Out-of-Network Liability and Balance Billing

Balance billing is when a provider bills a member for the difference between the provider’s charge and the allowed amount. For Medical Mutual, there are processing rules for members who are balance billed after receiving services from non-contracting providers whom they did not have an opportunity to choose.  The most common scenarios include:

  • Hospital-based physicians (HBP)
  • “Hospitalists” (providers who only see patients in a facility setting)
  • Non-contracting provider on-call for a contracting provider
  • Non-contracting provider performing an interpretation of a test
  • Medical Emergencies

Emergency services performed by non-contracting providers are covered at in-network benefit levels.

Additional Qualifying Criteria for Benefit/Payment Adjustment

Elective services (inpatient and /or outpatient) must be associated with an in-network facility or must qualify as a medical emergency in order to have the non-contracting provider-related claims processed at in-network level of benefit and be eligible to have claims paid at an adjusted (non-contracting rate).

Members may be subject to additional deductibles and out-of-pocket expenses when using out-of-network services. In certain instances, members may also be subject to balance billing from a non-network provider.

Enrollee Claims Submission

Most network providers will submit a claim for you. If you go to a doctor, hospital or provider that is not in your network, ask them to submit a claim for you on a standardized claim form. If he provider will not submit the claim for you, contact our Customer Care Center or log into My Health Plan for a claim form. Complete the claim form and attach an itemized bill that includes the diagnosis, procedure, date of service, charge and provider’s or facility’s name and address. Submit the completed form to our office within the timeframe stated in your Certificate or Benefit Book.

If you go to a hospital or provider outside the country, get a copy of all your records and an itemized bill. If needed, have your records and bills translated to English. Submit your claims forms, bills, medical records and proof of payment to the address listed on your ID card. Please remember that benefit coverage and limitations still apply. Refer to your Certificate or Benefit Book for details.

To access claims forms, please visit this page, or call (800) 242-1936 for more information.

Grace Periods and Claims Pending Policies during the Grace Period

Members must pay their premiums in full each month. If a member who receives an advanced premium tax credit becomes delinquent, they will have a three-month grace period to pay their premium in full. The grace period will begin on the first day of the first month for which full premium was not made. In order to re-set the grace flag, a member must pay premiums in full through the current month. If premiums are not paid in full by end of the third month, QHP will terminate due to non-payment of plan premiums. QHP will retro-terminate to end of the first month of the grace period. Medical Mutual executes the termination job at the beginning of each month. Members who remitted payment in full on the day prior to running non-payment termination jobs are manually reviewed and considered as paid within the grace period.

Medical Mutual will retain the first month’s APTC and will retroactively return any additional APTC collected for subsequent (second and third) months. Any premiums paid after the termination will be used to pay any outstanding premiums the member owes within the first month of the grace period (final month of coverage). Remaining premium payments on account after the final month’s member premium has been satisfied will be refunded back to the member.

Claims pending refers to a claim which is held without adjudication or payment due to premiums not being paid for the period in which the claim is incurred.  The claim is not rejected but is held until premiums for the corresponding period are paid.

Medical Mutual pays all claims incurred during the first month of the three month grace period in correspondence with federal regulations.

Retroactive Denials

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

Claims may be denied retroactively, even after the member has obtained services from the provider, if applicable.

If a medical service is rendered and paid, and additional information is obtained that makes the service not payable, the claim is adjusted and denied for the appropriate reason. Medical Mutual requests a refund from the provider. If the provider does not refund the requested overpayment or appeal the decision that the claim was paid in error, a future payment is offset to recoup the excess payment. These recoupments are limited to those identified within two years of the paid date of the claim. Most retro denials are not the responsibility of the member. However, a retro denial may be the responsibility of the member due to:

  • A retro contract cancellation
  • A member obtained services not covered by the contract or
  • A member receives services outside the network where the patient may not be protected from balancing billing

Examples of ways to prevent retroactive denials when possible include:

  • Paying premiums on time,
  • Staying in network
  • Understanding your benefits by reading the benefits book provided.

Enrollee Recoupment of Overpayments

Enrollee recoupment of overpayments is the refund of a premium overpayment by the member due to the over-billing by the issuer.

There are two scenarios in which a member can be refunded for a premium overpayment due to over-billing.

Scenario 1:

  • Members can Contact Customer Care at the number on the back of their ID card.
  • Medical Mutual will evaluate if the member was over-billed
  • Once overpayment of premium is confirmed, the premium is refunded. Members will receive their refund by credit card if this is the method you used for the initial payment, or by check. If the refund is via credit card, the record is sent to the credit card processor and in you should receive the payment to your account in 3-5 business days.

Scenario 2:

  • On a monthly basis, Medical Mutual runs a report of payments which are on account and unapplied for Disenrolled/Inactive groups.
  • Medical Mutual evaluates whether or not an active group exists for issues where money is unapplied on a Disenrolled/Inactive groups.
  • If another account exists, money is transferred to the active account.  If inactive without an active group, funds are refunded to the member.
  • Once Medical Mutual confirms the overpayment of premium, the premium is refunded. Members will receive their refund by credit card if this was the method initially used, or by check for all other situations.
  • If the refund is a check refund, a record is electronically transferred to Accounts payable who cuts checks on Tuesdays and Thursdays of each week.  Checks and ACH payments must be on the account for 14 days or greater (so that MMO does not receive bank return on the transaction) in order to be refunded.
  • If the refund is via credit card, the record is sent to the credit card processor and the member is informed that the transaction will hit their account in 3-5 business days.

Medical Necessity and Prior Authorization Timeframes and Enrollee/Member Responsibilities

Medical necessity is used to describe care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care.

Prior authorization is a process through which an issuer approves a request to access a covered benefit before the insured member accesses the benefit.

Before members receive certain healthcare services or prescription drugs, their doctor or health provider may need to get approval from Medical Mutual. This is called prior authorization. (The terms precertification and prior approval may also be used.) We may ask for details such as the member’s medical history, diagnosis, why the service or prescription drug is needed, and where the member is getting the service or prescription drug before we make a coverage decision. Some services or drugs must meet certain requirements before coverage is provided.

Medical Mutual uses evidence-based medical criteria that offer guidance for benefit determinations for both medical services and prescription drugs.

If all medical necessity and prior authorization procedures are not followed, you may be responsible for the full cost associated with the medical service and/or drug you receive.

Medical Services and Prescription Drugs Covered Under the Medical Benefit

For a list of services and prescription drugs that require prior approval under the medical benefit, please visit this page. This page includes information to help your provider understand how to submit a request.

To begin the prior authorization/medical necessity review process, you, your designee or your doctor can complete our Prior Approval Form and submit it to us. You and your provider will receive notification of our determination of coverage within 15 days of receiving all necessary information for a standard review, or within 72 hours of receiving all necessary information for an expedited review for exigent circumstances. (Exigent circumstances mean you have a condition that may seriously jeopardize your life, health or ability to regain maximum function if treatment is delayed.) The letter you get will tell you how long an approval lasts.

Prescription Drugs Covered Under the Pharmacy Benefit

Please reference our comprehensive formulary to find out which drugs are subject to prior authorization or other coverage review requirements.

If you are told at the pharmacy that your drug isn’t covered, you, your designee or your doctor may request a coverage review for prior authorization, step therapy or quantity limits. The medical necessity review will determine if your plan will cover your medication. To begin the process for a coverage review, you, your designee or your doctor can call Express Scripts at (800) 417-1764. Your doctor will receive a form to fill out and return. You and your provider will receive notification of our determination of coverage within 15 days (most often within 72 hours) of receiving all necessary information for a standard review, or within 72 hours of receiving all necessary information for an expedited review for exigent circumstances. (Exigent circumstances mean you have a condition that may seriously jeopardize your life, health or ability to regain maximum function if treatment is delayed.) The letter you get will tell you how long an approval lasts.

While waiting for approval, you may have to pay the full cost of the medication out of pocket, and there is no guarantee you will be reimbursed or that the coverage management review will be approved. If you do not follow the coverage review process outlined above, you will continue to pay the full cost of the medication out of pocket. Therefore, we recommend you reach out to your doctor to discuss switching to a plan-preferred drug or complete the coverage review process.

Drug Exceptions Timeframes and Enrollee/Member Responsibilities

Issuers’ exceptions processes allow enrollees to request and gain access to drugs not listed on the plan’s formulary.

How to obtain non-formulary drugs

Medical Mutual’s High Performance Formulary includes a variety of effective, lower-cost drugs that meet our strict clinical standards. If you choose to take a drug that is not included on the formulary, that drug will generally not be covered by your health plan. You will have to pay 100 percent of the cost. This will be true unless your doctor or health provider requests a formulary coverage review and an exception is made based on medical necessity.

To begin the process for a formulary coverage review, you, your designee or your doctor can call Express Scripts at (800) 417-1764. Your doctor will receive a form to fill out and return. Within 72 hours of receiving the request and information sufficient to complete the review, we will notify you of our determination of whether coverage is approved. An expedited review is available for exigent circumstances, meaning you have a condition that may seriously jeopardize your life, health or ability to regain maximum function, or are undergoing a current course of treatment using a non-formulary medication. We will respond to expedited reviews within 24 hours of receiving the request and information sufficient to complete the review.

  • If an exception is granted, the non-formulary drug and its refills will be covered for the duration of the prescription or, for an exigent circumstance, for the duration of the exigency. In addition, your out-of-pocket costs for that drug will accumulate toward your in-network maximum out-of-pocket amount.
  • If denied and your drug will not be covered by your plan, you will be told in writing of your external review rights as part of our initial decision. You may request an external review by an independent review organization (IRO) within 180 days from your receipt of the notice of Final Adverse Benefit Determination. All requests must be in writing, including electronically, except for expedited external reviews, which can be made orally. IROs will complete standard reviews within 30 days of receiving the request and information sufficient to complete the review, and expedited reviews within 72 hours of receiving the request and information sufficient to complete the review. An expedited review can be requested if your treating provider believes the Adverse Benefit Determination involves a medical condition that could seriously jeopardize your life or health or your ability to regain maximum function if treatment is delayed. You will be told in writing of the IRO’s decision.

There is no cost to you associated with requesting any applicable appeals or external reviews.

Information on Explanations of Benefits (EOBs)

An explanation of what an EOB is:

An Explanation of Benefits (EOB) is a document that tells a member how their claim was processed. It lists what was paid and what the member is responsible for paying. Each component of the member responsibility is explained. It includes a section on how to contact us if they have questions.

Information regarding when an issuer sends EOBs (i.e., after it receives and adjudicates a claim or claims).

An EOB is sent to the member after one of their claims has been finalized, paid or denied. The EOB lists each claim finalized since the last EOB they received. The member can get the document through the mail (paper), on MedicalMutual.com or both. Medical Mutual can mail copies of an EOB upon request.

How to Read and Understand Your EOB

An EOB guide is available to members. It includes:

  • Customer Care information and the member’s Medical Mutual identification number
  • A Summary of Claims: shows the total benefits paid by Medical Mutual and the total amount the enrollee is responsible for.
  • A Detail of Your Claims section: covers every physician and hospital claim during a payment cycle. The claims in this section will be presented by family member and may be several pages. In this section, the enrollee may also see notes, which are used like footnotes to indicate that some aspect of the benefit administration needs to be explained further.
  • An Update on Your Deductible and Coinsurance Balances section: will graphically show the amounts the enrollee and their dependents have accumulated toward the patient and family annual maximums as applicable.

Coordination of Benefits (COB).

Coordination of Benefits (COB) exists when an enrollee or family member is enrolled in more than one health plan. When this situation is identified, research is initiated to determine which health plan pays first and which health plan pays second. The results of the research are loaded to the enrollees record which is then used to process claims. Only if the member is set up to pay second under the plan being administered, will claims pend and will required payment information from the primary plan before secondary benefits can be determined. This process prevents duplication of payment across the plans in effect for this member.