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.
Some covered service expenses require prior authorization. This is to ensure that the requested services are covered by your benefit plan and that they are being rendered in an appropriate setting. Typically, your PCP or treating provider will contact Community First to request the services and will provide the necessary information related to your case. However, as a member of Community First, you also have a responsibility to make sure your provider has requested authorization for certain services. If services are received prior to obtaining authorization, you may be held financially responsible for payment of claims that are denied to the provider. Some of those services include, but are not limited to:
- Ambulatory/outpatient surgical procedures
- Behavioral health/chemical dependency services
- Hospital/inpatient admissions
- Imaging services
- Medications (injectable drugs over $500, excluding chemotherapy drugs)
- Nursing services (private duty nursing and home health services)
- Out of network services
- Pain management services
- Supplies/medical equipmentTelemedicine/telehealth services
- Therapy services
- Transportation (ambulance/air transport for non-emergent hospital transportation)
- Wound care
- Other services and tests (genetic testing and nutritional supplements/formulas)
Prior authorization requests should be submitted to Community First by phone/efax/Provider portal as follows:
- At least 5 days prior to an elective admission as an impatient in a hospital, extended care or rehabilitation facility, or hospice facility.
- At least 30 days prior to the initial evaluation for organ transplant services.
- At least 30 days prior to receiving clinical trial services.
- At least 5 days prior to a scheduled inpatient behavioral health or substance abuse treatment admission.
- At least 5 days prior to the start of home health care.
After prior authorization has been requested and all required or applicable documentation has been submitted, we will notify you and your Provider if the request has been approved as follows:
- For immediate request situations, within 1 business day, when the lack of treatment may result in an emergency room visit or emergency admission.
- For urgent concurrent review within 24 hours of receipt of the request.
- For urgent pre-service, within 72 hours from date of receipt of request.
- For non-urgent pre-service requests within 3 calendar of receipt of the request.
- For post-service requests, with in 30 calendar days of receipt of the request.
Failure to Obtain Prior Authorization
Failure to comply with the prior authorization requirements may result in benefits being reduced or not covered. Network providers should not bill you for services for which they fail to obtain prior authorization as required.
In the event of an emergency, no prior authorization is required, however, you must contact us as soon as reasonably possible after the emergency occurs to receive authorization for the emergency procedures in order for payment to be processed.
Drug Exceptions Timeframes and Enrollee Responsibilities
Standard Exception Request
An enrollee, an enrollee’s representative or an enrollee’s prescriber may request a standard review of a decision that a drug is not covered by the plan.The request can be made orally or in writing. If the request is submitted in writing, use the Exception to Coverage Request form (see attached document). You can also fill out the form and submit it electronically through the Navitus Member Portal (hyperlink to https://members.navitus.com/en-US/Session/Secured-Pages/Home.aspx). You may need to send attachments. If so, please fax or mail the form with additional information you need to include. If you need a hard copy of the form sent to you, call the phone number on the back of your Member ID card. You may also ask us for a coverage determination by phone. To do this, call the phone number on the back of your Member ID card.
Within 72 hours of the request being received, we will provide the enrollee, the enrollee’s designee or the enrollee’s prescribing provider with our coverage determination. Should the standard exception request be granted, we will provide coverage of the non-formulary drug for the duration of the prescription, including refills.
Expedited Exception Request
An enrollee, an enrollee’s representative or an enrollee’s prescriber may request an expedited review based on urgent circumstances. Urgent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee’s life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug.
Within 24 hours of the request being received, we will provide the enrollee, the enrollee’s representative or the enrollee’s prescriber with our coverage determination. Should the expedited exception request be granted, we will provide coverage of the non-formulary drug for the duration of the exigency.
External exception request review
If we deny a request for a standard exception or for an expedited exception, the enrollee, the enrollee’s representative or the enrollee’s prescriber may request that the original exception request and subsequent denial of such request be reviewed by an independent review organization.
We will make our determination on the external exception request and notify the enrollee, the enrollee’s representative or the enrollee’s prescriber of our coverage determination no later than 72 hours following receipt of the request, if the original request was a standard exception, and no later than 24 hours following its receipt of the request, if the original request was an expedited exception.
If we grant an external exception review of a standard exception request, we will provide coverage of the non-formulary drug for the duration of the prescription. If we grant an external exception review of an expedited exception request, we will provide coverage of the non-formulary drug for the duration of the necessity.
Information on Explanations of Benefits
An explanation of benefits (EOB) is a statement that we send to members to explain what medical treatments and/ or services we paid for on behalf of a member. This shows the amount billed by the provider, the issuer’s payment, and the enrollee’s financial responsibility pursuant to the terms of the policy. We will send an EOB to a member after we receive and adjudicate a claim on your behalf from a provider. If you need assistance interpreting your Explanation of Benefits, please contact Member Services at 1-888-512-2347.
Coordination of Benefits
The Coordination of Benefits (COB) provision applies when a person has healthcare coverage under more than one plan. Plan is defined below.
The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits in accord with its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. The secondary plan may reduce the benefits it pays so that payments from all plans equal 100 percent of the total allowable expense.