2024 Transparency Notice

A) Out-of-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 provider that is out-of-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 called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

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.

As a member, non-network providers should not bill you for covered services for any amount greater than your applicable in-network cost sharing responsibilities when:

1. You receive a covered emergency service or air ambulance service from a non-network provider. This includes services you may get after you are in stable condition unless the non-network provider obtains your written consent.
2. You receive non-emergency ancillary services (emergency medicine, anesthesiology, pathology, radiology, and neonatology, as well as diagnostic services (including radiology and laboratory services)) from a non-network provider at a network hospital or network ambulatory surgical facility.
3. You receive other non-emergency services from a non-network provider at a network hospital or network ambulatory surgical facility unless the non-network provider obtains your written consent.

B) Enrollee Claim Submission

Network providers will file claims on your behalf with us for covered services. Present your member identification card at the time of service for the provider to bills us for your care. Contact Member Services if you receive a bill for covered services.

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. If you pay out of pocket for covered services because the provider requires more than your appropriate cost sharing, you can request reimbursement for the amount you paid. When appropriate, we adjust your deductible, copayment, or cost sharing to reimburse you. We must receive notice of claim within 30 days after the occurrence or commencement of any loss or as soon as reasonably possible.

Your reimbursement request for a covered service should include:

• A copy of the detailed claim or bill from the treating provider
• The Member Reimbursement Claim Form, including the required documents listed on the form

Send all complete documentation to:

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

We will acknowledge receiving your reimbursement request and will process your request within 30 business days of receipt.

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.

If approved reimbursements are processed and payment will be issued to you within 45 calendar days of receipt.

If we reject your claim, our notices include the reason why and your appeal rights as detailed in your appeals packet.

C) Grace Periods and Claims Pending

If premiums are not paid by the due date, you will enter a grace period. The grace period is extra time given to pay.

During your grace period, you keep your coverage. However, if you don’t pay before the grace period ends, you run the risk of losing your coverage. During grace periods, we may hold or pend claim reimbursement requests. Neither you nor your treating provider is responsible for the cost of any claim reimbursement requests.

If your coverage terminates for not paying your premium, you are not eligible to enroll with us again until Open Enrollment or a Special Enrollment period.

When a member is receiving a premium subsidy

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 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 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. A member is not eligible to re-enroll once terminated, unless a member has a special enrollment circumstance, such as a marriage or birth in the family or during annual open enrollment periods.

When a member is not receiving a premium subsidy

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-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 policy 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

"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.

There are instances where claims deny retroactively for example if you 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. These scenarios will result in Ambetter recouping 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 recoupment is in error, you are encouraged to contact member’s services department by calling the number on your ID card.

E) Recoupment of Overpayments

To request a refund of overpaid premium please contact member services. Refunds are processed by two methods, electronically or by a manual check. The type of refund 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, are refunded via eCashering. Payments made via eCheck are 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 paper check.

F) Medical Necessity and Prior Authorization

Services are covered when medically necessary. Medically necessary services are health care services that a health care provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease or its symptoms, and that are:

• In accordance with generally accepted standards of medical practice;
• Clinically appropriate, 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 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, the views of physicians practicing in relevant clinical areas and any other relevant factors.

The fact that a provider may prescribe, order, recommend or approve a treatment, service, supply, or medicine does not in itself make the treatment, service, supply or medicine medically necessary as defined in this policy. The terms medically necessary, medically indicated, and medical necessity may be used interchangeably throughout this document.

Prior Authorization Required

Selected services and treatments included in your health plan require approval before you receive them to qualify for coverage payment referred to as prior authorization.

Although a service or treatment lists as a covered benefit, Ambetter requires a prior authorization before you receive the service or treatment. Even those services that are determined to be medically necessary by us must have prior authorization in order to be covered. Physicians and networks cannot deny a service or treatment for failure to obtain prior authorization. Only we can deny coverage of medical services for failure to obtain prior authorization. You can ask your primary care provider or our Member Services Department any questions you have concerning prior authorizations. Prior authorization does not guarantee coverage.

Circumstances in which the services ARE NOT covered include, but not limited to:

• Other plan provisions are not satisfied (for example, member not enrolled or eligible for service on the date the service is received, or the service is not a covered service);
• Fraudulent, materially erroneous or incomplete information is submitted; or
• A material change in the member’s health condition occurs between the provision date of the prior authorization and the date of the treatment that makes the proposed treatment no longer medically necessary for such member.

In the event that Ambetter certifies the medical necessity of a course of treatment limited by number, time period or otherwise, a request for treatment beyond the certified course of treatment shall be deemed to be a new request. 

Except for emergency services, ALL medical services and treatments require the direct coordination of your primary care physician and received within the service area. If they are not, services may be denied by Ambetter.

The following services or supplies may require prior authorization:

1. Hospital confinements
2. Hospital confinement as the result of a medical emergency
3. Hospital confinement for psychiatric care
4. Outpatient surgeries and major diagnostic tests
5. All inpatient services
6. Extended care facility confinements
7. Rehabilitation facility confinements
8. Skilled nursing facility confinements
9. Transplants and
10. Chemotherapy, specialty drugs and biotech medications.

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 should be submitted for medical necessity review as soon as the need for services identified. Requests must be received by telephone, fax, or provider web portal. Faxed requests must be submitted by providers using the required Arizona Department of Insurance and Financial Institutions (DIFI) form, or the plan is not able to review the request.

After prior authorization has been requested and all required or applicable documentation has been submitted, we will notify you and your provider with the authorization determination as follows:

1. For urgent concurrent review within 1 calendar day of receipt of the request.
2. For urgent pre-service review, within 3 calendar days from date of receipt of request.
3. For non-urgent pre-service requests no longer than 14 calendar days of receipt of the request.
4. For post-service requests, within 30 calendar days of receipt of the request.

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

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 or denied.

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

Standard Exception Request

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 FROM ARIZONA COMPLETE HEALTH
Attn: Member Services
1850 W. RIO SALADO PARKWAY, SUITE 211
TEMPE, ARIZONA 85281

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.

Standard Appeal (Level 2) Request

Your request: You or your treating provider may request a Level 2 Formal Appeal if we deny your request at Level 1. You or your treating provider have 60 days from the date of the Level 1 denial letter to request a Level 2 Formal Appeal in writing to:

Mail: Ambetter from Arizona Complete Health
Attn: Ambetter Appeals and Grievance Dept.
P.O. Box 10341
Van Nuys, CA 91410-0341

Fax: (877) 615-7734 OR

Email: AzCHGrievanceAndAppeals@azcompletehealth.com

To help us make a decision on your appeal, you or your provider should also send us any additional information (that you have not already sent us) to show why we should authorize the requested service or pay the claim.

Our acknowledgement: We have 5 business days after we receive your request for Formal Appeal (“the receipt date”) to send you and your treating provider a notice that we got your request.

Our decision: For a denied service that you have not yet received, we have 30 days after the receipt date to decide whether we should change our decision and authorize your requested service.

We send you and your treating provider our decision in writing that explains the reasons for our decision. We include information on the documents we used to base our decision.

• If we deny your Level 2 appeal, you have four months to appeal to Level 3.
• If we grant your request, we authorize the service, and the appeal is over.
• We may decide to skip Level 2 and refer your case straight to an independent reviewer at Level 3.

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. Within 72 hours of the request being received (24 hours for exigent circumstances), 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 exigency.

Expedited Appeal (Level 2) Request

If you disagree with the Level 1 decision, a Level 2 Expedited Appeal or Level 2 Formal Appeal is available as described in your Appeal Packet. The form is not required to request a Level 2 review.

Your doctor is able to contact our Medical Director to talk about the reasons for our decision (also referred to as a peer to peer” review).

Level 2: Expedited Appeal

The request: Your treating provider can file a Level 2 Expedited appeal if:

• We deny your Level 1 request.
  • If we grant your request, we authorize the service, and the appeal process is over.
  • We may decide to skip Levels 1 and 2 and send your case straight to an independent reviewer at Level 3.

Your treating provider can request a Level 2 Expedited Appeal after receiving our Level 1 denial. Your treating provider must immediately send the written request for a Level 2 Expedited Appeal to:

Email: AzCHGreivanceAndAppeals@azcompletehealth.com

Fax: (877) 615-7734

Our decision: We have 3 business days after we receive the information from your treating provider to decide whether we should change our decision and authorize the requested service.

Within that same business day, we call you and your treating provider with our decision. We also mail you and your doctor a written copy of our decision, including the reasons for our denial. 

External exception request review

Your request: You may request a Level 3 review only after you have appealed through Levels 1 and 2. You have four months after you receive our Level 2 decision to send us your written request for External Independent Review. Send your request and any more supporting information to:

Mail: Ambetter from Arizona Complete Health
Attn: Ambetter Appeals and Grievance Dept.
P.O. Box 10341
Van Nuys, CA 91410-0341

Email: AzGrievanceAndAppeals@azcompletehealth.com

Fax: (877) 615-7734

Toll Free Call: (866) 918-4450 (TTY: 711)

Neither you nor your treating provider is responsible for the cost of any external independent review.

The process: There are two types of Level 3 appeals, depending on the issues in your case:

Medical Necessity Cases

Within five business days of receiving your request, we mail a written acknowledgement of the request to you, the DIFI Director, and your treating provider. The following is included in the mailing to the DIFI Director:

• A copy of your request for a Level 3 review;
• A copy of your policy
• Evidence of coverage or similar document;
• All medical records and supporting documentation used to render our decision;
• A summary of the applicable issues including a statement of our decision;
• The criteria used and clinical reasons for our decision; and the relevant portions of our utilization review guidelines.
• The name and credentials of the health care provider who reviewed and upheld the denial at the earlier appeal levels.

Within five business days of receiving our information, the Insurance Director sends all the submitted information to an external independent reviewer organization (the “IRO”).

Within 21 days of receiving the packet of information, the IRO makes a decision, and sends the decision to the DIFI Director. The Director may extend the review timeframe an additional 31 days for good cause.

Within five business days of receiving the IRO’s decision, the Insurance Director mails a notice of the decision to you, your treating provider and us.

If the IRO decides that we should provide the service, we will authorize the service. If the IRO agrees with our decision to deny the service, the appeal is over. Your only further option is to pursue your claim in Superior Court.

Contract Coverage Cases

Within five business days of receiving your request, we:

1. Mail a written acknowledgement of your request to the ADIFI, you, and your treating provider.
2. Send the DIFI Director and the provider the following i:
   1. A copy of your request for a Level 3 review;
   2. A copy of your policy
   3. Evidence of coverage or similar document;
   4. All medical records and supporting documentation used to render our decision;
   5. A summary of the applicable issues including a statement of our decision;
   6. The criteria used and clinical reasons for our decision; and the relevant portions of our utilization review guidelines.
   7. The name and credentials of the health care provider who reviewed and upheld the denial at the earlier appeal levels.

The DIFI Director makes a coverage determination, issues a decision, and sends a written notice to us, you, and your treating provider within 15 business days.

In instances where the DIFI Director is sometimes unable to determine issues of coverage, the DIFI forwards the case to the IRO to complete a review within 21 days of receipt. The DIFI Insurance has five business days after receiving the IRO’s decision to send the decision to you, your treating provider and us.

If you, your treating provider, or we disagree with the DIFI Director’s final decision on a contract coverage issue, a request for a hearing with the Office of Administrative Hearings (“OAH”) can be filed within 30 days of receiving the Director’s decision. OAH schedules and completes a hearing for appeals from Level 3 decisions.

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 that 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 at 1-866- 918-4450.

I) Coordination of Benefits

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