Plan Support Materials

Balance Billing Out-of-Network

Balance billing is when you go out-of-network, and that doctor bills you for charges other than copayments, coinsurance, or your deductible. Get more details about balance billing when going out-of-network:

Claims Submissions by Members

In special cases, you may need to submit a claim instead of your doctor. Get more details and instructions:

Grace Periods

If you have a premium tax credit and have paid at least one full month's premium during the benefit year, you have a 90-day grace period to pay. Learn more about this period and how we handle claims during that time:

Retroactive Denials

A retroactive denial is when a previously paid claim is reversed, which makes you responsible for the payment. Learn more about why this happens and how to avoid it when possible:

Premium Overpayment Refunds

If you overpaid because of over-billing, follow these instructions to get a refund:

Medical Necessity and Preauthorization

These policies make sure that you meet certain requirements before we agree to cover it, which helps keep you safe and control your costs. Learn more about these policies, their timeframes, and your responsibilities as a member:

Drug Exceptions

Sometimes, you might need to request coverage of a drug not on our formularies. Learn more about how this process works, timeframes, and your responsibilities as a member:

Explanations of Benefits

A Claim's Journey

Once a claim is processed, you might receive an Explanation of Benefits (EOB). The EOB breaks down your benefits and the costs for a service, like a visit to the doctor's office. Learn more about what an EOB shows:

Coordination of Benefits

Coordination of Benefits (COB) is when you're also covered by another plan, and we have to determine which plan pays first. Learn more about this process and these rules: