2027 Ohio Transparency in Coverage

Out-of-Network Liability and Balance Billing

This is important information.

We use a network of participating providers (“network providers”) to provide services for you. Out-of-network providers do not have a contract with AmeriHealth Caritas Next to provide services to members under this plan. We will not cover services you receive from out-of-network providers except in very limited circumstances. Participating physicians, hospitals, and other health care providers are independent contractors and are neither agents nor employees of AmeriHealth Caritas Next. The availability of any provider cannot be guaranteed, and our provider network is subject to change.

Our plan contracts with network providers to provide covered services to you. This means that we will not pay for services you might receive from out-of-network providers unless:

  • You seek emergency services, or
  • We authorize services from an out-of-network provider because the medically necessary services you need are not available from a network provider, or
  • You receive medically necessary services from an out-of-network provider based in a network facility.

Additionally, if a network provider or network facility stops participating in our network, they become an out-of-network provider or out-of-network facility. You may continue receiving care from that out-of-network provider or out-of-network facility through your continuity/transition of care coverage if, when the network provider or network facility stops participating in our network, you are undergoing a course of treatment for a serious and complex condition or illness; undergoing a course of institutional or inpatient care from the provider or facility; or scheduled to undergo non-elective surgery from the provider, including receipt of postoperative care. This coverage will end when treatment for the condition is completed or you change providers to a network provider, whichever comes first, and is provided for a maximum of 90 days.

  • For example, if the out-of-network provider's charge is $100 and AmeriHealth Caritas Next's allowed amount is $80, the provider may bill you for the remaining $20.

By comparison, a network provider may not bill you for the difference between their charge and AmeriHealth Caritas Next's negotiated rate.

AmeriHealth Caritas Next will comply with the provisions of the No Surprises Act of the 2021 Consolidated Appropriations Act and any associated rules or regulations that the Centers for Medicare & Medicaid Services (CMS) or other regulatory authorities may issue. You will not be penalized and will not incur out-of-network benefit levels unless participating providers able to meet your health needs are reasonably available without unreasonable delay, or you agree to sign over your rights. You will not be charged for balance bills for out-of-network care (emergency services or care by a non-participating provider at a network facility) without your informed consent.

Member Claims Submission

How you get your bill paid — network providers

When you visit a network provider, show your AmeriHealth Caritas Next ID card and pay any required cost-share. After your visit, the network provider will bill AmeriHealth Caritas Next. This bill is called a claim. We will process the claim according to the terms of your insurance plan and any payment due to the network provider will be paid directly.

How you get your bill paid — out-of-network providers

When you visit an out-of-network provider, show your ID card and ask the provider if they will bill your insurance company. Out-of-network providers may agree to submit a bill on your behalf, but they are not required to. This bill is referred to as a claim. We will process the claim according to the terms of your insurance plan. If the claim fits into one of the out-of-network payment exceptions listed above and if authorized by you, any payment due will be made to the provider. Otherwise, any payment due will be made to you.

Remember that any amount due to the provider or you (AmeriHealth Caritas Next allowed amount) may be less than the amount the provider charged and, therefore, you may still be required to pay the difference between the two amounts (balance billed amount) directly to the provider in situations where balance billing is permissible.

If your provider does not agree to submit a bill on your behalf, you must send a completed claim form and an itemized bill to the address listed on your AmeriHealth Caritas Next ID card. You may also call the AmeriHealth Caritas Next Member Services number on your AmeriHealth Caritas Next ID card for information about how to submit a claim.

This is important information. To pay a claim, AmeriHealth Caritas Next must receive proper notice and required claim information within certain timeframes. Written notice of claim must be given within 20 days after a covered loss starts or as soon as reasonably possible. For out-of-network provider claims, no payment will be made for any claims filed by a member for services rendered by an out-of-network provider unless you give written notice of such a claim to AmeriHealth Caritas Next within 180 days of the date of service. Failure to submit a claim within this time does not invalidate or reduce any claim if it was not reasonably possible for you to file the claim within that time, provided that the claim is submitted as soon as reasonably possible. In no event, except in the absence of legal capacity of the member, may the claim be submitted later than one year from the time the claim submittal was originally required.

View the Claims Forms Link with Submission Instructions and Contacts (PDF)

Medical claims:
P.O. Box 7411
London, KY 40742-7411

Pharmacy claims: 
200 Stevens Drive
Philadelphia, PA 19113

AmeriHealth Caritas Next Member Services: 
1-844-350-2177 (TTY 711)

Grace Periods and Claims Pending Policies

During the Grace Period

Monthly premium payments are due on or before the first day of each month for coverage for that month. A grace period is a time period during which AmeriHealth Caritas Next will not terminate your coverage even if you have not paid your premium. Coverage will remain in force during the 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 following the due date.

After paying at least one full month’s premium, you will have a grace period of 31 days from the next premium due date to pay your next premium amount. Those receiving a federal premium subsidy will have a grace period of three consecutive months from the next premium due date to pay all outstanding premium amounts.

If we don’t receive full payment of your premium within the grace period, your coverage will end on the last day of the last month for which a premium has been paid. (For those receiving a federal premium subsidy, it will end on the last day of the first month of the grace period.) If you fail to pay your premium payments on time, we will send you a notice of late payment with an explanation of how the associated grace period works.

For those receiving a federal premium subsidy, AmeriHealth Caritas Next will pay for all appropriate claims for services rendered during the first month of the grace period.

However, claims for services received in the second and third months of the grace period may be pended. When a claim is pended, that means no payment will be made to the provider unless and until your late premium is paid in full. In addition to notifying you of any remaining unpaid premiums during the second and third months of a grace period, we will also notify any providers of the possibility of claims being denied, if applicable.

During the course of a grace period for those receiving a federal premium subsidy, we will continue to collect the subsidies from the U.S. Department of the Treasury (“Department”) on your behalf. However, if you have not paid the entire amount of premium owed by the end of the three-month grace period, iff applicable, we will return the subsidies for the second and third months to the Department at that time and provide you with prompt notice of the termination of your coverage.

Coverage for you and any dependents will be retroactively terminated as of the last day of the first month of the grace period. You cannot enroll again once coverage ends this way unless you qualify for a special enrollment period or during the next open enrollment period.

Retroactive Denials

A retroactive denial is the reversal of a previously paid claim, through which the member then becomes responsible for payment.

Claims may be denied retroactively, even after the member has obtained services from the provider, based on retroactive changes to eligibility, which include but are not limited to failure to pay premiums and follow instructions from the Health Insurance Marketplace.

Best practices to reduce the chance of retroactive denials:

  • Make premium payments on time and in full.
  • Talk to your provider about whether any service they perform is a covered benefit.
  • Whenever possible, obtain your medical services and prescriptions from network providers and pharmacies.

Member Recoupment of Overpayments

Member recoupment of overpayments is the refund of a premium overpayment by the member due to overbilling by the plan. Any premium overpayments will normally be credited to your account and applied to future premiums due. If you believe you have paid too much for your premium and would like a direct refund, please call the AmeriHealth Caritas Next Member Services phone number on the back of your ID card.

Medical Necessity and Prior Authorization

Time Frames and Member Responsibilities

Medical necessity is used to describe health services or supplies that are reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. Covered benefits and services under our plan must be medically necessary. We use clinical criteria, scientific evidence, professional practice standards, and expert opinions in making decisions about medical necessity. The cost of services and supplies that are not medically necessary will not be eligible for coverage and will not be applied to deductibles or out-of-pocket amounts.

Prior authorization is a process through which an issuer approves a request to access a covered benefit before members access the benefit. Certain services or supplies may need to be reviewed before you receive them to make sure, among other things, that they are medically necessary and being provided by a network provider and/or in an appropriate setting.

If you are receiving services from a network provider, the provider will be responsible for obtaining any necessary prior authorization before you receive services. If the prior authorization is denied and the provider still provides you with these services, the provider cannot bill you for these denied services unless you agreed to receive services at a self-pay rate.

If you are obtaining services outside of our service area or from an out-of-network provider, you will need to make sure that any necessary prior authorization has been received before receiving services. If you do not, the service may not be covered under this plan. Coverage will also depend on any limitations or exclusions for this plan, payment of premium, eligibility at the time of service, and any deductible or cost-sharing amounts. If you do not obtain prior authorization before an elective admission to a hospital or certain other facilities, you may be responsible for all charges related to services that fail to meet prior authorization requirements.

We will notify you and your providers in writing of our decision. If we deny the service as a result of our review, we will send written notice to both you and your provider within two business days after the determination is made. We will make our decision and mail you a letter with our decision within the time frames required by the state. We may need more information to make the right decision. If we need more information, we will notify you and your provider what information we need and the date we need it by.

Decisions are made on both an expedited and standard timetable from the date we receive your request and all required supporting documentation. Decisions will be made within the following timelines:

  • Concurrent:
    • 1 business day or 72 hours (whichever is sooner) from receipt of request. Extension: N/A.
  • Urgent Preservice:
    • 72 hours from receipt of the request. Extension: If more information is needed, up to 48 hours.
  • Retrospective Review:
    • Within 30 business days from receipt of request. Extension: If more information is needed, up to 15 calendar days

Formulary Drug Exceptions Time Frames and Member Responsibilities and Rights

Prior authorization and exception requests

For formulary drugs that have restrictions, such as prior authorization (PA), step therapy (ST), quantity limitations (QL), and age limitations (AL), a prior authorization request may be submitted for decisions. AmeriHealth Caritas Next’s Pharmacy Benefits Manager (PBM) will review the requests and will determine if a request meets the clinical drug criteria requirements.

For non-formulary drugs, non-formulary exception requests can be made. Non-formulary exception requests are reviewed on a case-by-case basis. Your provider will be asked to provide medical reasons and any other important information about why you need an exception. AmeriHealth Caritas Next’s PBM will review the requests and will determine if a request is consistent with our medical necessity guidelines.

We will cover non-formulary prescription drugs if the outpatient drug is prescribed by a network provider to treat a covered person for a covered chronic, disabling, or life-threatening illness if the drug:

  • Has been approved by the U.S. Food and Drug Administration (FDA) for at least one indication and is recognized in one of the following references as a for treatment of the indication for which the drug is prescribed in:
    • A prescription drug reference compendium approved by the Insurance Commissioner for the purposes of this section; or
    • Substantially accepted peer-reviewed medical literature;

and

  • There are no formulary drugs that can be taken for the same condition. If there are formulary alternatives to treat the same condition, then documentation must be provided that the member has had a treatment failure with, or is unable to tolerate, two or more formulary alternative medications.
  • Prescription drug samples, coupons, or other incentive programs will not be considered a trial and failure of a prescribed drug in place of trying the formulary-preferred or nonrestricted access prescription drug.

AmeriHealth Caritas Next’s PBM will review the request. If the requested drug is approved, it will be covered according to our medical necessity guidelines. If the request is not approved, then you, your authorized representative, or your provider can appeal the decision.

If the request for a non-formulary drug is approved, the medication will be covered on the highest tier.

You, your authorized representative, or your provider can request formulary drug prior authorizations (PA, ST, QL, and AL) and non-formulary exceptions in the following ways:

  • Electronically: directly to AmeriHealth Caritas Next’s PBM, through electronic prior authorization (ePA) in your electronic health record (EHR) tool software, or you can submit through either of the following online portals:
  • By fax: 1-833-977-7547 for standard (nonurgent) requests, 1-833-977-8874 for expedited (fast) requests
  • By mail:
    200 Stevens Drive
    Philadelphia, PA 19113
  • By phone: 1-844-614-1222

If you or your authorized representative submit the request for a prior authorization or non-formulary exception, your provider must provide follow-up clinical documentation.

Once all necessary and relevant information is received, AmeriHealth Caritas Next’s PBM will review the request. If the request is approved, they will provide an approval response to your provider with a duration of approval. If the request is denied, they will provide a denial response to you and your provider.

Prior authorization and non-formulary exception requests will be completed and notifications sent within the following time frames:

  • Standard (nonurgent): no later than 72hours after we receive the request and any additional required information
  • Expedited (fast)*: no later than 24 hours after we receive the request and any additional required information

*Expedited (fast) requests can be made based on exigent circumstances. Exigent circumstances exist when you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function; or when you are undergoing a current course of treatment using a non-formulary drug. You can indicate your exigent circumstance on the form and request an expedited review.

If the prior authorization request is denied and you feel we have denied the request incorrectly, you may challenge the decision through the internal appeal process for AmeriHealth Caritas Next.

You can ask for an appeal yourself. You may also ask a friend, a family member, your provider, or a lawyer to help you. You can call AmeriHealth Caritas Next at 1-844-350-2177 (TTY 711) if you need help with your appeal request. It’s easy to ask us for an appeal by using one of the options below:

  • Mail: Fill out and sign the Appeal Request Form in the notice you receive about our decision. Mail it to the address listed on the form. We must receive your form no later than 180 days after the date on this notice.
  • Fax: Fill out, sign, and fax the Appeal Request Form in the notice you receive about our decision. You will find the fax number listed on the form.
  • Phone: Call 1-844-350-2177 (TTY 711) and ask for an appeal.

For more information on appeals, please see the section on Appeals in the Member Handbook.

Non-formulary exception request denial rights

For non-formulary exception request denials, you also have the right to pursue either a standard or, if warranted and appropriate, an expedited external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO).

You may exercise your right to external review with an IRO upon initial denial or following a decision to uphold the initial denial pursuant to the internal appeal process of AmeriHealth Caritas Next. If a decision is made to uphold the initial denial, your denial notice will explain your right to external review and provide instructions on how to make this request. An IRO review may be requested by the member, member’s representative, or member’s prescribing provider by contacting AmeriHealth Caritas Next via mail, phone, or fax at the following address:

Mail: Member Appeals
AmeriHealth Caritas Next 
P.O. Box 7452
London, KY 40742- 7452

Phone: 1-844-350-2177 (TTY 711)

An expedited external review may be warranted if based on exigent circumstances. If your request for a standard external review is accepted, it is decided within 72 hours of receipt of your request. If your request for an expedited external review is accepted, it is decided within 24 hours of receipt of your request.

We must follow the IRO’s decision. If the IRO reverses our decision on standard external review, we will provide coverage for the non-formulary item for the duration of the prescription. If the IRO reverses our decision on an expedited external review, we will provide coverage for the non-formulary item for duration of the exigency.

In addition to contacting us, you may contact the Consumer Services Division at:

Ohio Department of Insurance
Consumer Services Division
50 West Town Street
Third Floor — Suite 300
Columbus, OH 43215
Phone: 1-614-644-2658 or toll-free in Ohio: 1-800-686-1526
Fax: 1-614-644-3744  
Email: consumer@insurance.ohio.gov
https://insurance.ohio.gov/

Information on Explanation of Benefits (EOBs)

Each time we process a claim submitted by you or your health care provider, we explain how we processed it in the form of an Explanation of Benefits (EOB).

The EOB is not a bill. It simply explains how your benefits were applied to that particular claim or to the service you received. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you may be responsible for paying the provider. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the Provider.

Coordination of Benefits

Coordination of benefits (COB) is required when you are covered under one or more additional group or individual plans, such as one sponsored by your spouse’s employer. An important part of coordinating benefits is determining the order in which the plans provide benefits. One plan provides benefits first. This is called the primary plan. The primary plan provides its full benefits as if there were no other plans involved. The other plans then become secondary. Further information about COB can be found in the Evidence of Coverage (PDF).