Out-of-network Liability and Balance Billing
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. 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. Please refer to the plan Evidence of Coverage and Summary of Benefit for additional information.
Enrollee Claim Submission
Contracted providers have at least 90 days to bill claims to Balance for services provided to Members. Out of network providers or non-contracted providers have six (6) months (or 180 days) to bill Balance for services provider to Members. Balance process claims within 45 business days from the date of receipt.
Grace Periods and Claims Pending
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.
Recoupment of Overpayments
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, please reach out to our Member Services.
Drug Exception Time Frames and Enrollee Responsibilities
Balance delegates the authority of managing the formulary and making coverage determinations for all lines of business to the contracted PBM. Coverage exceptions for non-formulary medications are reviewed by the PBM on behalf of Balance. These reviews will be completed in a timely manner, depending on the urgency of the request. Prescribers, members, or member representatives are required to complete a coverage determination and exception request form to initiate the reviewing process for non-formulary medications. This form may be obtained by calling Member Services, the contracted PBM Customer Care, or downloaded from our website. The completed form, with information regarding medical necessity, will be sent to the contracted PBM via fax. The contracted will have pharmacists and/or medical professionals who are competent in evaluating a clinical issues review and will render a decision, based on medical necessity, in a timely manner, depending on the line of business and/or urgency level of the request. Upon receipt of the completed form to the PBM, Commercial, and Exchange standard requests will have a decision rendered within 72 hours.
For matters marked urgent – as defined by the Department of Managed Health Care (DMHC) – decisions will be made within 24 hours.
i) For Commercial and Exchange products, if additional information is not sent within two days of the request, the coverage determination will be denied.
ii) An urgent request may apply to exigent circumstances when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee’s life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug.
Explanation of Benefits (EOB)
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. The EOB describes the payee, the payer, and the patient, the service performed with detail (date of service, description of service, place of service), the amount billed, if any patient’s financial liability, and Balance’s payment.
Coordination of Benefits (COB)
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.
