Below is information about your Community First Health Plans coverage including claims information, prior authorization and additional information. For a full review of your benefits and coverage, please refer to your Evidence of Coverage and Schedule of Benefits.
Table of Contents
- Out-of-network Liability and Balance Billing
- Enrollee Claim Submission
- Grace Periods and Claims Pending
- Retroactive Denials
- Recoupment of Overpayments
- Prior Authorization
- Failure to Obtain Prior Authorization
- Drug Exceptions Timeframes and Enrollee Responsibilities
- Information on Explanations of Benefits
- Coordination of Benefits
Out-of-Network Liability and Balance Billing
Except for emergency services, you should always access healthcare services through providers that are in our network. Coverage from out-of-network providers is not a covered benefit, unless if you have a true medical emergency. If you need to see an out-of-network provider due to an emergency, you will need to let us know as soon as you are able to and will need to arrange any follow-up care with your PCP.
If you receive care from a non-participating provider for an emergency, your copayment and deductible will not change. If you access care from a non-participating provider that is not considered a true medical emergency, you will be financially responsible for any and all payments.
When receiving care at one of our participating hospitals or emergency rooms, it is possible that some hospital-based providers (for example, anesthesiologists, radiologists, pathologists) may not be under contract with us as participating providers. These providers may bill you for the difference between our allowed amount and the provider’s billed charge — this is known as “balance billing.” We encourage you to inquire about the providers who will be treating you before you begin your treatment, so you can understand their participation status with us.
Enrollee Claim Submission
When you receive medical treatment from a Community First participating provider, there are no claim forms to complete and no bills to submit. You are responsible for your copayment(s) and/or coinsurances(s) at the time services are rendered. You should not get a bill from Community First or First Health participating providers for covered services.
Providers will typically submit claims on your behalf, but sometimes you may have to pay for a covered service and file a claim for reimbursement. This may happen if:
- Your provider is not contracted with us.
- You have an out-of-area emergency.
If you have paid for services we agreed to cover, you can request reimbursement for the amount you paid, less any deductible, copayment or cost sharing that is your financial responsibility.
To request reimbursement for a covered service, you need a copy of the detailed bill from the provider who provided the services. You also need to submit an explanation of why you paid for the covered services. Send this to us at the following address:Community First Health Plans
Attn: Claims Department
12238 Silicon Drive, Ste. 100
San Antonio, TX 78249
After getting your claim, we will let you know we have received it, begin an investigation and request all items necessary to resolve the claim. We will do this in 15 days or less.
We will notify you, in writing, that we have either accepted or rejected your claim for processing within 15 days after receiving all items necessary to resolve your claim. If we accept your claim, we will make payment within 5 business days after notifying you of the payment of your claim. If we reject your claim, we will give you the reason your claim is rejected. If we are unable to come to a decision about your claim within 15 days, we will let you know and explain why we need additional time, and will make our decision to accept or reject your claim no later than the 45th day after our notice about the delay.
If you don’t pay your premium by its due date, you’ll enter a grace period. This allows you extra time to pay.
During your grace period, you will still have coverage. However, if you don’t pay before a grace period ends, you run the risk of losing your coverage. During a grace period, we may hold — or pend —payment of your claims. If your premium is not brought current by the end of your grace period, you may be held responsible for services provided to you during that time.
If your coverage is terminated for not paying your premium, you won’t be eligible to enroll with us again until Open Enrollment or a Special Enrollment period.
If you receive a subsidy payment
After you pay your first bill, you have a three-month grace period. During the first month of your grace period, we will keep paying claims for covered services you receive. If you continue to receive services during the second and third months of your grace period, we may hold these claims. If your coverage is in the second or third month of a grace period, we will notify you and your healthcare providers about the possibility of denied claims. We will also notify the U.S. Department of Health and Human Services (HHS) that you haven’t paid your premium.
If you receive a subsidy payment
After you pay your first bill, you have a grace period of one month. During this time, we will continue to cover your care, but we may hold your claims. We will notify you, your providers and the HHS about this non-payment and the possibility of denied claims.
Recoupment of Overpayments
Members may call in to request a refund of overpaid premium. Refunds are processed by a manual check. Refunds may take up to two weeks for processing.