Coordination of Benefits

The Coordination of Benefits (COB) provision applies when a person has health care coverage under more than one plan. 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 accordance 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 does not exceed 100% of the total allowable expense.

Please see the policy (“Coordination of Benefits”) for more details.

Information on Explanation of Benefits (EOB)

How do you know if Jefferson Health Plans paid a claim?

Your doctor's office submits a claim for payment to Jefferson Health Plans after you see your doctor or receive other medical care.

If your provider is not submitting a claim on your behalf, you must send a completed claim form and an itemized bill to the address listed on your ID card.

After the claim is processed, Jefferson Health Plans will provide an Explanation of Benefits (EOB) to you. We send this statement to explain what medical treatments and/or services were paid. It tells you how your claim was paid, including the amount that was paid and to whom it was paid. It’s simple and clear, so you can see what was submitted, what’s been paid and what you owe.

EOBs will be sent via mail. You'll also find:

• An item-by-item breakdown of your health care visit with claim details page displayed in an easy-to-read format.
• How much you have paid toward your plan deductible and out-of-pocket limits.
• A summary page with the amount saved and what you owe.

Machine-Readable Files

In order to comply with the Transparency in Coverage legislation, insurance plans are required to make available machine-readable files for in-network rates (for doctors in the plan's network) and for out-of-network rates (for doctors not in the plan's network).

Select click on the link below to access the desired file for more information.

Please note: These files contain a large amount of data and may require several minutes to download/open.

Medical

October 2024 in-network rates medical
October 2024 in and out-of-network index medical
October 2024 out-of-network allowed amounts medical

Behavioral Health

Magellan Health provides mental health services on behalf of Jefferson Health Plan. Developers may access Magellan’s machine-readable files using the links below. These files are in JSON format and are updated monthly.

October 2024 in-network rates behavioral
October 2024 in-network index behavioral
October 2024 out-of-network index behavioral
October 2024 out-of-network allowed amounts behavioral

Medical Necessity and Prior Authorization

A prior authorization is an approval from your health plan. Certain settings, services, treatments, supplies, devices, or prescription drugs may require a prior authorization. Prior authorization review is intended to confirm the medical necessity, as defined in your policy, of a setting, service, treatment, supply, device, or prescription drug. Prior authorization is not a guarantee that benefits will be payable.

Prior authorization can be obtained by you, your family member(s) or the provider by calling the number on the back of your ID card. To verify prior authorization requirements for inpatient services, call us at the number on the back of your ID card, or visit the Prior Authorization page.

Member Claims Submissions

Notice of Claim: There is no paperwork for claims for services from participating providers. You will need to show your ID card and pay any applicable copayment; your participating provider will submit a claim to us for reimbursement. Claims for emergency services from non-participating providers can be submitted by the provider if the provider is able and willing to file on your behalf. If a non-participating provider is not submitting on your behalf, you must send your completed claim form and itemized bills to the claims address listed on your ID card.

Claim Forms: You may get the required claim forms by calling Customer Service using the toll-free number on your ID card.

Please see your policy (“How to File a Claim for Benefits”) for more details.

Member Complaints, Grievances and Appeals – Medical

We are here to listen and help. If You have a concern regarding a person, a service, the quality of care, an initial eligibility denial, contractual benefits, or a rescission of coverage, you can call our toll-free number and explain your concern to one of our customer service representatives. Please call us at the customer service toll-free number that appears on your ID card, explanation of benefits or claim form.

We will do our best to resolve the matter on your initial contact. If we need more time to review or investigate your concern, we will get back to you as soon as possible, but in any case, within 30 days.

If you are not satisfied with the results of a coverage decision, you can start the appeals procedure.

Please see your policy (“When You Have a Complaint or an Appeal”) for more details.

Member Complaints, Grievances and Appeals - Prescription Drugs

We are here to listen and help. If you have a concern regarding a person, a service, the quality of care, an initial eligibility denial, contractual benefits, or a rescission of coverage, you can call our toll-free number and explain your concern to one of our customer service representatives. Please call us at the customer service toll-free number that appears on your ID card, explanation of benefits or claim form.

We will do our best to resolve the matter on your initial contact. If we need more time to review or investigate your concern, we will get back to you as soon as possible, but in any case, within 30 days.

If you are not satisfied with the results of a coverage decision, you can start the appeals procedure.

Please see your policy (“When You Have a Complaint or an Appeal” under “General Provisions”) for more details.

Member Recoupment of Overpayments

If you overpaid your insurance premium, you may qualify for a refund. If you think you overpaid, please call the number on the back of your ID card with questions about your premium payment and possible refund.

Nonpayment of Premium and Grace Period for Premium Tax Credits

You must remit the amounts specified by us, to us, pursuant to Your Policy, for the applicable period of coverage on or before the first day of each such period of coverage.

If You did not purchase your Policy from a Marketplace, or You purchased your Policy from a Marketplace but did not elect to receive advanced premium tax credit (APTC), there is a grace period of 30 days during which premiums may be paid without loss of coverage (this does not include the first binder premium payment). Coverage will continue during the grace period. Any claims submitted during this grace period will be pended or denied until such time as your premium is paid. If we do not receive your premium due in full before the end of the grace period, your coverage will be terminated as of the last day of the grace period.

If You purchased your Policy from a Marketplace and You have elected to receive advanced premium tax credit (APTC), there is a grace period of ninety (90) consecutive days during which the premiums may be paid without loss of coverage. Coverage will continue during the grace period, however, claims for services rendered after the first 30 days of the grace period will be either pended or denied until such time as your premium is paid. However, if we do not receive your premium due in full before the end of the grace period, your coverage will be terminated as of the last day of the first month of the grace period. Grace periods do not apply to your first month’s premium payment.

Please see your policy (“Terms of the Policy”) for more details.

Out-of-Network Services and Balance Billing

HMO Plans: To receive benefits from coverage, members must use a network doctor. However, payment will be made at the network doctor level of benefits for services provided by an out-of-network doctor when the services are provided for a medical emergency. Jefferson Health Plans will provide the member with listings of in-network providers in the Jefferson Health Plans service area. The member is responsible for choosing their doctors for health care services.

PPO Plans: Members have benefits for services received by an out-of-network provider. Because out-of-network providers are not contractually required to accept Jefferson Health Plans reimbursement as full payment for services, if a member chooses to receive non-emergency services or benefits, the provider may bill the member for the balance of their charge above the reimbursement received. JHP out-of-network provider claims allowances are 125% of the then-current applicable CMS reimbursement rates and methodologies. This includes medications covered under the medical benefit. For services with codes not priced on the CMS Medicare Fee Schedule, reimbursement is based on the current JHP Payer Fee Schedule, less any applicable member copayment, deductible, or coinsurance.  If you have any questions, please call Customer Service using the toll-free number on the back of your ID card.

For covered emergency services, HMO and PPO members will pay in-network cost sharing (copayment, coinsurance and deductible). Members will also pay in-network cost sharing for services provided by some out-of-network doctors (such as anesthesiologists or pathologists) that provide services at a network hospital or if the out-of-network doctor provides certain services at in a network hospital or facility and does not notify the member of their out-of-network status. These out-of-network doctors are also prohibited from billing the member for any amounts in excess of the member’s cost sharing responsibility.

Prescription Drug Exception and Expedited Process

Exceptions for Prescription Drugs and Related Supplies Not on the Prescription Drug List

If your physician prescribes a prescription drug or related supply that is not on our prescription drug list, he or she can request that we make an exception and agree to cover that drug or supply for your condition. To obtain an exception for a prescription drug or related supply, your physician must follow the process described below.

Prescription Drug and Related Supply Authorization and Exception Request Process

To obtain an exception, your physician may call us, or complete the appropriate form and fax it to us to request an exception. Your physician can certify in writing that you have previously used a prescription drug or related supply that is on our prescription drug list or in a step therapy protocol, and the prescription drug or related supply has been detrimental to your health or has been ineffective in treating your condition and, in the opinion of your physician, is likely to again be detrimental to your health or ineffective in treating the condition. The exception request will be reviewed and completed by us within 72 hours of receipt.

Expedited Review of a Prior Authorization, Step Therapy or Prescription Drug Exception Request

An expedited review may be requested by your physician when you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function or when you are undergoing a current course of treatment using a prescription drug or related supply not on our prescription drug list. The expedited review will be reviewed and completed by us within 24 hours of receipt. If the request is approved, your physician will receive confirmation. The authorization/exception will be processed in our pharmacy claim system to allow you to have coverage for those prescription drugs or related supplies. The length of the authorization will be granted until you no longer use the prescription drug or related supply for which the authorization or exception was approved. When your physician advises you that coverage for the prescription drugs or related supplies has been approved, you should contact the pharmacy to fill the prescription(s). If the request is denied, you and your physician will be notified that coverage for the prescription drugs or related supplies was not authorized.

Appeal of a Prior Authorization, Step Therapy or Prescription Drug Exception Denial

If you, a person acting on your behalf or the prescribing physician or other prescriber disagree with a coverage decision, you, a person acting on your behalf or the prescribing physician or other prescriber may appeal that decision in accordance with the provisions of your policy, by submitting a written request stating why the prescription drugs or related supplies should be covered. Please see the section of your policy entitled “When You Have a Complaint or an Appeal” which describes the process for the external independent review. If you have questions about specific prescription drug list exceptions, prior authorization or a step therapy request, call customer service at the toll-free number on the back of your ID card.

Prescription Drugs Requiring a Prior Authorization

Prior Authorization

When Your physician prescribes certain prescription drugs or related supplies, including high cost and specialty medications, we require your physician to obtain authorization before the prescription or supply can be filled. To obtain prior authorization, your physician must follow the process detailed in “Prescription Drug Exception and Expedited Process” above.

Step Therapy

Step therapy is a type of prior authorization. We may require an insured person to follow certain steps before covering some prescription drugs and related supplies, including without limitation, some higher cost and specialty medications. If a prescription drug or related supply is subject to a step therapy requirement, then you must try one or more similar prescription drugs and related supplies before the policy will cover the requested prescription drug or related supply. The prescription drugs and related supplies that require step therapy can be identified on the prescription drug list on the Formulary page. To obtain step therapy authorization, your physician must follow the prescription drug and related supply authorization and exception request process as described below. Step therapy or history of drug failure will not be required for prescription drugs related to the treatment of stage four, advanced metastatic cancer, if both of the following apply:

• The drug is approved by the United States Food and Drug Administration for this indication; and
• The prescription of the drug is consistent with the best clinical practices for the treatment of stage four, advanced metastatic cancer or a severe adverse health condition experienced as a result of stage four, advanced metastatic cancer, and is supported by peer-reviewed medical literature.

Prior Authorization Timeframe

Standard organization determinations

Standard organization determinations are made as expeditiously as the member’s health condition requires, but no later than 15 calendar days after we receive the request for service. However, if more time is needed due to matters beyond our control, we will notify you or your representative within 15 days after receiving the request. This notice will include the date a determination can be expected, which will be no more than 30 days after receipt of the request.

Expedited organization determinations

Expedited organization determinations are made when the member or their clinician believes that waiting for a decision under the standard timeframe could place the member’s life, health or ability to regain maximum function in serious jeopardy. The determination will be made as expeditiously as the member’s health condition requires, but no later than 72 hours after receiving the member or clinician’s request. However, if necessary information is missing from the request, we will notify you or your representative within 24 hours after receiving the request to specify what information is needed. We will notify you or your representative of the determination within 48 hours of receiving this information.

Retroactive Denial of Claims

A retroactive denial is the reversal of a claim we've already paid. If we retroactively deny a claim we have already paid for you, you are responsible for payment. Some reasons why you might have a retroactive denial include:

• Having a claim that was paid during the second or third month of a grace period
• Having a claim paid for a service for which you were not eligible
• Having a claim paid that was a result of fraud or intentionally mispresented facts

You can avoid retroactive denials by paying your premiums on time and in full, and making sure you talk to your doctor about whether the service performed is a covered benefit. You can also avoid retroactive denials by obtaining your medical services from an in-network doctor.

Rights and Responsibilities

Read more about your rights and responsibilities as a Jefferson Health Plans member