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Claims Payment Policies & Other Information

CommunityCare HMO

  1. What is out-of-network liability and balance billing?
  2. How does an enrollee submit a claim?
  3. What is a grace period and how are claims handled during the grace period?
  4. What are retroactive denials?
  5. What is enrollee recoupment of overpayments?
  6. What are medical necessity, prior authorizations and enrollee responsibilities?
  7. What are drug exceptions timeframes and enrollee responsibilities?
  8. What information is available on an Explanation of Benefits (EOB)?
  9. What is Coordination of Benefits (COB)?

What is out-of-network liability and balance billing?

Balance billing occurs when an out-of-network provider bills an enrollee for charges – other than copayments, coinsurance, or any amounts that may remain on a deductible.

Except for emergency services in an emergency department of a hospital, out-of-network services are not covered if they are obtained without prior authorization from CommunityCare.

Out-of-network ancillary services related to an in-network hospital stay will be considered at the same level of benefit as the in-network hospital services.

An enrollee may be billed for any non-covered out-of-network service.

How does an enrollee submit a claim?

In some situations an enrollee, instead of the provider, may need to submit a claim to CommunityCare, requesting payment for services that have been received.

If an enrollee needs to file a claim, the enrollee needs to include the following information:

  1. Name of patient
  2. Name of physician or hospital
  3. Tax identification number of provider
  4. Date of treatment
  5. Procedure code
  6. Diagnosis code
  7. Amount of charge

The claim should be submitted to the following address:

CommunityCare
P.O. Box 3249
Tulsa, OK 74101

CommunityCare must receive acceptable written proof of loss (e.g., medical bills) within 120 days after the date of such loss. This form can be used to assist with claim submission.

CommunityCare Customer Service can be reached at (918) 594-5242 (Tulsa) / 1-800-777-4890 (Statewide). Our phones are answered 8 a.m. - 6 p.m., Monday through Friday.

What is a grace period and how are claims handled during the grace period?

The grace period does not apply to employer group plans.

A QHP issuer must provide a grace period of three consecutive months if an enrollee receiving advance payments of the premium tax credit has previously paid at least one full month's premium during the benefit year. During the grace period, the QHP issuer must provide an explanation of the 90 day grace period for enrollees with premium tax credits pursuant to 45 CFR 156.270(d).

An enrollee with a Marketplace plan who qualifies for advance payments of the premium tax credits (APTC) to lower the monthly premium and has paid at least one full month's premium during the benefit year, has a short period of time to pay should they fall behind on their monthly health insurance premium. This period of time is called a 'grace period.' This grace period is 90 days.

During the first 30 days of the grace period, claims will be processed following CommunityCare's normal processing guidelines.

Beyond the first 30 days, all claims will be held pending resolution of the outstanding premium payment. If the outstanding premium is paid in full, the claims will be finalized following CommunityCare's normal processing guidelines. If the outstanding premium is not paid, the claims will be denied for loss of coverage.

What are retroactive denials?

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

Claims may be denied retroactively due to retroactive coverage termination. Retroactive coverage termination may occur;

  • due to failure to pay premium/contribution.
  • due to employment termination if the employee did not make any payment of premium/contribution toward the benefits after he/she left the job. In this case, the plan sponsor may terminate coverage as of the employment termination date.
  • when the plan does not cover divorced ex-spouses and an employee failed to notify their employer about the divorce until after the divorce, and the employee or ex-spouse did not pay premium/contribution toward the benefit coverage.

Retroactive coverage terminations can be prevented by making all monthly premium payments on time.

What is enrollee recoupment of overpayments?

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

If we discover that we did not reduce the portion of the premium charged to or for an enrollee for the applicable month(s) by the amount of the advance payment of the premium tax credit, we will notify the enrollee of the improper reduction within 45 calendar days of our discovery of the improper reduction and refund any excess premium paid by or for the enrollee, as follows:

  1. Unless a refund is requested by or for the enrollee, we will, within 45 calendar days of discovery of the error, apply the excess premium paid by or for the enrollee to the enrollee's portion of the premium (or refund the amount directly). If any excess premium remains, we will apply the excess premium to the enrollee's portion of the premium for each subsequent month for the remainder of the period of enrollment or benefit year until the excess is fully applied (or refund the remaining amount directly to the enrollee). If any excess premium remains at the end of the period of enrollment or benefit year, we will refund any excess premium within 45 calendar days of the end of the period of enrollment or benefit year, whichever comes first.
  2. If a refund is requested by or for the enrollee, we will refund the enrollee within 45 calendar days of the date of the request.

An enrollee can initiate a refund of premium overpayment by calling CommunityCare Customer Service at (918) 594-5242 (Tulsa) / 1-800-777-4890 (Statewide). Our phones are answered 8 a.m. - 6 p.m., Monday through Friday.

What are medical necessity, prior authorizations and enrollee 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 accesses the benefit.

Medical necessity is defined a medically necessary services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Referral/Authorization Process

If your PCP determines that you need more tests, specialty care or hospitalization, your PCP may send a referral to CommunityCare or your network's referral Center asking that the plan authorize those services.

Your PCP and, when appropriate, your specialist will be notified of the referral decision and recommendations. If more tests or treatments are recommended or if hospitalization is needed, an authorization will be sent to the appropriate provider.

Some referrals are automatically approved by Medical Management staff using network and national criteria. Your PCP knows which services are automatically approved and can arrange your initial visit without the need for further action by CommunityCare. If a medically urgent referral request is received for services that require CommunityCare's prior authorization, CommunityCare's Medical Management staff will process the referral within 24-48 hours. If sufficient information is not provided to make a determination, CommunityCare will request the specific information from the provider before making a decision. In this case, you will receive notification of the decision within 72 hours of receipt.

For non-urgent services that require CommunityCare's prior authorization, your PCP will refer you to a specialist or hospital affiliated with your PCP's network. If CommunityCare authorizes the referral, you will receive written confirmation of the determination from CommunityCare. You may also call Customer Service at 1-800-777-4890, or at (918) 594-5242 in Tulsa. Your PCP will be notified if CommunityCare denies the referral, and you and your PCP will have the right to appeal that denial in accordance with CommunityCare's Pre-Service Claim determination appeal procedures.

If your PCP submits a referral for Medically Necessary care that is not available within CommunityCare's provider network, CommunityCare will identify an appropriate out-of-network provider and issue a pre-authorization for that service. You will be financially responsible for applicable deductible, copayments and/or coinsurance, and other non-medical expenses, such as transportation and lodging.

If medically appropriate care is available within CommunityCare's provider network, but you choose to receive care from an out-of-network provider, CommunityCare will deny payment for those services.

What are drug exceptions timeframes and enrollee responsibilities?

Issuer's exceptions processes allow enrollees to request and gain access to drugs not listed on the plan's formulary, pursuant to 45 CF 156.127(c).

Prescription Drug Exception Request

You, your authorized representative or your physician can submit a request for CommunityCare to make an exception and cover FDA-approved clinically appropriate drugs not on our formulary. This is called a request for exception.

Standard Exception Request

Your physician may call or complete the appropriate prior authorization form and fax it to CommunityCare to request a standard review of a decision for a drug that is not on our formulary. The physician can obtain the Non-Formulary Exception form at ccok.com/Providers/forms.asp or by calling the Pharmacy Help Desk at 1-877-293-8628. The physician should make this request before writing the prescription. CommunityCare will make a determination on the standard exception request and notify you or the prescribing physician of its coverage determination no later than 72 hours following receipt of the complete request. When CommunityCare grants a standard exception request, we will provide coverage of the non-formulary drug for the duration of the prescription.

Expedited Exception Request

You, your authorized representative or your physician can request an expedited review based on exigent circumstances. Exigent circumstances exist when you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function or when you are undergoing a current course of treatment using a non-formulary drug. CommunityCare will make its coverage determination on an expedited review request based on exigent circumstances and notify you and the prescribing physician of its coverage determination no later than 24 hours following receipt of the complete request. When CommunityCare grants an exception based on exigent circumstances, we will provide coverage of the non-formulary drug for the duration of the exigency.

External Prescription Request Review

If CommunityCare denies a request for a standard exception or for an expedited exception, you, your authorized representative or the prescribing physician can request that the original exception request and subsequent denial of such request be reviewed by an independent review organization. CommunityCare will make its determination on the external exception request and notify you and the prescribing physician of its coverage determination no later than 72 hours following its receipt of a standard exception request, and no later than 24 hours following its receipt of an expedited exception request. If CommunityCare grants 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 CommunityCare grants an external exception review of an expedited exception request, we will provide coverage of the non-formulary drug for the duration of the exigency.

What information is available on an Explanation of Benefits (EOB)?

An EOB is a statement an issuer sends the enrollee to explain what medical treatments and/or services it paid for on an enrollee's behalf, the issuer's payment, and the enrollee's financial responsibility pursuant to the terms of the policy.

A CommunityCare explanation of benefits (EOB) is a statement sent to patients indicating what action CommunityCare has taken on your claims. The EOB is not a bill. The EOB verifies that your claim was processed and is sent to you for your information and records. EOBs are sent to you within ten days after CommunityCare processes your claims.

Elements of an EOB

Hover over the icon near the various elements of the EOB to discover more information.
Sample CommunityCare HMO Explanation of Benefits (EOB)
Company Name and Address
CommunityCare's physical address.
Customer Service
This is the number used to contact customer service.
Claim No.
This is a number assigned by CommunityCare to identify the claim. You will need this claim number if you have any questions for CommunityCare.
Group Name
Identifies the Group Name for the member. When coverage is provided by an employer, this is usually the employer's name. When the coverage is an individual health plan, this is the name of the plan type.
Group No
Identifies the group number associated with the plan.
Employee
Identifies the contract holder. This is usually the name of the person who carries the insurance.
Patient
The name of the person who received the service. This may be the contract holder or one of his dependents.
Patient Acct
The account number with the patient's health care provider.
Contract #
The identification number assigned to a member by CommunityCare. This should match the number on your insurance card.
Date
Indicates the date on which the claim was processed.
Member Responsibility
This section details the portion of the bill that is a member's responsibility to pay. Ths amount might include copayments, deductible, coinsurance, and products/services not covered by the plan. If a member receives payment intended for a provider, it is the member's responsibility to pay the provider.
Provider of Service
The name of the provider who performed the services for the member. This may be the name of a doctor, a laboratory, a hospital, or other healthcare provider.
Dates of Service
The beginning and end dates of the health-related service a member received from the provider.
Charged Amount
The full amount charged by a health care provider for services a member received.
Not Covered
The portion of the charges not covered under the health plan. Examples of Not Covered amount include any of the following: Amounts for services that are not medically necessary. Amounts for services that are not covered by CommunityCare. Amounts for services that have reached contract or benefit maximums. Amounts for services that have not received any required prior authorization.
EX Code
This is a code associated with any adjustment or Not Covered amount. Additional explanation is provided in the Message Description.
Penalty
This is not applicable for CommunityCare HMO plans.
Allowable Amount
Amount for services rendered after the applicable discount has been applied.
Deductible Amount
A deductible is a set amount of covered charges that a member must pay each calendar year before benefits become payable.  Amounts that are not covered are not applied to the deductible. Generally, each member will have his own deductible to meet.
Co-Pay Amount
A set amount a member pays for certain covered services such as office visits. Co-payments are usually paid at the time of service.
Co-Ins Amount
The amount, calculated using a fixed percentage, a member pays for certain covered services. The health care provider may bill the member for these charges.
Payment Amount
The portion of the charges eligible for benefits minus a member's copayment, coinsurance, network discount and amount paid by another source up to the billed amount.
Other Insurance Credits or Adjustments
An example of Other Insurance Credits is payment by another health insurance carrier.
Total Payment Amount
This is the amount paid on the claim.
CCOK Payment To
This is the name of the recipient of the payment.
Check No
This field is blank on an explanation of benefits.
Amount
This is the amount paid on the claim.
Code
This is a code associated with any adjustment or Not Covered amount. Additional explanation is provided in the Message Description.
Message Description
A description of the EX Code.
Year to Date - Individual Deductible - In Network
The amount of Individual Deductible a member has incurred for the year. This amount may change based on retroactive adjustments.
Year to Date - Individual Out Of Pocket - In Network
The amount of Individual Out-of-Pocket a member has incurred for the year. This amount may change based on retroactive adjustments.
Name and address
The member's name and address. This will be the contract holder for any claims related to a minor.

What is Coordination of Benefits (COB)?

Coordination of benefits exists when an enrollee is also covered by another plan and determines which plan pays first.

Like most health plans, your plan has a COB provision. This provision applies when an enrollee is eligible for benefits under more than one health plan and ensures that the enrollee's covered expenses will be paid, but that the combined payments of all the health care plans do not amount to more than 100% of Allowable Expenses for the enrollee's care.

It is the responsibility of enrollees to advise CommunityCare of their participation in any other health care plan. CommunityCare will request information from an enrollee regarding duplicate health coverage upon initial enrollment and annually at the Group's renewal. If we do not receive a response in the required time, CommunityCare may deny coverage.

CommunityCare follows the COB rules established by Oklahoma law, including the rules for determining the order in which benefits are to be paid. Therefore, CommunityCare enrollees do not have the option of choosing which health plan they wish to have pay benefits first.

Updated: 8/4/2016
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