1-888-671-5274
AmeriHealth will review an initial standard appeal for a drug exception denial within seventy-two (72) hours from when we receive the request.
AmeriHealth will review an initial expedited appeal for a drug exception denial within twenty-four (24) hours from when we receive the request.
If not satisfied with the outcome of the internal appeals process, if your plan is an Insured plan and subject to New Jersey state laws, the Covered Person, the Covered Person’s authorized representative, or prescribing provider may initiate an External Appeal/Review by contacting, Maximus, an Independent Utilization Review Organization (IURO) consistent with New Jersey requirements.
The Claimant should electronically file the request by providing the requested information at njihcap.maximus.com.
Claimants who are unable to submit their requests electronically, can download and print the appeal from the Maximus website above. Claimants may also contact Maximus by regular mail and/or by fax. The completed appeal form may be returned to Maximus by fax or mail as set forth below:
Fax: 585-425-5296
Maximus Federal-NJ IHCAP 3750
Monroe Avenue, 705
Pittsford, New York 14534
Questions about the application process can be directed to Maximus Federal by calling: 1-888-866-6205 or emailing Stateappealseast@maximus.com.
For external review of standard exception requests that were initially denied, the timeframe for review is seventy-two (72) hours from when Maximus receive the request.
For external review of expedited exception requests that were initially denied, the timeframe for review is twenty-four (24) hours from when Maximus receives the request.
AmeriHealth must accept the decision made by Maximus.
Preapproval for coverage of services
Certain services require preapproval from AmeriHealth. (Preapproval is sometimes called precertification.) It is needed before the service is performed. Your doctor will submit the paperwork for this type of request. If your doctor has questions about our process, please share with them the process information. We do not require members to submit a preapproval by a certain date.
If your doctor needs help with this type of request, they should call 1-888-YOUR-AH1 (1-888-968-7241) and select the prompt for “authorizations.” Providers registered with the PEAR portal may use PEAR Practice Management to submit requests for services to be rendered at an acute care facility or ambulatory surgical center.
When obtaining services from in-network providers, the provider is responsible for obtaining the preapproval. Members with POS plans who need services out-of-network are responsible for obtaining the preapproval when necessary.
The Care Management and Coordination (CMC) department will evaluate the request. They will notify the member and provider once a decision has been reached for those cases that require clinical review. Failure to complete the required preapproval process may result in a reduction in payment or nonpayment.
A member or doctor may appeal our decision or provide additional information to support the request at any time during the evaluation process. Once notification of an emergent admission or request for prior approval is submitted, clinical information allowing for utilization review must be provided within 72 hours. In the event such information is not submitted within 72 hours, the case will be deemed withdrawn. A determination will be rendered within 24 hours of receipt of all clinical information for emergent admissions. For non-urgent services, a decision will be completed no later than 15 days from receipt of complete clinical information.
The Departments of the Treasury, Labor, and Health and Human Services (the Departments) have issued the Transparency in Coverage final rules (85 FR 72158) that require non-grandfathered group health plans and health insurance issuers in the individual and group markets to disclose certain cost-sharing information to a participant, beneficiary, or enrollee (or his or her authorized representative), upon request. To get a cost estimate, please log in at amerihealth.com/login and use the Care Cost Estimator. This notice contains important information about the cost estimate and information on the amount you may be required to pay for an item or service.
Additional information
For individual and/or family coverage:
- Please refer to the benefit booklet of your plan or Summary of Benefits and Coverage (SBC) of your plan of interest for more information.
Third-party payment
The information on this page refers to the health plans offered to our Individual members. If you are enrolled in a group plan provided by your employer, please refer to your specific plan benefit booklet or Summary of Benefits and Coverage documents for additional information available on your member portal.