Plan Support Materials

Balance Billing Out-of-Network

Balance billing is when you go out-of-network, and that doctor bills you for charges other than copayments, coinsurance, or your deductible. Get more details about balance billing when going out-of-network:

Out-of-Network Liability and Balance Billing

Claims Submissions by Members

In special cases, you may need to submit a claim instead of your doctor. Get more details and instructions:

Instructions for Claim Submissions by Members

Retroactive Denials

A retroactive denial is when a previously paid claim is reversed, which makes you responsible for the payment. Learn more about why this happens and how to avoid it when possible:

Retroactive Denials

Premium Overpayment Refunds

If you overpaid because of over-billing, follow these instructions to get a refund:

Instructions on Getting a Refund of Premium Overpayment

Medical Necessity and Prior Authorization

These policies make sure that you meet certain requirements before we agree to cover it, which helps keep you safe and control your costs. Learn more about these policies, their timeframes, and your responsibilities as a member:

Medical Necessity and Preauthorization Timeframes and Member Responsibilities

Drug Exceptions

Sometimes, you might need to request coverage of a drug not on our formularies. Learn more about how this process works, timeframes, and your responsibilities as a member:

Drug Exceptions Timeframes and Enrollee Responsibilities

Explanations of Benefits

Once a claim is processed, you might receive an Explanation of Benefits (EOB). The EOB breaks down your benefits and the costs for a service, like a visit to the doctor's office. Learn more about what an EOB shows:

Information on Explanations of Benefits (EOBs)

Coordination of Benefits

Coordination of Benefits (COB) is when you're also covered by another plan, and we have to determine which plan pays first. Learn more about this process and these rules:

Coordination of Benefits