Claims Payment Policies & Other Information
Healthcare Reform
- Out-of-Network Liability and balance billing
- Enrollee claim submission
- Grace periods and claims pending
- Retroactive denials
- Recoupment of overpayments
- Medical necessity and prior authorization time frames and enrollee responsibilities
- Drug exception time frames and enrollee responsibilites
- Explanation of benefits (EOB)
- Coordination of benefits (COB)
- Number of Claims Denied in Calendar Year 2018
- Number of Claims Denied in Calendar Year 2019
- Number of Internal Appeals Filed in Calendar Year 2018
- Number of Internal Appeals Filed in Calendar Year 2019
- Number of Internal Appeals Overturned from Calendar Year 2018 Appeals
- Number of Internal Appeals Overturned from Calendar Year 2019 Appeals
- Number of External Appeals Filed in Calendar Year 2018
- Number of External Appeals Filed in Calendar Year 2019
- Number of External Appeals Overturned from Calendar Year 2018 Appeals
- Number of External Appeals Overturned from Calendar Year 2019 Appeals
- Plan Level Denials – 2019 Service dates
