Ambetter Health Solutions 2025 Transparency Notice

Indiana 2025 Transparency Notice
Georgia 2025 Transparency Notice
Missouri 2025 Transparency Notice (PPO and EPO)
Mississippi 2025 Transparency Notice
Ohio 2025 Transparency Notice
South Carolina 2025 Transparency Notice

Indiana 2025 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 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.

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, less any deductible, copayment amounts or cost sharing that is your financial responsibility.

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 AmbetterHealth.com under “Member Resources”. Send all the documentation to us at the following address:

Ambetter Health
Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-5010

Benefits will be paid within 30 calendar days for clean claims filed electronically or 45 calendar days for clean claims filed on paper. "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 30 calendar days of our initial receipt of the claim and will complete our processing of the claim within 15 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 do not receive a subsidy payment

After you pay your first bill, you have a grace period of 60 days. During this time, we will continue to cover your care, but we may hold your claims. We will notify you, your providers and HHS about this non-payment and the possibility of denied 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.

Retroactive denials can be avoided 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

If you believe you have paid too much for your premium and should receive a refund, please contact Member Services immediately at the number listed on the back of your member identification card. 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) system, 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. In general, network 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 Schedule of Benefits, you must obtain authorization from us before you:

Receive a service or supply from a non-network provider;
Are admitted into a network facility by a non-network provider; or
Receive a service or supply from a network provider to which you or your dependent member were 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 (medical and behavioral health) requests must be received by phone/e-fax/provider portal as follows:

At least five calendar days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility or hospice facility.
At least 30 calendar days prior to the initial evaluation for organ transplant services.
At least 30 calendar days prior to receiving clinical trial services.
Within 24 hours of any inpatient admission, including emergent inpatient admissions.
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 received, we will notify you and your provider if the request has been approved as follows:

For urgent concurrent reviews, within one calendar day of receipt of the request.
For urgent pre-service reviews, within 48 hours of receipt of the request.
For non-urgent pre-service reviews within five business days of receipt of the request.
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 will result in benefits being reduced. A non-network provider can balance bill you for these services.

Network providers cannot bill you for services for which they fail to obtain prior authorization as required.

In cases of emergency, 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 the 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 providers can submit a drug exception request to us by contacting Member Services or by sending a written request to the following address:

Ambetter Health
550 North Meridian Street
Suite 101
Indianapolis, IN 46204

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.

Expedited exception request

A member, a member’s designee 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. The request can be made in writing or via telephone. Within 24 hours of the request being received, we will provide the member, the member’s designee 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 designee, 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 designee, or the member’s prescribing physician of our coverage determination no later than three business days following receipt of the request if the original request was a standard exception and no later than one business day 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 at.

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 contracts. 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.

Georgia 2025 Transparency Notice

A) Out-of-network liability and balance billing

The Ambetter Health 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).

When receiving care at a network hospital it is possible that some hospital-based providers may not be network 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-network provider in excess of the eligible expense will not apply to your deductible amount or maximum out-of-pocket amount.

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.

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, less any deductible, copayment or cost sharing that is your financial responsibility. We must receive notice of claim within 30 calendar days of the date the loss began 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 also need to submit a copy of the Member Reimbursement Claim Form (PDF) posted at AmbetterHealth.com under “For Member – Forms and Materials.” Send all the documentation to us at the following address:

Ambetter Health
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. We will do this in 30 calendar days or less.

We will notify you, in writing, that we have either accepted or rejected your claim for processing within 20 days. If we are unable to come to a decision about your claim within 20 days, we will let you know and explain why we need additional time.

For services that do not fall under Georgia state law balance billing protections, benefits will be processed within 30 calendar days after receipt of proper proof of loss. For services that fall under Georgia state law balance billing protections, benefits will be paid within 15 working days for clean claims filed electronically or 30 calendar days for clean claims filed on paper.

C) Grace Periods and Claims Pending

If you don’t pay your premium by its due date, you’ll 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 don’t 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 won’t 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 three-month 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 healthcare providers about the possibility of denied claims.

If you don’t receive a subsidy payment

After you pay your first bill, you have a 60-day grace period. During this time, we will continue to cover your care, but we may hold your claims. We will notify the member of the non-payment of premiums, as well as providers of the possibility of denied claims.

D) Retroactive Denials

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 Health, provide late notification of other coverage due to new coverage, or have a change in circumstance, such as divorce or marriage. This causes Ambetter Health 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 benefit. 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’s services department by calling the number on your member Identification card.

E) Recoupment of Overpayments

If you believe you have paid too much for your premium and should receive a refund, please contact Member Services immediately at the number listed on the back of your member identification card. 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 eCashiering, interactive voice response (IVR), auto pay, or member portal, as well as credit card payments sent to our lockbox vendor, will be refunded via eCashering. Payments made via eCheck 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 any medical service, items, supply, or treatment to diagnose and treat a member's illness or injury:

Is consistent with the symptoms or diagnosis;
Is provided according to generally accepted standards of medical practice;
Is not custodial care;
Is not solely for the convenience of the provider or the member;
Is not experimental or investigational;
Is provided in the most cost effective care facility or setting;
Does not exceed the scope, duration, or intensity of that level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment; and
When specifically applied to a hospital confinement, it means that the diagnosis and treatment of your medical symptoms or conditions cannot be safely provided as an outpatient.

Charges incurred for treatment not medically necessary are not eligible expenses.

Prior Authorization Required

Some medical and behavioral health covered service expenses require prior authorization. In general, network providers must obtain authorization from us prior to providing a service or supply to a member. However, there are some network eligible service 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 you or your dependent member:

Receives a service or supply from a non-network provider;
Are admitted into a network facility by a non-network provider; or
Receives a service or supply from a network provider to which you or your dependent member was referred by a non-network provider.

Prior authorization requests (medical and behavioral health) must be received by phone, efax, or provider web portal as follows:

At least 5 calendar days prior to an elective admission as an inpatient in a Hospital, extended care or Rehabilitation facility, Hospice facility, or residential treatment facility.
At least 30 calendar days prior to the initial evaluation for organ transplant services.
At least 30 calendar days prior to receiving clinical trial services.
Within 24 hours of any inpatient admission, including emergent inpatient admissions.
At least 5 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 received, we will notify you and your provider if the request has been approved as follows:

For urgent concurrent reviews within 1 calendar day of receipt of the request.
For urgent pre-service reviews, within 72 hours from date of receipt of request.
For non-urgent pre-service reviews, within 7 calendar days of receipt of the request.
For post-service requests or retrospective reviews, within 30 calendar days of receipt of the request.

In situations where additional information is needed to make a decision, these timeframes may be extended in accordance with applicable law.

Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements will result in benefits being reduced. Please see the Schedule of Benefits for specific details.

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 the 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 Health Solutions
Attn: Member Services
1100 Circle 75 Parkway, Suite 1100
Atlanta, GA 30339

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. 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 be granted, we will provide coverage of the non-formulary drug for the duration of the prescription, including refills.

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. The request can be made in writing or via telephone. 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 expedited exception request be granted, we will provide coverage of the non-formulary drug 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. 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 request, we will provide coverage of the non-formulary drug 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 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 enrollee’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

Coordination of Benefits exists when an enrollee is covered by another plan besides Ambetter Health and 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.

Missouri 2025 Transparency Notice PPO

A) Non-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-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 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. As a member, non-network providers should not bill you for covered services for any amount greater than your applicable in-network cost responsibilities when balance billing protections apply to covered services that are: Emergency services provided to a member, as well as services provided after the member is stabilized unless the member gave notice and consent to be balance billed for the post-stabilization services;
2. Non-emergency health care services provided to a member at a network hospital or at a network ambulatory surgical center unless if member gave notice and consent pursuant to the federal No Surprises Act to be balance billed by the non-network provider; or
3. Air ambulance services provided to a member by a non-network provider.

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.

Written proof of loss must be furnished to us in case of claim for loss for which this contract provides any periodic payment contingent upon continuing loss within 90 calendar days after the termination of the period for which the insurer is liable and in case of claim for any other loss within 90 calendar days after the date of such loss. Failure to furnish such proof within the time required will not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required. Subject to due written proof of loss, all accrued indemnities for loss for which this contract provides periodic payment will be paid monthly.

If you have paid for services we agreed to cover, you can request reimbursement for the amount you paid, less any deductible, copayment or cost sharing that is your financial responsibility.

To request reimbursement for a covered service, you need a copy of the detailed claim from your provider. You also need to submit the copy of the member reimbursement claim form (PDF) posted at AmbetterHealth.com under “Member Resources”. Send all the documentation to us at the following address:

Ambetter Health Solutions
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. We will do this in 30 days or less.

We will notify you, in writing, that we have either accepted or rejected your claim for processing within 30 business days as well. If we are unable to come to a decision about your claim within 30 business days, we will let you know and explain why we need additional time.

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 29 business days after the notice has been made.

C) Grace Periods and Claims Pending

If you don’t pay your premium by its due date, you’ll enter a grace period. This is the extra time we give you to pay.

If your coverage is terminated for not paying your premium, you won’t be eligible to enroll with us again until Open Enrollment or a Special Enrollment period.

If you receive a subsidy payment

After the first premium is paid, a grace period of 3 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 notify the U.S. Department of Health and Human Services (HHS) of the non-payment of premiums, the member, as well as providers of the possibility of denied claims when the member is 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.

If you don’t receive a subsidy payment

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 60 calendar 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 contract will stay in force; however, claims may pend for covered services rendered to the member during the grace period. We will notify the member, as well as providers, of the possibility of denied claims when the member is in the grace period.

D) Retroactive Denials

There are instances where claims may be denied retroactively if you: receive 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.

If you believe the denial is in error, you are encouraged to contact Member Services Department by calling the number on your member identification card.

E) Recoupment of Overpayments

If you believe you have paid too much for your premium and should receive a refund, please contact Member Services immediately at the number listed on the back of your member identification card. 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 eCashiering, interactive voice response (IVR), auto pay, or member portal, as well as credit card payments sent to our lockbox vendor, will be refunded via eCashering. Payments made via eCheck 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 means, based on our determination, any medical service, items, supply or treatment to diagnose and treat a member’s illness or injury:

Is consistent with the symptoms or diagnosis;
Is provided according to generally accepted standards of medical practice;
Is not custodial care;
Is not solely for the convenience of the physician or the member;
Is not experimental or investigational;
Does not exceed the scope, duration, or intensity of that level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment; and
When specifically applied to a hospital confinement, it means that the diagnosis and treatment of your medical symptoms or conditions cannot be safely provided as an outpatient.

Charges incurred for treatment not medically necessary are not eligible service expenses.

Prior Authorization Required

Some medical and behavioral health covered services require prior authorization. In general, network providers must obtain prior authorization from us prior to providing a network eligible service or supply to a member. However, there are some cases in which you must obtain the prior authorization. For example, if you:

Wish to receive a service or supply from a non-network provider;
Are admitted into a network facility by a non-network provider; or
Are requesting a non-covered service.

Prior authorization must be obtained for the following services, except for urgent care or emergency services. This list is not exhaustive. To confirm if a specific service requires prior authorization, please contact Member Services.

Non-emergency health care services provided by non-network providers ;
Reconstructive procedures;
Diagnostic tests such as specialized labs, procedures and high technology imaging;
Injectable drugs and medications;
Inpatient health care services;
Specific surgical procedures;
Nutritional supplements;
Pain management services; and Transplant services.

Prior authorization requests (medical and behavioral health) can be submitted by your provider electronically or via telephone, eFax, or provider web portal. Although not required, submitting requests within the recommended timeframes below will allow for timely review of prior authorization requests:

At least five calendar days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, hospice facility or residential treatment facility.
At least 30 calendar days prior to the initial evaluation for organ transplant services.
At least 30 calendar days prior to receiving clinical trial services.
Within 24 hours of any inpatient admission, including emergent inpatient admissions.
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 necessary information, including the results of any face-to-face clinical evaluation or second opinion that may be required has been submitted, we will notify you and your provider if the request has been approved as follows:

For urgent concurrent review, within one calendar day of receipt of the request.
For immediate or urgent request situations within 60 minutes, when the lack of treatment may result in an emergency room visit or emergency admission
For non-urgent pre-service requests regarding proposed admission, procedure or service, within 36 hours, which shall include one business day, of obtaining all necessary information
For urgent pre-service requests, within 24 hours from the date of receipt of the request of service.
For post-service requests and retrospective reviews, we will make our determination within 30 calendar days of receipt of the request. We will notify you in writing of the determination within ten calendar days of making the determination

Except for medical emergencies, prior authorization must be obtained before services are rendered or expenses are incurred.

Failure to Obtain Prior Authorization

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 the emergency services.

G) Drug Exceptions Timeframes and Enrollee Responsibilities

Prescription Drug Exception Process

Ambetter Health Solutions
Attn: Member Services
7711 Carondelet Ave.
St. Louis, MO 63105

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. 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. The request can be made in writing or via telephone. 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 external 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.

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 enrollee’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

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.

Due to Missouri Law, Ambetter does not coordinate benefits with other commercial plans. However, coordination with Medicare may be required to avoid duplication of benefits when Ambetter members who become eligible for and enroll in Medicare. In that instance, Medicare is considered to be the primary payer, with Ambetter paying secondary up to Medicare’s allowable amount, subject to our benefits. It is important to note that dually enrolled members may not qualify for any government premium subsidies they once qualified for prior to Medicare becoming effective. If a member has any questions or concerns regarding being dually enrolled with Medicare and Ambetter, please contact the Health Insurance Marketplace for more information on the best course of action.

Ambetter complies with federal and state laws and regulations for COB and follows COB guidelines published by National Association of Insurance Commissioners (NAIC).

“Allowable expense” is the necessary, reasonable, and customary item of expense for health care, when the item is covered at least in part under any of the plans involved, except where a statute requires a different definition. When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered as both an allowable expense and a benefit paid.

Missouri 2025 Transparency Notice EPO

A) Non-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-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 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. As a member, non-network providers should not bill you for covered services for any amount greater than your applicable in-network cost responsibilities when balance billing protections apply to covered services that are: Emergency services provided to a member, as well as services provided after the member is stabilized unless the member gave notice and consent to be balance billed for the post-stabilization services;
Non-emergency health care services provided to a member at a network hospital or at a network ambulatory surgical center unless if member gave notice and consent pursuant to the federal No Surprises Act to be balance billed by the non-network provider; or
Air ambulance services provided to a member by a non-network provider.

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, less any deductible, copayment or cost sharing that is your financial responsibility.

Ambetter Health Solutions
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. We will do this in 30 days or less.

C) Grace Periods and Claims Pending

If you don’t pay your premium by its due date, you’ll enter a grace period. This is the extra time we give you to pay.

If your coverage is terminated for not paying your premium, you won’t be eligible to enroll with us again until Open Enrollment or a Special Enrollment period.

If you receive a subsidy payment

If you don’t receive a subsidy payment

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 30 calendar 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 contract will stay in force; however, claims may pend for covered services rendered to the member during the grace period. We will notify the member, as well as providers, of the possibility of denied claims when the member is in the grace period.

D) Retroactive Denials

If you believe the denial is in error, you are encouraged to contact Member Services Department by calling the number on 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 eCashiering, interactive voice response (IVR), auto pay, or member portal, as well as credit card payments sent to our lockbox vendor, will be refunded via eCashering. Payments made via eCheck 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

Is consistent with the symptoms or diagnosis;
Is provided according to generally accepted standards of medical practice;
Is not custodial care;
Is not solely for the convenience of the physician or the member;
Is not experimental or investigational;
Does not exceed the scope, duration, or intensity of that level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment; and
When specifically applied to a hospital confinement, it means that the diagnosis and treatment of your medical symptoms or conditions cannot be safely provided as an outpatient.

Charges incurred for treatment not medically necessary are not eligible service expenses.

Prior Authorization Required

Wish to receive a service or supply from a non-network provider;
Are admitted into a network facility by a non-network provider; or
Are requesting a non-covered service.

Non-emergency health care services provided by non-network providers ;
Reconstructive procedures;
Diagnostic tests such as specialized labs, procedures and high technology imaging;
Injectable drugs and medications;
Inpatient health care services;
Specific surgical procedures;
Nutritional supplements;8. Pain management services; and Transplant services.

At least five calendar days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, hospice facility or residential treatment facility.
At least 30 calendar days prior to the initial evaluation for organ transplant services.
At least 30 calendar days prior to receiving clinical trial services.
Within 24 hours of any inpatient admission, including emergent inpatient admissions.
At least five calendar days prior to the start of home health care except those members needing home health care after hospital discharge.

For urgent concurrent review, within one calendar day of receipt of the request.
For immediate or urgent request situations within 60 minutes, when the lack of treatment may result in an emergency room visit or emergency admission
For non-urgent pre-service requests regarding proposed admission, procedure or service, within 36 hours, which shall include one business day, of obtaining all necessary information
For urgent pre-service requests, within 24 hours from the date of receipt of the request of service.
For post-service requests and retrospective reviews, we will make our determination within 30 calendar days of receipt of the request. We will notify you in writing of the determination within ten calendar days of making the determination

Except for medical emergencies, prior authorization must be obtained before services are rendered or expenses are incurred.

Failure to Obtain Prior Authorization

G) Drug Exceptions Timeframes and Enrollee Responsibilities

Prescription Drug Exception Process

Ambetter Health Solutions
Attn: Member Services
7711 Carondelet Ave.
St. Louis, MO 63105

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. 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 external 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.

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 enrollee’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

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.

Ambetter complies with federal and state laws and regulations for COB and follows COB guidelines published by National Association of Insurance Commissioners (NAIC).

Mississippi 2025 Transparency Notice

A) Non-network liability and balance billing

If you receive services from a provider that is not in the network, you may have to pay more for services you receive. Non-network providers may be permitted to bill you for the difference between what your plan agreed to pay, and the full 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 limit. However, you will not be balance billed when balance billing protections apply to covered services.

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 usually happens 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 written proof of loss within 90 days of the loss or as soon as is reasonably possible. Proof of loss furnished more than one year late will not be accepted, unless you or your covered dependent member had no legal capacity to submit such proof during that year.

To request reimbursement for a covered service, you need a copy of the detailed claim from your provider. You also need to submit the member reimbursement claim form (PDF) posted at AmbetterHealth.com under “For Members – Forms and Materials”. Send all the documentation to us at the following address:

Ambetter Health
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. We will do this in 15 days or less.

We will notify you, in writing, that we have either accepted or rejected your claim for processing within 15 business days as well. If we are unable to come to a decision about your claim within 15 business days, we will let you know and explain why we need additional time.

We will accept or reject your claim no later than 45 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 14 business days after the notice has been made.

C) Grace Periods and Claims Pending

If you don’t pay your premium by its due date, you’ll enter a grace period. This is the extra time we give you to pay.

If your coverage is terminated for not paying your premium, you won’t be eligible to enroll with us again until Open Enrollment or a Special Enrollment period.

If you receive a subsidy payment

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 advanced 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.

If you don’t receive a subsidy payment

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 60-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 contract will stay in force; however, claims may pend for covered services rendered to the member during the grace period. We will notify the member, as well as providers, of the possibility of denied claims when the member is in the grace period. We will notify the member, of the non-payment of premiums, as well as providers of the possibility of denied claims when the member is in the grace period.

D) Retroactive Denials

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 Health to request recoupment of payment from the provider. We will not retroactively deny reimbursement as a result of an overpayment determination more than 24 months after the date we initially paid the provider.

If you believe the denial is in error, you are encouraged to contact member’s services department by calling the number on your member identification card.

E) Recoupment of Overpayments

If you believe you have paid too much for your premium and should receive a refund, please contact Member Services immediately at the number listed on the back of your member identification card. 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 eCashiering, interactive voice response (IVR), auto pay, or member portal, as well as credit card payments sent to our lockbox vendor, will be refunded via eCashiering. Payments made via eCheck 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 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 service expenses require prior authorization. There are some network eligible service expenses for which you must obtain the prior authorization.

For services, items, or supplies that require prior authorization, as shown in your Schedule of Benefits, you must obtain authorization from us before you or your dependent member:

Receive a service or supply from a non-network provider;
Are admitted into a network facility by a non-network provider; or
Receive a service or supply from a network provider to which you or your dependent member were 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 (medical and behavioral health) requests must be received by telephone, fax or provider portal as follows:

At least five days prior to an elective admission as an inpatient in a hospital, extended care, or rehabilitation facility, hospice facility, or residential treatment facility.
At least 30 days prior to the initial evaluation for organ transplant services.
At least 30 days prior to receiving clinical trial services.
Within 24 hours of any inpatient admission, including emergent inpatient admissions.
At least five days prior to the start of home health care except those members needing home health care after hospital discharge.

After prior authorization has been received, we will notify you and your provider if the request has been approved as follows:

For urgent concurrent reviews within 1 calendar day of receipt of the request.
For urgent pre-service reviews, within 48 hours from date of receipt of the request.
For non-urgent pre-service reviews within 7 calendar days from date of receipt of the request.
For post-service or retrospective reviews, within 30 calendar days from date of receipt of the request.

In situations where additional information is needed to make a decision, these timeframes may be extended in accordance with applicable law.

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.

G) Drug Exceptions Timeframes and Enrollee Responsibilities

Prescription Drug Exception Process

Ambetter Health
Attn: Member Service
1020 Highland Colony Parkway, Suite 502
Ridgeland, MS 39157

Standard exception request

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. The request can be made in writing or via telephone. 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 expedited exception request be granted, we will provide coverage of the non-formulary drug for the duration of the exigency.

External exception request review

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 enrollee’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

The coordination of benefits (COB) provision applies when you have health care coverage under more than one plan as stated herein.

The order of benefit determination rules govern the order which each plan will pay a claim for benefits.

The plan that pays first is called the primary plan. The primary plan must pay benefits according to its contract terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. The secondary plan may reduce the benefits it pays so that payments from all plans do not exceed 100 percent of the total allowable expense.

Ohio 2025 Transparency Notice HMO

A) Out-of-network liability and balance billing

If you receive services from a non-network provider, you may be responsible for the difference between the amount the provider charges for the service (billed amount) and the allowed amount that we pay. However, you will not be responsible for balance billing for non-network care that is subject to balance billing protections and otherwise covered under your contract. If you are balance billed in these situations, please contact Member Services immediately at the number listed on the back of your member identification card.

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.

We must receive written proof of loss within 90 calendar days of the loss or as soon as is reasonably possible. Proof of loss furnished more than one year late will not be accepted, unless you or your covered dependent member had no legal capacity to submit such proof during that year.

If you have paid for services we agreed to cover, you can request reimbursement for the amount you paid, less any deductible, copayment or cost sharing that is your financial responsibility. 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 or bill from the provider. You also need to submit an explanation of why you paid for the covered services along with the Member Reimbursement Claim Form (PDF) posted at AmbetterHealth.com under “For Members-Forms and Materials”. Send this to us at the following address:

Ambetter Health Solutions
Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-5010

Benefits will be paid within 30 calendar days after receipt of proof of loss. Should we determine that additional supporting documentation is required to establish responsibility of payment, we shall pay benefits within 45 calendar days after receipt of proof of loss. If we do not pay within such period, we shall pay interest at the rate of 18 percent per annum from the 31st calendar day after receipt of such proof of loss to the date of late payment.

C) Grace Periods and Claims Pending

If you don’t pay your premium by its due date, you’ll enter a grace period. This is the extra time we give you to.

If your coverage is terminated for not paying your premium, you won’t be eligible to enroll with us again until Open Enrollment or a Special Enrollment period.

If you receive a subsidy payment

If you don’t receive a subsidy payment

After you pay your first bill, you have a grace period of 60 calendar days. During this time, we will continue to cover your care, but we may hold your claims. We will notify you, your providers and HHS about this non-payment and the possibility of denied claims.

D) Retroactive Denials

Retroactive denials can be avoided 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 benefit. You can also avoid retroactive denials by obtaining your medical services from an in-network provider.

If you believe the denial is in error, you are encouraged to contact Member Services by calling the number on your member identification card.

E) Recoupment of Overpayments

If you believe you have paid too much for your premium and should receive a refund, please contact Member Services immediately at the number listed on the back of your member identification card. 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 consistent with the symptoms or diagnosis;
Are provided according to generally accepted standards of medical practice;
Are not custodial care;• Demonstrate that the member is reasonably capable of improving in his/her functional ability;
Are not solely for the convenience of the provider or the member;
Are not experimental or investigational;
Are provided in the most cost-effective care facility or setting;
Do not exceed the scope, duration, or intensity of that level of care that is needed to provide safe, adequate, and appropriate diagnosis or treatment; and
When specifically applied to a hospital confinement, it means that the diagnosis and treatment of your medical symptoms or conditions cannot be safely provided as an outpatient.

Some covered service expenses require prior authorization. There are some network eligible service 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 you:

Receive a service or supply from a non-network provider;
Are admitted into a network facility by a non-network provider; or
Receive a service or supply from a network provider to which the member was referred by a non-network provider.

Prior Authorization requests must be received by phone/e-fax/Provider portal as follows:

At least 5 calendar days prior to an elective or scheduled admission as an inpatient in a hospital, extended care or rehabilitation facility, or hospice facility or as soon as reasonably possible.
At least 30 calendar days prior to the initial evaluation for organ transplant services or as soon as reasonably possible.
At least 30 calendar days prior to receiving clinical trial services or as soon as reasonably possible.
Within 24 hours (or as soon as reasonably possible) of any inpatient admission, including emergent inpatient admissions.
At least 5 calendar days prior to the start (or as soon as reasonably possible) of home health care except those members needing home health care after hospital discharge.

After prior authorization has been received, we will notify you and your provider if the request has been approved or denied as follows:

For urgent care services, within one calendar day of receipt of the request.
For urgent concurrent review within 48 hours of receipt of the request.
For non-urgent pre-service requests within 10 calendar days of receipt of the request.
For post-service requests, within 30 calendar days of receipt of the request.

In situations where additional information is needed to make a decision, these timeframes may be extended in accordance with applicable law.

Failure to Obtain Prior Authorization

Failure to comply with the prior authorization requirements will result in benefits being denied.

In cases of emergency, benefits will not be reduced for failure to comply with prior authorization requirements. However, you must contact us as soon as reasonably possible after the emergency occurs.

Network providers cannot bill you for services for which they fail to obtain prior authorization as required.

G) Drug Exceptions Timeframes and Enrollee Responsibilities

Ambetter Health Solutions
Attn: Member Services
4349 Easton Way
Suite 120
Columbus, OH 43219

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. 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 be granted, we will provide coverage of the non-formulary drug for the duration of the prescription, including refills.

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. The request can be made in writing or via telephone. 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 expedited exception request be granted, we will provide coverage of the non-formulary drug for the duration of the exigency.

External exception request review

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 enrollee’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

The Coordination of Benefits (COB) provision applies when you have healthcare coverage under more than one Plan.

The order of benefit determination rules governs the order which each Plan will pay a claim for benefits. The Plan that pays first is called the Primary Plan. The Primary Plan must pay benefits according to its policy terms without regard to the possibility that another Plan may cover some expenses. The Plan that pays after the Primary Plan is the Secondary Plan. The Secondary Plan may reduce the benefits it pays so that payments from all Plans do not exceed 100 percent of the total Allowable Expense.

South Carolina 2025 Transparency Notice EPO

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, less any deductible, copayment amounts or cost sharing that is your financial responsibility.

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

Ambetter Health
Attn: Claims Department
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 2024. 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.

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 60 days. During this time, we will continue to cover your care, but we may hold your claims.

D) Retroactive Denials

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

If you believe you have paid too much for your premium and should receive a refund, please contact Member Services immediately at the number listed on the back of your member identification card. 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:

Receives a service or supply from a non-network provider;
Is admitted into a network facility by a non-network provider; or
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 (medical and behavioral) requests must be received by phone/e-fax/provider portal as follows:

At least five calendar days prior to an elective admission as an inpatient in a hospital, skilled nursing or rehabilitation facility or hospice facility.
At least 30 calendar days prior to the initial evaluation for organ transplant services.
At least 30 calendar days prior to receiving clinical trial services.
Within 24 hours of any inpatient admission.
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 received, we will notify you and your provider if the request has been approved as follows:

For urgent concurrent review within one calendar day of receipt of the request.
For urgent pre-service requests, the lesser of two working or three calendar days from receipt of the request.
For non-urgent pre-service reviews, within two working days of receipt of the request.
For post-service or retrospective reviews, two working days of receipt of the request.

In situations where additional information is needed to make a decision, these timeframes may be extended in accordance with applicable law.

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.

G) Drug Exceptions Timeframes and Enrollee Responsibilities

Prescription Drug Exception Process

Ambetter Health
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. The request can be made in writing or via telephone. 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.

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.