Claims Payment Policies & Practices

Balance by CCHP is designed for Members to obtain services from a network of doctors. Members may choose to receive services from doctors outside this network. Covered services obtained from out-of-network providers may result in a higher share of cost for the Member. Charging this extra amount is called balance billing. In cases like these, you will be responsible for paying for what your plan does not cover. Balance billing may be waived for emergency services received at an out-of-network facility. Certain medical services might need to be pre-authorized by Balance before the plan will cover it. Some services are not covered unless given by a network provider.

For more information, refer to your plan’s Evidence of Coverage and Summary of Benefit.

We do not accept claim submissions from an enrollee unless it is for a direct member reimbursement.

A claim is a request to an insurance company for payment of health care services. Usually, providers file claims with us on your behalf. If you received services from an out-of-network provider, and if that provider does not submit a claim to us, and you paid for the services to the provider, you can file the claim directly. There are time limits on how long you have to submit claims, the maximum claim filing time limit is 90 Days.

To file a claim, follow these steps:

1. Complete this Reimbursement Claim Form. This form can also be obtained by contacting Member Services.
2. Attach an itemized bill from the provider for the covered service.
3. Attach a copy of the payment receipt. Be sure to keep a copy for your records.
4. Mail your claim to:

Balance by CCHP
Attn: Claims Department
Post Office Box 1599
San Leandro, CA 94577

The grace period will begin one day after the premium due date, this period will continue for 30 consecutive days (90 consecutive days for individuals receiving tax credits). Balance will pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period. Balance will continue to provide coverage consistent with the terms of the health plan contract.

Members will be sent a notice of suspension due to nonpayment of premiums on the first day of the effective grace period (one day after the premium due date). The notice is sent separately from the original premium bill and will include the dollar amount due to Balance, disclosure of the grace period, and other necessary information.

A retroactive denial is the reversal of a claim we have already paid. If we retroactively deny a claim we have already paid for you, you will be responsible for payment. Some reasons why you might have a retroactive denial include having a claim that was paid during the second or third month of a grace period or having a claim paid for a service for which you were not eligible.

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 an in-network provider.

If you have overpaid for your premium and it is detected by Balance, the excess amount will be automatically refunded. However, if you believe you are owed a refund on your premium and it has not been automatically processed, contact Member Services.

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

Prior authorization is a process by which an issuer approves a request to access a covered benefit before the enrollee accesses the benefit. Some services may require prior authorization and may be subject to review for medical necessity. For example, any kind of inpatient hospital care (except maternity care), ambulatory surgery/procedure, or services provided by an out-of-network provider (except emergency care or urgently needed service) require prior authorization.

Objective criteria are used in making utilization decisions and are reviewed and updated
against current clinical and medical evidence as necessary, but no less than yearly. The
sources of criteria are:

State and Federal (CMS) Mandates and Guidelines:

• Member Benefits
• InterQual
• Balance medical policy
• Hayes Medical Technology Directory
• National standards reflecting best practice
• Other sources as appropriate and available
• For Mental Health/Substance User Disorder services, Balance uses the non-profit professional associations (NPA) in accordance with SB 855:
  • • ASAM (current version) guideline developed by the American Society of Addiction Medicine (ASAM) for Substance Use Disorder for any age
    • Level of Care Utilization System (LOCUS) (current version) developed by the American Association of Community Psychiatrists (AACP) for Mental Health Disorders for patients 18 and older
    • Child and Adolescent Level of Care Utilization System (CALOCUS-CASII) (current version) developed by the American Association of Community Psychiatrists (AACP) and the American Academy of Child & Adolescent Psychiatry (AACAP) for Mental Health Disorders for patients 6 to 17 years of age
    • Early Childhood Service Intensity Instrument (ESCII) (current version) developed by AACAP for Mental Health Disorders for patients 0 to 5 years of age
    • WPATH Standards of Care (current version) developed by the World Professional Association for Transgender Health (WPATH) for patients with Gender Dysphoria

The review process must not interfere with, cause delay in services, or preclude delivery of services. When making a determination based on medical necessity, only information reasonably necessary to make a decision will be requested. The UM process will ensure that the information needed to determine medical necessity such as patient medical records, conversations with appropriate providers, and other clinical information is used in the decision-making process to either approve or deny.

Appropriately, licensed healthcare professionals supervise all medical necessity decisions. Staff members who are not qualified healthcare professionals may collect data for prior authorization and concurrent review under the supervision of appropriately licensed healthcare professionals. They may also have the authority to approve (but not deny) services for which there are explicit criteria.

All authorization and UM decisions are based upon the appropriateness and medical necessity of care and service. Staff who issue denials of coverage or service care are not specifically rewarded. Financial incentives are not offered to decision-makers which may encourage decisions that result in underutilization. Copies of clinical criteria are made available and may be received upon request by members, at no cost.

Utilization decisions are made in a timely manner in accordance with regulatory requirements and depending on the urgency of the request. The UM Department maintains a tracking system for identifying the status of all authorization requests.

For routine authorizations, decisions are made within 5 business days of request for members. Urgent decisions are made in a timely manner, appropriate for the member’s condition, not to exceed 72 hours after receipt of the request. The provider is notified within one working day of the decision. Medical necessity decisions in retrospective situations are resolved within 30 calendar days of receipt of the request. Providers and members are informed of retrospective denials within 30 calendar days of receipt of the request.

If an authorization request is denied, the member and practitioner are given written or electronic confirmation of the denial within two working days of making the decision. If an urgent case is denied, the member and practitioner are notified as to how to initiate an expedited appeal at the time they are notified of the denial.

Balance must approve some services before you obtain them. This is called prior authorization or preservice review. For example, any kind of inpatient hospital care (except maternity care) requires prior authorization. If you need a service that we must first approve, your in-network doctor will call us for authorization. If you don’t get prior authorization, you may have to pay up to the full amount of the charges. The number to call for prior authorization is included on the ID card you receive after you enroll. Please refer to the specific coverage information you receive after you enroll.

Sometimes our members need access to drugs that are not listed on the plan’s formulary (drug list). These medications are initially reviewed by our contracted Pharmacy Benefit Management (PBM) through the Formulary exception review process. The member or provider can submit the request to us by faxing the Pharmacy Formulary Exception Request Form to 1-858-790-7100.

• For initial standard exception review, the timeframe for review is 72 hours from when we receive the request.
• For initial expedited exception review, the timeframe for review is 24 hours from when we receive the request.

If you received a denial of a non-formulary request, you, your representative, or your prescribing provider may request to have your denial reviewed by Balance by filing for a grievance and/or an appeal. Your appointed relative, attorney, advocate, friend, or someone else, with appropriate appointment documents, could file the grievance or appeal on your behalf.

Learn more about our Grievance & Appeals process or contact Member Services directly to file your grievance or appeal.

If you are not satisfied with the results of the Balance decision regarding your grievance or appeal, you may file a complaint for an independent review of your case to the Department of Managed Health Care (DMHC) through the Independent Medical Review (IMR) process by completing this IMR Application/Complaint Form.

You can submit the IMR Form by mail or fax to:

Department of Managed Health Care
980 9th Street, Suite 500
Sacramento, CA 95814
Fax 916-255-5241

To submit a complaint electronically visit DMHC’s How to File a Complaint webpage.

Balance will send out Explanation of Benefits (EOB) by the 15th of each month for claims processed in the previous month. EOB is a statement by Balance to its members explaining what Medical services are paid for on their behalf. An EOB is not a bill. It explains how your benefits were applied to that particular claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you’re responsible for paying the provider. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.

The Services covered under the Combined Evidence of Coverage and Disclosure Form are subject to coordination of benefits (COB) rules. If you have a medical or dental plan with another health plan or insurance company, we will coordinate benefits with the other coverage under the COB rules of the California Department of Managed Health Care. Those rules are incorporated into this Combined Evidence of Coverage and Disclosure Form. If both the other insurer’s coverage and Balance covers the same Service, the other insurer’s coverage and Balance will see that up to 100 percent of your covered medical expenses are paid for that Service. The COB rules determine which coverage pays first, or is “primary,” and which coverage pays second, or is “secondary.” The secondary coverage may reduce its payment to take into account payment by the primary coverage. You must give us any information we request to help us coordinate benefits.