A. Out-of-network liability and balance billing
Financial liability for out-of-network services
We do not have contracts with out-of-network providers and they may not agree to accept our payment arrangements. Therefore, you are responsible for any difference between the amount charged and our payment.
Exceptions to out-of-network liability, such as for emergency services
Out-of-network providers do not participate with Wellmark Blue HMOSM network or any other Blue Cross and/or Blue Shield Plan. Generally, you are only covered for services received from out-of-network providers in case of emergency, from an out-of-network ancillary provider when you are receiving services at an in-network facility, or approved out-of-network referral.
Balance-billing
We do not have contracts with out-of-network providers and they may not agree to accept our payment arrangements. Therefore, you are responsible for any difference between the amount charged and our payment.
B. Enrollee claims submission
Submitting a claim in lieu of a provider
Once you receive services, we must receive a claim to determine the amount of your benefits. The claim lets us know the services you received, when you received them, and from which provider.
When to file a claim
You need to file a claim if you:
- Use a provider who does not file claims for you. Wellmark Blue HMO network providers file claims for you.
- Purchase prescription drugs from a participating pharmacy but do not present your ID card.
- Pay in full for a drug that you believe should have been covered.
Your submission of a prescription to a participating pharmacy is not a filed claim and therefore is not subject to appeal procedures. However, you may file a claim with us for a prescription drug purchase you think should have been a covered benefit.
Wellmark must receive claims within 180 days following the date of service of the claim.
How to file a claim
If you recently received care from an out-of-network provider, work with your doctor to file a claim.
C. Grace periods and claims pending during the grace period
If you are receiving advance payment of the Premium Tax Credit and you do not pay your premium by the premium due date, Wellmark will allow you a three consecutive month grace period if you had previously paid at least one full month's premium during the benefit year in which the nonpayment of premium occurs. Claims with dates of service during the first month of the grace period will be processed and paid if the services are covered under this policy. Medical claims with dates of service during the second and third months of the grace period will be suspended pending the payment of the premium and denied if the premium is not received by expiration of the grace period. Pharmacy claims with dates of service during the second and third months of grace period will be reduced by Wellmark’s negotiated rate and will be 100% your liability. If you do not pay your premium by the premium due date, Wellmark will notify you as soon as reasonably practicable that your premium payment is delinquent. If you do not pay the premium due by the expiration of the three month grace period, Wellmark will promptly notify you of the termination of your coverage. Our notice will include the reason for the termination and the effective date of the termination of your coverage. If premium is paid in full prior to the expiration of the three month grace period, medical claims will process according to the benefits of this policy. To seek reimbursement for pharmacy claims with dates of service during the second and third month of grace period if premium is paid in full prior to the expiration, you must file a paper claim.
"Claims pending" means that Wellmark has received a claim but is not processing the claim. Claims are pended in the context of a Grace Period when the premium due has not been paid by the date the premium is due.
D. Retroactive denials
Claims may be denied retroactively, even after the enrollee has obtained services from the provider, if:
- Premium is not paid on or before the expiration of the Grace Period applicable to the health plan or policy.
- Wellmark made a payment in error, in which case we may recover the amount we paid.
- The health plan or policy is fraudulently used or material facts are intentionally misrepresented or concealed in the application for coverage.
- The enrollee was not eligible for coverage.
- The services received from the provider are not a covered benefit under the terms of the health plan or policy.
Ways to prevent a retroactive denial of benefits:
- Always pay the premium amount due by the premium due date.
- Always review the Explanation of Health Care Benefits (“EOB”). If there is an error on the EOB, please contact Wellmark Customer Service at the toll free telephone number on the back of your Wellmark ID card. Learn how to read your EOB.
- Always provide accurate information on the application for coverage and to any requests for information from Wellmark or your provider.
- If you have a question about your eligibility for coverage, please check with Healthcare.gov or contact Wellmark through the toll free telephone number listed on Wellmark.com.
- Review the health plan or policy to confirm the services to be performed by your provider are a covered benefit of your health plan or policy. If you have a question about whether a planned service is a covered benefit, you may contact Wellmark through the toll free telephone number listed on Wellmark.com.
E. Enrollee recoupment of overpayments
In the event of an overpayment of your premium the overpayment will be credited on your account and applied to your next premium due. You may call the number on the back of your ID card to initiate a refund.
F. Medical necessity and prior authorization timeframes and enrollee responsibilities
Some services require prior authorization and/or subject to medical necessity review
Many services require a notification to us or a review by us. If you do not follow notification requirements properly, you may have to pay for services yourself. Review a complete list of services that require a pre-service review or call the Customer Service number on your ID card.
Providers in the Wellmark Blue HMO network should handle notification requirements for you. If you are admitted to a Participating facility outside the Wellmark Blue HMO network, the Participating Provider should handle notification requirements for you.
If you receive any other covered service (i.e., services unrelated to an inpatient admission) from a Participating Provider outside the Wellmark Blue HMO network or if you see an Out-of-Network Provider, you or someone acting on your behalf are responsible for notification requirements.
More than one of the notification requirements and care coordination programs described in this section may apply to a service. Any notification or care coordination decision is based on the medical benefits plan in effect at the time of your request. If your coverage changes for any reason, you may be required to repeat the notification process.
You or your authorized representative, if you have designated one, may appeal a denial or reduction of benefits resulting from these notification requirements and care coordination programs.
Ramifications of not properly following prior authorization procedures
If you do not follow notification requirements properly, you may have to pay for services yourself, so the information in this section is critical.
Timeframe for prior authorization requests
There are different types of pre-service reviews. Wellmark will respond to requests for a precertification, prior approval, or prior authorization within:
- 72 hours in a medically urgent situation
- 15 days in a medically non-urgent situation
G. Drug exceptions timeframes and enrollee responsibilities
Exceptions for non-formulary drugs
Prescription drugs not on the Wellmark Blue Rx EssentialsSM drug list External Site are not covered. To begin the Formulary Exception Request process work with your doctor to complete the Global Prior Authorization Form External Site or contact Wellmark Customer Service at the number printed on the back of your ID card. Your prescribing physician or other provider must provide a clinical justification supporting the need for the non-formulary drug to treat your condition. The provider should include a statement that:
- All covered formulary drugs on any tier have been ineffective; or
- All covered formulary drugs on any tier will be ineffective; or
- All covered formulary drugs on any tier would not be as effective as the non-formulary drug; or
- All covered formulary drugs would have adverse effects.
Timeframe for a decision based on a standard or expedited review due to exigent circumstances
Wellmark will respond within 72 hours of receiving the Exception Request for Non-Formulary Prescription Drugs form. For expedited requests, Wellmark will respond within 24 hours. In the event Wellmark denies your exception request, you and your provider will be sent additional information regarding your ability to request an independent review of our decision. If the independent reviewer approves your exception request, we will treat the drug as a covered benefit for the duration of your prescription. You will be responsible for out-of-pocket costs (for example: deductible, copay, or coinsurance, if applicable) as if the non-formulary drug is on the highest tier of the Wellmark Blue Rx Essentials drug list. Amounts you pay will be counted toward any applicable out-of-pocket maximums. If the independent reviewer upholds Wellmark’s denial of your exception request, the drug will not be covered, and this decision will not be considered an adverse benefit determination, and will not be eligible for further appeals. You may choose to purchase the drug at your own expense. The Exception Request for Non-Formulary Prescription Drugs process is only available for FDA approved prescription drugs that are not on the Wellmark Blue Rx Essentials drug list. It is not available for items that are specifically excluded under your benefits, such as cosmetic drugs, convenience packaging, non-FDA approved drugs, infused drugs, most over-the-counter medications, nutritional, vitamin and dietary supplements, or antigen therapy. The preceding list of excluded items is illustrative only and is not a complete list of items that are not eligible for the process.
H. Information on Explanation of Benefits (EOBs)
You will receive an Explanation of Benefits (EOB) following your claim. The EOB is a statement outlining how we applied benefits to a submitted claim. It details amounts that providers charged, network savings, our paid amounts, and amounts for which you are responsible. Learn how to read your EOB.
In case of an adverse decision, the notice will be sent within 30 days of receipt of the claim. We may extend this time by up to 15 days if the claim determination is delayed for reasons beyond our control. If we do not send an explanation of benefits statement or a notice of extension within the 30-day period, you have the right to begin an appeal. We will notify you of the circumstances requiring an extension and the date by which we expect to render a decision.
If an extension is necessary because we require additional information from you, the notice will describe the specific information needed. You have 45 days from receipt of the notice to provide the information. Without complete information, your claim will be denied.
If you have other insurance coverage, our processing of your claim may utilize coordination of benefits guidelines.
Once we pay your claim, whether our payment is sent to you or to your provider, our obligation to pay benefits for the claim is discharged. However, we may adjust a claim due to overpayment or underpayment for up to 18 months after we first process the claim.
In the case of Out-of-Network hospitals, M.D.s, and D.O.s located in Iowa, the health plan payment is made payable to the provider, but the check is sent to you. You are responsible for forwarding the check to the provider, plus any difference between the amount charged and our payment.
I. Coordination of benefits (COB)
Coordination of benefits applies when you have more than one insurance policy or plan that provides the same or similar benefits as this plan. Benefits payable under this policy, when combined with those paid under your other coverage, will not be more than 100 percent of either our payment arrangement amount or the other carrier’s payment arrangement amount.
A. Out-of-network liability and balance billing
Financial liability for out-of-network services
We do not have contracts with out-of-network providers and they may not agree to accept our payment arrangements. Therefore, you are responsible for any difference between the amount charged and our payment.
Exceptions to out-of-network liability, such as for emergency services
Out-of-network providers do not participate with Wellmark Blue EPOSM network or any other Blue Cross and/or Blue Shield Plan. Generally, you are only covered for services received from out-of-network providers in case of emergency, from an out-of-network ancillary provider when you are receiving services at an in-network facility, or approved out-of-network referral.
Balance-billing
We do not have contracts with out-of-network providers and they may not agree to accept our payment arrangements. Therefore, you are responsible for any difference between the amount charged and our payment.
B. Enrollee claims submission
Submitting a claim in lieu of a provider
Once you receive services, we must receive a claim to determine the amount of your benefits. The claim lets us know the services you received, when you received them, and from which provider.
When to file a claim
You need to file a claim if you:
- Use a provider who does not file claims for you. Wellmark Blue EPO network providers file claims for you.
- Purchase prescription drugs from a participating pharmacy but do not present your ID card.
- Pay in full for a drug that you believe should have been covered.
Your submission of a prescription to a participating pharmacy is not a filed claim and therefore is not subject to appeal procedures. However, you may file a claim with us for a prescription drug purchase you think should have been a covered benefit.
Wellmark must receive claims within 180 days following the date of service of the claim.
How to file a claim
If you recently received care from an out-of-network provider, work with your doctor to file a claim.
C. Grace periods and claims pending during the grace period
If you are receiving advance payment of the Premium Tax Credit and you do not pay your premium by the premium due date, Wellmark will allow you a three consecutive month grace period if you had previously paid at least one full month's premium during the benefit year in which the nonpayment of premium occurs. Claims with dates of service during the first month of the grace period will be processed and paid if the services are covered under this policy. Medical claims with dates of service during the second and third months of the grace period will be suspended pending the payment of the premium and denied if the premium is not received by expiration of the grace period. Pharmacy claims with dates of service during the second and third months of grace period will be reduced by Wellmark’s negotiated rate and will be 100% your liability. If you do not pay your premium by the premium due date, Wellmark will notify you as soon as reasonably practicable that your premium payment is delinquent. If you do not pay the premium due by the expiration of the three month grace period, Wellmark will promptly notify you of the termination of your coverage. Our notice will include the reason for the termination and the effective date of the termination of your coverage. If premium is paid in full prior to the expiration of the three month grace period, medical claims will process according to the benefits of this policy. To seek reimbursement for pharmacy claims with dates of service during the second and third month of grace period if premium is paid in full prior to the expiration, you must file a paper claim.
"Claims pending" means that Wellmark has received a claim but is not processing the claim. Claims are pended in the context of a Grace Period when the premium due has not been paid by the date the premium is due.
D. Retroactive denials
Claims may be denied retroactively, even after the enrollee has obtained services from the provider, if:
- Premium is not paid on or before the expiration of the Grace Period applicable to the health plan or policy.
- Wellmark made a payment in error, in which case we may recover the amount we paid.
- The health plan or policy is fraudulently used or material facts are intentionally misrepresented or concealed in the application for coverage.
- The enrollee was not eligible for coverage.
- The services received from the provider are not a covered benefit under the terms of the health plan or policy.
Ways to prevent a retroactive denial of benefits:
- Always pay the premium amount due by the premium due date.
- Always review the Explanation of Health Care Benefits (“EOB”). If there is an error on the EOB, please contact Wellmark Customer Service at the toll free telephone number on the back of your Wellmark ID card. Learn how to read your EOB.
- Always provide accurate information on the application for coverage and to any requests for information from Wellmark or your provider.
- If you have a question about your eligibility for coverage, please check with Healthcare.gov or contact Wellmark through the toll free telephone number listed on Wellmark.com.
- Review the health plan or policy to confirm the services to be performed by your provider are a covered benefit of your health plan or policy. If you have a question about whether a planned service is a covered benefit, you may contact Wellmark through the toll free telephone number listed on Wellmark.com.
E. Enrollee recoupment of overpayments
In the event of an overpayment of your premium the overpayment will be credited on your account and applied to your next premium due. You may call the number on the back of your ID card to initiate a refund.
F. Medical necessity and prior authorization timeframes and enrollee responsibilities
Some services require prior authorization and/or subject to medical necessity review
Many services require a notification to us or a review by us. If you do not follow notification requirements properly, you may have to pay for services yourself. Review a complete list of services that require a pre-service review or call the Customer Service number on your ID card.
Providers in the Wellmark Blue EPO network should handle notification requirements for you. If you are admitted to a Participating facility outside the Wellmark Blue EPO network, the Participating Provider should handle notification requirements for you.
If you receive any other covered service (i.e., services unrelated to an inpatient admission) from a Participating Provider outside the Wellmark Blue EPO network or if you see an Out-of-Network Provider, you or someone acting on your behalf are responsible for notification requirements.
More than one of the notification requirements and care coordination programs described in this section may apply to a service. Any notification or care coordination decision is based on the medical benefits plan in effect at the time of your request. If your coverage changes for any reason, you may be required to repeat the notification process.
You or your authorized representative, if you have designated one, may appeal a denial or reduction of benefits resulting from these notification requirements and care coordination programs.
Ramifications of not properly following prior authorization procedures
If you do not follow notification requirements properly, you may have to pay for services yourself, so the information in this section is critical.
Timeframe for prior authorization requests
There are different types of pre-service reviews. Wellmark will respond to requests for a precertification, prior approval, or prior authorization within:
- 72 hours in a medically urgent situation
- 15 days in a medically non-urgent situation
G. Drug exceptions timeframes and enrollee responsibilities
Exceptions for non-formulary drugs
Prescription drugs not on the Wellmark Blue Rx EssentialsSM drug list External Site are not covered. To begin the Formulary Exception Request process work with your doctor to complete the Global Prior Authorization Form External Site or contact Wellmark Customer Service at the number printed on the back of your ID card. Your prescribing physician or other provider must provide a clinical justification supporting the need for the non-formulary drug to treat your condition. The provider should include a statement that:
- All covered formulary drugs on any tier have been ineffective; or
- All covered formulary drugs on any tier will be ineffective; or
- All covered formulary drugs on any tier would not be as effective as the non-formulary drug; or
- All covered formulary drugs would have adverse effects.
Timeframe for a decision based on a standard or expedited review due to exigent circumstances
Wellmark will respond within 72 hours of receiving the Exception Request for Non-Formulary Prescription Drugs form. For expedited requests, Wellmark will respond within 24 hours. In the event Wellmark denies your exception request, you and your provider will be sent additional information regarding your ability to request an independent review of our decision. If the independent reviewer approves your exception request, we will treat the drug as a covered benefit for the duration of your prescription. You will be responsible for out-of-pocket costs (for example: deductible, copay, or coinsurance, if applicable) as if the non-formulary drug is on the highest tier of the Wellmark Blue Rx Essentials drug list. Amounts you pay will be counted toward any applicable out-of-pocket maximums. If the independent reviewer upholds Wellmark’s denial of your exception request, the drug will not be covered, and this decision will not be considered an adverse benefit determination, and will not be eligible for further appeals. You may choose to purchase the drug at your own expense. The Exception Request for Non-Formulary Prescription Drugs process is only available for FDA approved prescription drugs that are not on the Wellmark Blue Rx Essentials drug list. It is not available for items that are specifically excluded under your benefits, such as cosmetic drugs, convenience packaging, non-FDA approved drugs, infused drugs, most over-the-counter medications, nutritional, vitamin and dietary supplements, or antigen therapy. The preceding list of excluded items is illustrative only and is not a complete list of items that are not eligible for the process.
H. Information on Explanation of Benefits (EOBs)
You will receive an Explanation of Benefits (EOB) following your claim. The EOB is a statement outlining how we applied benefits to a submitted claim. It details amounts that providers charged, network savings, our paid amounts, and amounts for which you are responsible. Learn how to read your EOB.
In case of an adverse decision, the notice will be sent within 30 days of receipt of the claim. We may extend this time by up to 15 days if the claim determination is delayed for reasons beyond our control. If we do not send an explanation of benefits statement or a notice of extension within the 30-day period, you have the right to begin an appeal. We will notify you of the circumstances requiring an extension and the date by which we expect to render a decision.
If an extension is necessary because we require additional information from you, the notice will describe the specific information needed. You have 45 days from receipt of the notice to provide the information. Without complete information, your claim will be denied.
If you have other insurance coverage, our processing of your claim may utilize coordination of benefits guidelines.
Once we pay your claim, whether our payment is sent to you or to your provider, our obligation to pay benefits for the claim is discharged. However, we may adjust a claim due to overpayment or underpayment for up to 18 months after we first process the claim.
In the case of Out-of-Network hospitals, M.D.s, and D.O.s located in South Dakota, the health plan payment is made payable to the provider, but the check is sent to you. You are responsible for forwarding the check to the provider, plus any difference between the amount charged and our payment.
I. Coordination of benefits (COB)
Coordination of benefits applies when you have more than one insurance policy or plan that provides the same or similar benefits as this plan. Benefits payable under this policy, when combined with those paid under your other coverage, will not be more than 100 percent of either our payment arrangement amount or the other carrier’s payment arrangement amount.
