General Plan Information
Be Enrolled and Pay Required Premiums
- Benefits are available to you only if you are enrolled for coverage under the plan. To be enrolled under the plan and receive benefits, your enrollment must be in accordance with the plan’s and the Health Insurance Marketplace’s eligibility requirements, as applicable. You must also qualify as a covered person. You must also pay any premiums required by the Marketplace and/or the plan.
Choose Your Health Care Provider
- It is your responsibility to select the network providers and network pharmacies that will provide your health care. We can help you find network providers and network pharmacies. Use the Quick Links to access our Find a Doctor/Provider tool and our Find a Pharmacy tool.
Your Financial Responsibility
- You must pay copayments, coinsurance and the annual deductible for most covered services.
- If you are a member of a federally recognized tribe and your household income is at or below 300% of the federal poverty level, you will have no cost sharing (including copayments, coinsurance, and deductibles) for covered services. More information, including a list of federally recognized tribes, is available online at: healthcare.gov.
- Regardless of your household income, there is no cost sharing if you receive services from an Indian health care provider or through referral under the Contract Health Services program administered by the Indian Health Service.
Pay the Cost of Limited and Excluded Services
- You must pay the cost of all health care services and items that exceed the limitations on payment of benefits or are not covered services.
Show Your ID Card
- To make sure you receive your full benefit under the plan, you should show your ID card every time you request health care services. If you do not show your ID card, your provider may fail to bill us for the health care services delivered. Any resulting delay may mean that you will not receive benefits under the plan to which you would otherwise be entitled.
Explanation of Benefits
After you receive health care services, you will receive a written Explanation of Benefits (EOB) summarizing the benefits you received. This EOB is not a bill for health care services. The EOB shows you what services were billed to CareSource and how they were paid. It lists:
- The member who got the service
- The provider who billed for the service
- The date the service was received
- A description of the service
- The amount CareSource paid for the service
- How much you owe or already paid for the service, if anything
If you do owe for a service, you will get a bill from the provider. We encourage you to save these EOB statements and pay only the amount listed as your responsibility. If you get a bill from a provider for more than the amount the EOB shows as your responsibility, please call Member Services.
Premium Payment Grace Period
A grace period is a short period after your monthly health insurance payment is due.
If your policy has been effectuated (if you have paid your first premium), a grace period of three (3) consecutive months shall be granted for the payment of any premium.
If you pay a premium for any period of time after your coverage is terminated, we will refund that premium to you. The refund will be for the time after your coverage ends.
During this three-month grace period, we will:
- Pay for covered services during the first month of the grace period;
- Deny all prescription and non-prescription drug claims during the second and third months of the grace period;
- Notify network Providers of the possibility for denied claims during the second and third months of the grace period;
- Notify the United States Department of Health and Human Services of such non-payment if you are receiving advance payments of the premium tax credit through the Marketplace; and
- For claims currently pended when the member moves into the grace period, payment decisions will be made based on the date of service and the member’s status on this date.
- A pended claim is a claim that has not yet been approved or denied. A pended claim is typically missing information necessary for the insurer to make a coverage decision.
- Additional claims may be pended for services rendered to the enrollee in the second or third months of the grace period.
- If you do not bring your account current by the end of the grace period, your coverage will be terminated back to the end of the first month of the grace period and all claims paid after the termination date will be recovered.
Prescription Drug Formulary
Your plan uses a covered list of drugs, called the Marketplace Drug Formulary. Your cost share and limitations of coverage are represented on this list. Drugs not included on this list are not covered. In the event you need an exception to cover a drug not listed on the Formulary, you may call Member Services to make the request, or complete the online Member Exception Request for Non-Formulary Medication to begin the request for an Internal Exception Review.
CareSource then contacts the appropriate health partner. CareSource may ask the health partner to provide written clinical documentation about why the member needs an exception. Health partners must provide this information.
For standard exception review of medical requests, the timeframe for review is 72 hours from when we receive the request. For expedited exception review requests, the timeframe for review is 24 hours from when we receive the request.
If CareSource denies the drug exception, you have the right to request an external review. If you feel we have denied the non-formulary drug exception request incorrectly, you or your Authorized Representative may send a written request for an External Review. We must follow the External Reviewer’s decision.
An External Review may be requested by a member, member’s representative, or prescribing provider by mailing or calling:
West Virginia Offices of the Insurance Commissioner
P.O. Box 50540
Charleston, WV 25305
Toll Free: 1-888-879-9842
Online request form: https://www.wvinsurance.gov/Portals/6/pdf/External%20Review%20Request%20Form%202-2016.pdf?ver=2020-01-24-095316-047
To request an expedited review for exigent circumstance, select the “Request for Expedited Review” option in the External Review Request Form.
Out-of-Network Liability and Balance Billing
Health care services you receive from non-network providers are not covered services unless:
- A non-network provider renders emergency health services to you;
- You receive urgent care services while you are temporarily outside the service area;
- There is a specific situation involving the continuity of your health care
- You receive health care services from a non-network provider (such as an anesthesiologist or radiologist) while you are in a hospital or other facility that is a network provider, as explained above; or
- The Health Care Services you need are Covered Services under the Plan and not available from a Network Provider or Facility. In this case, you, your PCP or Network Provider must obtain our Prior Authorization.
If you receive emergency care from a non-network provider you will not be responsible for cost share (deductible, coinsurance, and copayments) amounts more than what they would have been if you received care from an in-network provider.
For non-emergency care, in addition to applicable in-network cost shares (deductible, coinsurance, and copayments), you may be required to pay the excess of the amount of the out-of-network provider charges over the amount that CareSource is required to pay. This is called balance billing.
An out-of-network provider may balance bill you for amounts over the amount paid by the plan or for non-covered services.
In some situations as required by law, a non-network provider is not allowed to bill you for services covered by CareSource, when they are aware CareSource is a Health Maintenance Organization. Please refer to your Evidence Of Coverage for more details.
Network providers are not allowed to balance bill you for covered services.
If you receive a bill, you can submit it to CareSource with a claim form. You may obtain a claim form by calling Member Services at the phone number on your ID card (TTY for the hearing impaired: 711).
Medical Necessity and Prior Authorization Timeframes
Medically necessary services are health care services that are determined to be medically appropriate in accordance with CareSource’s medical policies and nationally recognized guidelines. These are services that are not experimental or investigational in nature, are necessary to meet the basic health needs of the covered person and are rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service.
Medically necessary services are consistent in the type, frequency and duration of treatment with scientifically-based guidelines of national medical, research or health care coverage organizations or governmental agencies that are accepted by us; they are consistent with the diagnosis of the condition; are required for reasons other than the convenience of the covered person or his/her physician; and are demonstrated through prevailing peer-reviewed medical literature to be either:
- Safe and effective for treating or diagnosing the condition or sickness for which their use is proposed, or
- Safe with promising efficacy for treating a life-threatening sickness or condition in a clinically controlled research setting using a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health. (For purposes of this definition, the term “life threatening” is used to describe sickness or conditions that are more likely than not to cause death within one year of the date of the request for treatment.)
- If your Network Provider fails to obtain Prior Authorization from us for Health Care Services as required by us, and such provider renders such Health Care Services to you, the Network Provider shall be responsible for those Health Care Services and neither the Plan nor you will be required to pay for those Health Care Services. If you receive Health Care Services from a Non-Network Provider and you or the Non-Network Provider did not obtain Prior Authorization for such Health Care Services, you are responsible for making full payment to the Non-Network Provider.
The fact that a physician has performed or prescribed a procedure or treatment, or the fact that it may be the only available treatment for an injury, sickness or mental sickness, or the fact that the physician has determined that a particular health care service is medically necessary or medically appropriate does not mean that the procedure or treatment is a covered service under CareSource.
We will make our benefit decisions within the timeframes set forth below.
|Review Request Category||Timeframe for Making Decision|
|Urgent||As soon as possible, taking into account the medical exigencies, but not later than seventy-two (72) hours from the receipt of request.|
|Prospective Urgent submitted through secure electronic transmission||As soon as possible, taking into account the medical exigencies, but not later than forty-eight (48) hours from the receipt of the request.|
|Prospective||Within two (2) Business Days after receiving all necessary information, or fifteen (15) calendar days from the receipt of the request, whichever is less.|
|Prospective submitted through secure electronic transmission||Within two (2) Business Days after receiving all necessary information or within ten (10) calendar days from the receipt of the request, whichever is less.|
|Concurrent Urgent when request is received at least twenty-four (24) hours before the expiration of the previous authorization or no previous authorization exists||Within twenty-four (24) hours from the receipt of the request, taking into account the medical exigencies.|
|Concurrent Urgent when request is received less than twenty-four (24) hours before the expiration of the previous authorization or no previous authorization exists||As soon as possible, taking into account the medical exigencies, but not later than seventy- two (72) hours from the receipt of request, whichever is less.|
|Concurrent||Within one (1) Business Day after receiving all necessary information.|
|Retrospective||Thirty (30) calendar days from the receipt of the request.|
Services that Require a Prior Authorization
CareSource keeps track of the services you get from health care providers. We discuss some services with your providers before you get them. We do this to make sure the services are appropriate and necessary.
Your doctor will assist you in getting a prior authorization from us for services that need one. For example, some procedures and most inpatient hospital stays require prior authorization.
Many other services do not need a prior authorization. You do not need one to see your PCP or most specialists. Your doctor will tell you when you need these types of care.
Your Evidence of Coverage includes a detailed list of covered services and requirements. Check this document if you have questions about a specific service.
Download our Prior Authorization List here
Your provider is responsible for requesting payment from us. If your provider is unable to submit claims, you may submit a claim directly to us using the member claim form or by calling Member Services.
Written notice of claim must be given to us within 60 days from the date services were rendered, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the member to CareSource or to any authorized agent of CareSource, with information sufficient to identify the member, shall be deemed notice to us.
Submit claims to: CareSource, P.O. Box 8730, Dayton, OH 45401-8730
See your EOC or call Member Services for more information about Claims policies for your plan.
Coordination of Benefits
Coordination of Benefits (COB) is the process used to determine which health plan or insurance policy will pay first and/or determine the payment obligations of each health plan, medical insurance policy or third party resource when two or more health plans, insurance policies or third party resources cover the same benefits.
The Order of Benefit Determination Rules govern the order in which each health plan will pay a claim for benefits. The health plan that pays first is called the primary health plan. The primary health plan must pay benefits in accordance with its policy terms without regard to the possibility that another health plan may cover some expenses. The health plan that pays after the primary health plan is the secondary health plan. The secondary health plan may reduce the benefits it pays so that payments from all health plans do not exceed the primary health plan’s maximum allowable amount.
Refer to your EOC on the Plan Documents & Resources page for more information.
A retroactive denial is the reversal of a previously paid claim. That is, we deny a claim after we have paid it, and take the money back from the provider. If a claim is retroactively denied, you the enrollee, may become responsible for payment.
If we authorize a proposed service to be provided by a network provider based upon the complete and accurate submission of all necessary information relative to a covered person, we will not retroactively deny this authorization if the network provider renders the health care service in good faith and pursuant to the authorization and all of the terms and conditions of the Evidence of Coverage (EOC) and the network provider’s contract with us. If coverage is retroactively terminated, then the payment will be recouped from the provider. You will be notified of a retroactive denial with an Explanation of Benefits (EOB).
Examples that Result in Retroactive Denials:
- When a third party is legally responsible for payment
- Another health insurance company made a payment and we did not receive notice
- You didn’t pay your premiums on time and your coverage was terminated
- We paid for a service you did not receive, was not medically necessary, or was not covered by your benefits
- There was an error on the claim
- The list above is not all inclusive
Ways you can Prevent Retroactive Denials:
- Pay your premium on time
- Bring your CareSource ID card to every visit. This way your insurance information will be up to date and the doctor or pharmacy can bill us correctly
- Let your doctors know if a third-party insurer is responsible for paying your claims. For example, if you’re getting care for work or accident related injuries, we may not be responsible for paying your claims.
- If CareSource is your secondary insurance carrier, request that your primary insurance carrier send us an Explanation of Benefits (EOB).
Recoupment of Overpayments
If you received an invoice from CareSource with a credit balance shown, this represents money owed to you. We can apply the balance toward future premium amounts or refund the money to you at your request. If you choose to receive a refund, please contact Member Services between the hours of 7 a.m. and 7 p.m. Monday through Friday. The telephone number is on your ID card. If you request a premium refund, it will be sent to you within 30 days. If your coverage has been terminated, any refunds of premiums that may be due will be generated and sent to you within 90 days.