The Health Insurance Marketplaces

An in-network provider may reduce your cost sharing amount owed (see your schedule of benefits). Also, an in-network provider will not balance bill you for covered service charges that exceed your benefits under this policy. Your policy provides reasonable access to an in-network provider. You can find an in-network provider [here]. You may also contact BEST Life Customer Service at 1-800-433-0088 or at cs@bestlife.com, Monday through Friday, 7 am to 5 pm Pacific Time for assistance. If there is not an in-network provider within fifty (50) miles of your home or workplace, covered services from an out-of-network provider will be paid at the in-network provider benefit levels. Emergency palliative treatment services are also paid at the in-network provider benefit levels.

If you use a provider that is not in-network, they may bill you for all charges that exceed what is covered by your plan, or bill you the balance owed.

An insurance company participating on the federal marketplace is required to provide a grace period of three (3) consecutive months to any enrollee receiving advance payments of the premium tax credit (“APTC”) that has previously paid at least one full month's premium during the benefit year.

We will pay all appropriate claims for services rendered to such an enrollee during the first month of the three month grace period and will pend claims for services rendered to such an enrollee in the second and third months of the grace period.

Definitions:

A grace period is a number of days after premium is due during which premium will still be accepted and the policy will stay in force.

A pended claim is a claim for services that has been submitted but is not yet approved or denied.

A retroactive denial is the reversal of a previously paid claim, through which the enrollee then becomes responsible for payment.

Claims may be denied retroactively, even after the enrollee has obtained services from the provider, if all terms and conditions of the policy are not met.

Retroactive denials are avoidable. For example, claims pended during a grace period will be paid, if appropriate, according to the terms of the policy as long as premium is paid in full before the expiration of the policy grace period.

Recoupment of overpayments is the refund of a premium overpayment due to overbilling.

If you have overpaid premium due to overbilling, contact BEST Life customer service at 800-433-0088.

Your policy covers the least expensive care option that meets professionally recognized care standards. If you choose a more expensive care option when there is a less expensive care option, you are responsible for charges in excess of the less expensive care option. If clinical review criteria are used to determine whether a service is medically necessary, that clinical review criteria may be obtained by contacting us.

If You need to obtain covered services from an out-of-network provider because there is not an in-network provider within a reasonable distance of home or workplace, members may contact us to obtain prior written notice of care to ensure that claims are properly adjudicated. We may also be able to find a local in-network provider or assist in adding a desired local provider to the network.

Predetermination is not required, but it is recommended. Predetermination is a way to estimate how recommended services will be covered under the policy. Services that are not medically necessary or appropriate may not be covered.

We recommend that members notify us if they are scheduled for certain covered services before they are received. We will provide them with a Predetermination. Predetermination shows how benefits for services will be paid. If a service is found to not be medically necessary or appropriate, the service will not be covered and charges for the service will be denied. Additionally, if there is a similarly effective and less expensive alternative service available, reimbursement for the service will be reduced to the cost of the less expensive service.

Predetermination is not necessary for the following:

• Covered Services costing less than $500
• Emergency services, but some notice of care is requested
• Oral examinations and prophylaxis

Predetermination is recommended suggested for the following services for children up to nineteen (19) years of age:

• Medically necessary services or supplies
• Periodontal scaling and root planing
• Dentures
• Orthodontia, including preorthodontic treatment visit

Predetermination is recommended for the following services at any age:

• Crowns, Anterior, except with posts or root canal
• Crowns, 2 or more Posterior, except with posts or root canal
• Inlays or Onlays, 2 or more, except with posts or root canal
• Laminates
• Anterior composites
• 2 or more multiple surfaces
• Bridges – initial or replacement
• Eligible partial dentures – initial or replacement
• Periodontal surgery costing more than $500
• Full bony impactions, two (2) or more

We will make and send notice of determination to members and their treating provider within thirty (30) days of receipt of the request.

An Explanation of Benefits (EOB) is a statement explaining what medical treatments and/or services were paid for on their behalf. This is sent to an individual once the claim has been adjudicated and payment for coverage has been determined. It shows what the provider charged, what amount was allowed, what amount was paid by your plan and the amount, if any, that you owe to the provider.

▶ Understanding your Explanation of Benefits.

Coordination of Benefits is the process of determining, when a person has more than one insurance policy providing benefits for the same service, which of the policies will have the primary responsibility of processing/paying a claim and the extent to which the other policies will contribute.