Transparency & Interoperability
Transparency Information
Out-of-Network Liability and Balance Billing
If you receive covered services from a non-plan provider, your cost-sharing will be higher, as described in the out-of-network portion of your Schedule of Benefits. It is your responsibility to ensure the providers you receive services from are in the Community Health Options network. If we approve your claim for payment of services rendered by a non-plan provider, we will pay benefits up to the maximum allowable amount. Charges above the maximum allowable amount will not apply to your out-of-network cost-sharing and will be your responsibility, if the non-plan provider chooses to bill you. This means you may have financial responsibility greater than the cost-sharing described on your Schedule of Benefits. This is sometimes referred to as balance billing.
Enrollee Claims Submission
Plan providers will file claims directly with the plan. Members may need to submit a claim for reimbursement for services from a non-plan provider. If you need to submit a claim for a service, you or your designee must do so within 120 days after the service is rendered. However, you may be allowed extra time if there is good reason why the claim cannot be submitted on time, and if you submit the claim as soon as you reasonably can.
Grace Periods and Claims Pending Policies During the Grace Period
When you purchase coverage, you pay the premium on a monthly basis. Premium payments are due the first day of each month for which coverage is provided. For a short period after your monthly premium payment is due, you may make your payment during the grace period and avoid losing your health coverage. No grace period applies to the binding premium payments.
Retroactive Denials
A retroactive denial is a reversal of a previously paid claim, through which the enrollee then becomes responsible for the payment.
Enrollee Recoupment of Overpayments
If you believe you have paid too much for your premium and should receive a refund, please call the Member service number on the back of your ID card.
Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities
Medical necessity is used to describe care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. Prior authorization is a process through which an issuer approves a request to access a covered benefit before the insured accesses the benefit.
Drug Exception Timeframes and Enrollee Responsibilities
We have a process for allowing exceptions to our formulary. To obtain coverage for a drug not on our formulary, you, your designee, or the prescribing provider must submit a request to Community Health Options with a clinical rationale for the exception.
Information on Explanation of Benefits (EOB)
An EOB is a statement an issuer sends the enrollee to explain what medical treatments and/or services it paid for on an enrollee’s behalf, the issuer’s payment, and the enrollee’s financial responsibility pursuant to the terms of the policy.
Coordination of Benefits
Coordination of benefits (“COB”) exists when an enrollee is also covered by another plan and determines which plan pays first.
Transparency in Coverage Regulations
Transparency regulations require health insurers and group health plans to disclose pricing information in machine-readable files (MRF). In-network files include negotiated rates with in-network providers; out-of-network files include allowed amounts and billed charges from out-of-network providers. Public access to these files may be found on this page. The presentation of MRFs follow the Centers for Medicare & Medicaid Services (CMS) defined layout and format and will be updated every 30 days.
Machine-readable files are not meant to be consumer-friendly—they are a digital representation of data or information in a file that can be imported or read by a computer system. To understand Member benefits and cost sharing, please contact Member Services at (855) 624-6463.
Interoperability
What is interoperability?
Interoperability in healthcare is the ability for information, in the form of data, to be shared and used among providers, laboratories, hospitals, pharmacies and the consumer/patient. The goal of sharing healthcare data within the health service industry is to create a more effective and efficient means to provide quality care by enabling quicker and more informed decisions.
What does interoperability mean for me?
It is important for Community Health Options Members to know that you control your health-related data sharing through health applications, like exercise trackers, which you must choose to connect through your smartphone, tablet, etc. If you choose not to share your access – your information remains private. You turn data sharing on and off via your health and wellness application on your personal device. If you don’t download an app and turn on permission, nothing changes.
What do I need to know before I connect an app?
If you choose to connect health care provider or commercial health tracking apps, you are placing a copy of your personal health information/data outside of Community Health Options' systems and data protections. This information includes, but is not limited to, your name, date of birth, health insurance plan information, healthcare providers you have seen, claims made for medical, pharmaceutical and laboratory visits, and other data.
You must contact the organization or business that created your app for information about how they will protect, share, or sell your data. It’s important to remember that not all organizations or individuals are covered by health information protection (HIPAA) regulations. Read more about HIPAA here: https://www.hhs.gov/hipaa/for-individuals/index.html. To learn more about your rights related to online data access, visit the Office of Civil Rights here: https://www.hhs.gov/ocr/index.html and the Federal Trade Commission here: https://www.ftc.gov/tips-advice/competition-guidance/industry-guidance/health-care.
How do I start sharing my data?
You control your health-related data sharing through health apps, like step and exercise trackers, or through provider office chart applications, which you must choose to connect through your smartphone, tablet, etc. See a list of the healthcare applications here: https://myhealthapplication.com.
How do I stop sharing my data?
If you do choose to share access through your personal devices and want to stop sharing, you must change your preferences on your personal device(s), not at your Member portal or anywhere else on the Community Health Options website.
How do I correct inaccuracies in data that I see in my app?
You must contact the organization or business that created your app to address any inaccuracies in the data displayed by that app. If there are inaccuracies in medical records, billing records, payment and claims records, or enrollment records maintained by Community Health Options, please contact Member Services at (855) 624-6463 for a “Request for Amendment to PHI” form.