We believe it’s important for our members to have a clear understanding of our policies and how they may impact you. This page will provide an overview of some of our policies relating to your benefits and claims. For more information, please see your Evidence of Coverage or contact Customer Service.
Out-of-Network Liability
Chorus Community Health Plans (CCHP) is an Exclusive Provider Organization plan, which means you must obtain services from in-network providers. In-network providers are the key to providing and coordinating your health care services. Services you obtain from any practitioner other than an in-network provider are considered out-of-network, unless otherwise indicated in the Evidence of Coverage, and will not be covered.
You will not be required to file any claims for services you obtain directly from in-network providers. In-network providers will seek payment for covered services from us and not from you except for applicable coinsurance, copayments, and/or deductibles. You may be billed by your practitioner (s) for any non-covered services you receive or when you have not acted in accordance with the Contract.
If you are outside of the service area, or if you are in the service area, but seek coverage by an out-of-network provider, and it is not an emergency, and prior authorization has not been obtained, you may be responsible for all related fees and expenses.
Balance Billing - Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care – like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
- Emergency services: If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
- Certain services at an in-network hospital or ambulatory surgical center: When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact:
- Wisconsin Office of the Commissioner of Insurance – 1-800-236-8517 P.O. Box 7873 Madison, WI 53707-7873
- No Surprise Help Desk (NSHD) – 1-800-985-3059
- Chorus Community Health Plans Appeals and Complaints Team – 877-900-2247 ex. #3
Visit http://www.cms.gov/nosurprises for more information about your rights under federal law.
Price Transparency – Machine Readable Files
- In accordance with the Price Transparency Final Rule (85 FR 72158) set forth by the Department of the Treasury, the Internal Revenue Service, the Department of Labor, the Employee Benefits Security Administration, and the Department of Health and Human Services, health plans or issuers must disclose in-network negotiated rates and out-of-network allowed amount rates with certain medical providers through two machine-readable files posted on a public facing internet website beginning July 1st, 2022.
- In Network File
- Out of Network File
- Provider Reference File
- The pricing information contained in the fee schedules is accurate as of the date it was accessed and is subject to changes over time. Furthermore, the pricing information is not a guarantee of coverage and payment and may not always reflect final member cost share amounts based on claim processing. Eligibility and benefit determinations are made when the claim is processed by CCHP. The disclosed rate data is for informational purposes only and should not in any way direct, limit, or enhance care.
- Data contained in the machine-readable files published by CCHP are based on the technical specifications set for by CMS in accordance with schema version 1.0.0 published by CMS at https://github.com/CMSgov/price-transparency-guide.
- For a more user-friendly price shopping experience, please access our Treatment Cost Calculator.
Member Claims Submission
When you receive covered services from an out-of-network provider, the claim must be filed in a format that contains all of the information we require, as described below. The practitioner will likely file the claim for payment from us, but ultimately you are responsible.
You should submit a claim for payment of covered services within 90 days after the date of service. If you don’t provide this information to us within 15 months of the date of service, benefits for that health service will be denied or reduced, at our discretion. The time limit does not apply if you are legally incapacitated. If your claim relates to an inpatient stay, the date of service is the date your inpatient stay ends. A request for the payment of benefits should include the following information:
- The contract holder’s name and address
- The patient’s name and age
- The number on your ID card
- The name and address of the provider of the covered services
- The name and address of any ordering provider
- A diagnosis from the provider
- An itemized bill from your provider that includes the Current Procedural Terminology (CPT) codes or a description of each charge
- The date the injury or sickness began
The out-of-network claim submission form can be mailed to:
CCHP Claims
PO Box 106013
Pittsburgh, PA 15230-6013
Contact Customer Service at 844-201-4672 with any questions.
Grace Periods
Except for your first premium, any premium not paid to us by the due date is in default. However, there is a grace period beginning with the first day of the payment period during which you fail to pay the premium. Your grace period is 30 days from the due date, unless you are receiving an advanced premium tax credit from the Federal Government, in which case you will have a 3-month grace period. If you are not receiving an advanced premium tax credit, CCHP will pend payment of any claims received during your 30 day grace period. If you are receiving an advanced premium tax credit from the Federal Government, we reserve the right to pend payment of all applicable claims that occur in the second and third month of the grace period. When a claim is pended, that means no payment will be made to the provider until the delinquent premium is paid in full.
Important: Partial premium payments will not extend the duration of your grace period. You must pay all past due amounts in order to be paid current on your account.
If you do not pay your past due premiums before the end of the grace period, your coverage will be terminated retroactively to the end of your first grace period month. If this happens, any pended claims will not be paid and it will become your responsibility to pay providers directly for the services that you received during months two and three of the grace period if receiving an advanced premium tax credit or during the one-month grace period if not receiving an advanced premium tax credit. If claims were paid during the grace period, and coverage is terminated, CCHP will recoup payments from the provider and the provider will bill you for any outstanding balances on your account. It will be your financial responsibility to pay for these services.
If however, you pay the full outstanding premium before the end of the grace period, CCHP will pay all claims for covered services we receive during the grace period that are properly submitted.
Retroactive Denials
A retroactive denial is the reversal of a claim that was previously paid. CCHP makes all claims payment determinations based on the information available at the time the claim is processed. If CCHP determines that a claim was paid in error (e.g., due to changes in member eligibility status, provider participation, or coordination of benefits with other coverage), the claim may be retroactively denied. If you have a retroactive denial, payment for the reversed claim will become your responsibility.
Tips to help avoid retroactive denials:
- Make premium payments on time to avoid a possible retroactive denial due to member ineligibility.
- Before visiting a new provider for the first time or going back to a familiar provider after your plan has changed, confirm that they are a participating provider in the Individual and Family Plan network.
- Tell Chorus Community Health Plan about other coverage that you may have. This can include coverage for a child from two different parents or benefits under government programs.
Member Recoupment of Overpayments
CCHP has established a process to help you get reimbursed for premium overpayments in a timely manner. If your insurance policy has been cancelled or terminated and you have made payments for a coverage period beyond your cancellation or termination date, you will be refunded after the next premium billing cycle. Requests for recoupment of other types of overpayments, such as duplicate monthly premium payments, will be processed in a timely manner. You can request recoupment of an overpayment by calling Customer Service at 844-201-4672.
Medical Necessity and Prior Authorization for Certain Services
CCHP wants its members to get the best possible care when they need it most. To ensure this, we use a prior authorization process, which is part of our Utilization Management (UM) program. UM decision-making is based only on appropriateness of care and service, and existence of coverage. CCHP does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
Prior authorization is a process performed to determine whether the requested treatment or service is medically necessary, that such treatment or service will be obtained in the appropriate setting, and/or will be a covered service.
Please see the Prior Authorization section of your Evidence of Coverage for a full list of covered services requiring prior authorization. When prior authorization is required:
- Ask your health care provider to start the process as soon as possible before the beginning of treatment. It’s always in your best interest to make sure there’s a prior authorization on file before you receive services.
- Your provider can submit a prior authorization request form online in our Provider Portal.
- Prior authorization is not required for emergency services.
Prior Authorization does not guarantee either payment of benefits or the amount of benefits. Eligibility for, and payment of benefits are subject to all terms and conditions in the Evidence of Coverage. If you choose to receive a service that has been determined not to be medically necessary, is not a covered service, or has not been prior authorized though prior authorization is required, you will be responsible for paying all charges and no benefits will be paid.
We will make a decision on your non-urgent requests within 15 days of our receipt of a correctly submitted request. If the request is an incomplete prior authorization or incorrectly filed prior authorization, we will notify you of a 15 day extension and the specific information needed. You will then have 45 days from the receipt of the notice to provide the requested information. Once we have received the additional information, we will make our decision within the period of time equal to the 15-day extension in addition to the number of days remaining from the initial 15-day period.
If you or a health care professional with knowledge of your medical condition have an urgent request for prior authorization, the request may be submitted to us via the CCHP Provider Portal. We will make a decision on your request and notify you within 72 hours of our receipt of a correctly submitted request, or as soon as possible if your condition requires a shorter time frame.
Questions on the prior authorization process can be directed to Customer Service at 844-201-4672.
Drug Exceptions Timeframes and Member Responsibilities
If the medication you take is not on the list of covered drugs for your benefit plan (also called a “formulary”), you can ask us to cover it. This is called a “non-formulary exception.” A request for a non-formulary exception will only be approved if there is documented evidence that the formulary alternatives are not effective in treating your condition, the formulary alternatives would cause adverse side effects, or a contraindication exists such that you cannot safely try the formulary drug.
As a first step, you can contact Customer Service for a list of similar drugs that are covered by your plan or you can review the Prescription Medication List for this information. When you have the list, show it to your doctor and see whether they are able to prescribe one of the drugs on this list.
If you need to request a non-formulary exception, contact Customer Service or access the exception request form in the CCHP Connect member portal. When you make this request, we may contact your prescriber or physician for information to support your request. After CCHP receives your request, we will make our decision within 72 hours. You can request a faster (expedited) decision if you or your doctor believes that waiting up to 72 hours for a decision could seriously harm your health. If your request to expedite is granted, we must give you a decision no later than 24 hours from when we received your request.
If we deny your request for a non-formulary exception, you may first request an internal review of that decision by contacting Customer Service. If the denial of the non-formulary exception request is upheld through an internal review, you may then request an external review by an Independent Review Organization (IRO). Requests for an external review can also be made by contacting Customer Service at 844-201-4672.
Information on Your Explanation of Benefits (EOB)
An Explanation of Benefits (EOB) is a statement that explains how CCHP has processed and either paid or denied a claim for medical services under your plan. An EOB provides important information about your benefits, including the status of claims and confirmation of costs you are responsible for, such as copayments, deductibles, and coinsurance. CCHP has published an EOB Tutorial to help you read and understand your EOB. You can also call Customer Service with any questions.
CCHP will send you an EOB shortly after a claim for medical services you receive has been processed. You will receive your EOB in the mail, or you can log into CCHP Connect to opt out of receiving paper EOBs and instead request to receive them electronically. If you receive a service that is paid by CCHP at 100% and you are not responsible for any cost-sharing, we will not mail you an EOB. Electronic EOBs are available for all claims.
Coordination of Benefits
This provision applies when a person has health care coverage under more than one policy or plan. The process by which these plans work together to make sure you get the most out of your coverage is referred to as coordination of benefits.
A primary plan must pay benefits in accordance with its policy terms without regard to the possibility that this contract may cover some expenses. This contract pays after the primary plan, and may reduce the benefits it pays so that payments from all coverage do not exceed 100% of the total allowable expense.
For more information please refer to the Coordination of Benefits section in your Evidence of Coverage.
Any outstanding questions can be directed to our Customer Service department at 844-201-4672.
Written explanation justifying rate increase (effective January 1, 2022)
The rate change requested impacts approximately 16,000 existing members. The changes vary by plan, mainly due to increasing medical and prescription drug costs, COVID-19 adjustments to claim experience, and updates to the 2022 reinsurance parameters under the Wisconsin Healthcare Stability Plan. The average rate change is 2.76% relative to our January 1, 2021 rating levels.