Transparency in coverage

Understanding your health care coverage, benefits and related information is important. The following is a summary of key areas to help you better understand technical terms and processes. We encourage you to call Customer Service at 1 (855) 857-9944 or email CS@BridgeSpanHealth.com to ask additional questions.

If you choose to see a provider who is out-of-network, your out-of-pocket expenses will typically be higher than if you visit an in-network provider. Also, if you visit an out-of-network provider, you could be billed for balances beyond any deductible, copayment and/or coinsurance. This practice is called balance billing.

Out-of-network providers have not agreed to accept our negotiated allowed amount as full compensation for covered services. This means you are responsible for paying any difference between the amount billed by the out-of-network provider and the allowed amount. In addition, you are responsible for paying the deductible, copayment and/or coinsurance. For out-of-network providers, the allowed amount may be based upon the billed charges for some services, as determined by us or as otherwise required by law.

Emergency room services do not need to be preauthorized. Preauthorization is a decision by your health insurance company that a specific service, prescription drug, treatment plan or medical equipment is necessary. If you are admitted to an out-of-network hospital directly from the emergency room, services will be covered at the in-network benefit level. This means we will cover your services to the extent covered in your plan. However, an out-of-network provider may bill you for balances beyond any deductible, copayment and/or coinsurance. Contact Customer Service for further information and guidance.

Note: Even if you're visiting an in-network hospital, you could still be charged for out-of-network services. Some hospital services, such as anesthesiology, might be out of network.

A claim is a request for payment or reimbursement for services you received.

When you receive medical care, you or someone on your behalf (such as a doctor) submits a claim to your health insurance company asking payment for the medical goods or services you used.

We process the claim by matching it against the details of your policy, such as your deductible, your coinsurance, the network status of your health care provider and your plan benefits.

After processing the claim, we pay the health care provider its share of the bill (or will pay you directly if it's a reimbursement claim). You will then be responsible for paying the balance, if any. We will send you an explanation of benefits statement, which is a document (not a bill) that describes exactly how much of the claim we paid and what you may owe.

When you receive care from an in-network provider or pharmacy, it will process your claims directly with us, so you don't need to handle any paperwork.

However, if you receive care from a provider or pharmacy outside of your service area, you may have to pay at the time of service. If the bill is for covered or authorized services, you can file a claim with us for reimbursement. If you pay the bill, ask the provider's office for an itemized bill and keep a record of your payment.

To file a claim for reimbursement, follow these steps:

1. Complete and sign the Direct Member Reimbursement Form (ID, OR, UT) / Direct Member Reimbursement Form (WA) or the BridgeSpan Health Drug Claim Form.
2. Enclose an itemized bill from the provider or pharmacy for the covered service

3. Mail your claim to the address shown on the form.

Alternatively, you can sign into your member account to submit your claim online.

You need to file a claim within one year after the date of service for which a claim is made. We will deny a claim that is not filed in a timely manner. However, if you can prove it was not reasonably possible to file your claim within a year of service, we will process your claim as long as you've filed your claim as soon as it was reasonably possible. If your claim is denied because of timing, you have the right to appeal the denial if you can demonstrate that the claim could not have been filed in a timely manner.

Under the rules of the Affordable Care Act Marketplace, people who have outstanding premium payments for their Qualified Health Plan (QHP) insurance have a small window to pay after the payment due date before their insurance company can take away their coverage. This short period of time is called a "grace period" and the length varies depending on whether you are receiving Advanced Premium Tax Credits (APTC) or not.

Under current rules, QHP issuers must:

• Allow consumers who receive APTC a three-month grace period if they have paid at least one full month's premium during the benefit year.
• Grant consumers who do not receive APTC a grace period in accordance with state rules.
  If you or one of your enrolled dependents receives an Advance Premium Tax Credit, we will provide you with coverage for all allowable claims incurred within the first month of a three-month grace period, and we may hold allowable claims in the second and third month of the grace period. Note the full outstanding balance must be paid by the end of the three months.
  

If we don't receive your premium payment by the end of the three-month grace period, your coverage will be terminated retroactively to the end of the first month. The following will also occur:

• Pending claims submitted during the second or third month of the grace period will then be denied for no coverage.
• If the full balance is not paid by the end of the three-month grace period, any claims paid during the first month will remain paid.
  Subsidies received within the first month as a partial payment will be kept, and subsidy amounts received for the following two months will be returned to the government.
  

If we pay a benefit you or one of your enrolled dependents were not entitled to, or if we pay a person who is not eligible for benefits at all, we can recover the payment from the person we paid or anyone else who benefited from it, including a doctor or hospital. Our right to recovery includes the right to deduct the mistakenly paid amount from future benefits we would provide the policyholder or any enrolled dependents, even if the mistaken payment was not made on that person's behalf.

If Claims is unable to process an adjustment request due to delinquent premiums the Claim will be "pended," or held, until either a payment is received, 30 days have passed with no payment, or the member is cancelled. If payment is received within 30 days, the claim will be sent on for processing.

Here are some things you can do to help prevent a retroactive denial:

• Verify the benefits, limitations and exclusions of your benefit policy by calling Customer Service
• Utilize In-Network providers
• Pay premiums on time

• If this health plan is secondary to another insurer, request your primary insurer to send us an Explanation of Benefits

Refund requests can be submitted using any of the following:

• In writing (must be signed and dated by the subscriber)
• Call Customer Service at the number located on the back of your card. All phone calls are recorded as required by law.
• Sign in to this website and submit a request to Customer Service via Message Center.

• Email us at CS@bridgespanhealth.com.

Note: Premium refunds will be held for 10 business days after the refund request is received. We will issue the refund afterward unless more information is required.

Important: A cancellation of a refund is sometimes possible, but there are several determining factors. If for some reason you want to cancel the refund, contact Customer Service for help to determine if a cancellation of refund can be given. This number is found on the back of your card. Refund checks are sent to the billing address listed in your policy. If your policy does not list a billing address, we will send your check to your mailing address.

Medically necessary or medical necessity refers to health care services or supplies that a health care provider, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms. The service of supply must be:

• In accordance with generally accepted standards of medical practice;
• Appropriate for the patient, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease; and
• Not primarily for the convenience of the patient, physician or other health care provider, and not more costly than an alternative service or sequence of services or supply at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.
  For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations and the views of physicians and other health care providers practicing in relevant clinical areas and any other relevant factors.
  

Some medical procedures require pre-authorization before you receive treatment to get coverage from your health plan. (You can use any of the benefits of this coverage without a referral, which is different from a pre-authorization.)

Pre-authorization allows us to review your treatment within the context of any other health issues you may have and to consider the latest scientific research available to manage your condition. Some conditions have a wide range of treatment choices, and some treatments work better than others. Checking in on your progress after a series of treatments helps us make sure your treatment is effective, medically necessary and right for you.

To obtain approval, pre-authorization requests must be received before the services are rendered. If your provider does not submit a pre-authorization request before providing care, we will conduct a medical necessity review after the fact. Based on that review, you may be accountable for the cost of the care you received.

If you use an in-network provider, you don't need to do anything. The provider's office will handle the pre-authorization process. Our clinical partner evaluates your treatment plan to make sure it is the most effective treatment based on published research. Our partner also ensures that it is medically necessary and covered by your health plan.

If you use an out-of-network doctor, call the number on the back of your member ID card and we can talk with you about your options. Using an out-of-network doctor may mean higher out-of-pocket costs for you.

We do not require out-of of-network providers to seek pre-authorization for services. However, your plan may provide little or no coverage for out-of of-network services and you may be responsible for the full cost of services.

Note that additional timeframes are after receipt of the documentation or the timeframe for submission of the requested information has expired—whichever comes first.

If a prescribed drug is not on the formulary for a member's plan, an exception may be requested under the Substitution Process. We will cover a nonformulary drug under the Substitution Process if it is found to be medically necessary. A drug may be considered medically necessary if:

• You are unable to tolerate an equivalent formulary drug(s); or

• Your doctor determines that the drug(s) on the formulary is not effective for treating the condition.

You or your physician may request an exception by calling Customer Service at 1 (800) 572-0316, or by completing and submitting the online Request for Prescription Drug Coverage Exception form. We will give you a decision within 72 hours after we receive your request. If you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, we will give you our decision no later than 24 hours following receipt of the request.

If we approve the exception request, the substituted drug will be covered at the Substituted Medication Copayment and/or Coinsurance level determined by your policy's benefit and will count toward your deductible or out-of-pocket maximum. If we do not approve your exception, you can appeal our decision. If we deny your request, we will let you know how to file an appeal. If the drug is denied again, you have the right to an external review.

If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case to an external review by an impartial, third party reviewer known as an Independent Review Organization (IRO). We must follow the IRO’s decision.

An IRO review may be requested by a member, member’s representative, or prescribing provider by mailing, calling, or faxing the request as described in your appeal decision letter. Call the number on the back of your ID card if you need further assistance. If you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, you may request your case be handled as expedited.

An explanation of benefits, also called an EOB, is a statement sent by a health insurance company to its customers after they receive medical treatment. The EOB explains what medical treatments, services, or both, were paid for on their behalf.

Within 30 days of receiving a claim, we will let you know our decision. However, this 30-day period may be extended to 45 days in the following situations:

• If we are unable to take action on your claim due to circumstances beyond our control, we will notify you within the initial 30-day period that we need an extension. We will let you know why we need an extension and let you know when we will have a decision.

• If we cannot take action on your claim because we don't have enough information, we will notify you within the initial 30-day period that we need an extension. We will also ask you for the information we need and explain why we need it.

If we ask you for additional information, we will give you at least 45 days to send it to us. If we do not receive the information we requested within 45 days, we will deny your claim.

We will tell you how we have acted on a claim using an explanation of benefits, or EOB. We may pay claims, deny them or accumulate them toward satisfying any deductible. If we deny all or part of a claim, we will give you our reason on your claims processing report. The claims processing report will also include instructions for filing an appeal or grievance if you disagree with our decision. The EOB also includes information such as what services were provided, what we covered, what was paid to the provider, and what you owe. It is not a bill.

In accordance with privacy guidelines, information included with the EOB regarding services provided must be general. For example, the EOB may refer to "surgery" instead of the specific procedure with additional details.

If you have more than one medical, vision, pharmacy or dental health plan, Coordination of benefits (COB) applies to you. When you have multiple types of health insurance plans, your health insurance companies will coordinate benefits with each other to help you receive the full benefit of those plans. COB is one of the ways we work to keep premiums lower. Note that you are required to notify us if you have more than one insurance provider. We then follow our local COB insurance laws to determine which one is the primary payer.