Transparency in Coverage

Costs for doctors and hospitals not in your plan, and balance billing

Your health plan has certain doctors and hospitals in it. With some plans, we'll also pay for a portion of the cost of care received from those who are NOT on your plan. But those doctors and hospitals don't have an agreement with us, so they can charge higher amounts if they want. Balance billing is when they send you a bill for some or all their fees, which in most cases have to come out of your own pocket.

It's always a good idea to look at the details of your plan or contact us to see if your plan covers care from doctors and hospitals not in your plan. Also, check whether you need your primary care physician (PCP) to refer you to other doctors for services to be covered.

You can avoid being balance billed by always going to doctors or hospitals in your plan. If you choose to go to one that isn't, check with them first to see what they charge, then call us for information on how much of that we may cover.

If you're having an emergency, you need to get care right away and you don't need to worry about what it costs. When you receive emergency care, for example in the emergency room (ER), we cover it the same whether the hospital is in your plan or not. Going to the ER for care that is not an emergency is not a good idea, and will likely cost more than care from a non-emergency doctor. If you're admitted to the hospital by the ER, you need to make sure the hospital and the doctors treating you are in your plan.

Submitting claims timely for care you've received

One of the advantages of choosing a doctor or hospital that's part of your plan is that they submit claims for you. When you go to one that's NOT in your plan, you'll often need to fill out a claim form yourself.

To file a claim, call Member Services at 1-800-595-0619. Our representatives will assist you in filing a claim. Submit your claim as soon as possible — most plans have time limits on how long you have to submit claims.

Enrollee medical claim submission and filing time limit

Imperial Insurance Companies, Inc.
P.O. Box 60567, Pasadena, CA 91116
Maximum claim filing time limit: 90 days

Enrollee dental claim submission and filing time limit

Submit at deltadentalins.com/members/after-your-visit
Maximum claim filing time limit: 365 days

Grace period for monthly payments

If you're getting financial help from the government to pay your health plan, once you've paid at least one monthly payment, you can get a grace period of up to three months if you fall behind on payments.

We'll continue to pay claims for your care for the first month of this grace period, then we'll hold (or "pend") claims — meaning we won't pay them yet, but we'll keep them and get ready to pay them.

If you're able to pay all the missed monthly payments before your grace period is up, we will go back and pay any claims we were holding. If you don't pay for all the missed months, we have to deny any claims that we were holding, and you'll be responsible to cover those costs.

Retroactive denial

Retroactive denial means going back and denying claims that were paid in the past — for example, if we paid a claim and then your bank says there's not enough money in your account and we never get a new payment from you. One way to avoid having your claims denied is by always paying your monthly payment on time.

Getting money back if you pay us more than you owe

If you pay more than what you owe, we'll either refund or credit the extra amount to you or your account. If you believe you've paid more than you needed to, call the member service number on the back of your ID card or log in to your online account and send us a message.

Medical necessity and prior authorization

Medical necessity is a standard that doctors and health plans use to determine if the care you're getting is right for you — is it reasonable and necessary to protect your life, prevent significant illness or disability, or alleviate severe pain? Sometimes, to help us figure out ahead of time if a health service or device is medically necessary and covered, you or your doctor may need to contact us for "prior authorization."

If you're admitted to the hospital, contact us as soon as you can — ideally within 24 hours of admission (this is not necessary for childbirth admissions unless there's a complication).

Prior authorization timeframes

Prior authorization timeframes are set by state regulation and can vary by state. In Arizona, current timeframes are:

Non-Urgent: 14 calendar days from receipt of the request
Urgent: 3 calendar days from receipt of the request

Nevada, Texas, and Utah members: your state's specific timeframes are provided in your Evidence of Coverage, or call Member Services at 1-800-595-0619 (TTY: 711) to confirm.

When you need a prescription drug not on your plan's drug list

If you and your doctor feel you need a prescription drug that's not on your plan's drug list, have your doctor or pharmacist get in touch with us. We'll make a decision within 72 hours of getting the request.

If we deny coverage of the drug, you have the right to request an External Review by an Independent Review Organization (IRO), which will make a decision within 72 hours. For urgent "exigent circumstances," we'll make a decision within 24 hours, and an IRO review (if needed) will also be decided within 24 hours.

Your doctor may use the MedImpact coverage determination/exception form, or contact MedImpact's Pharmacy Help Desk at 844-269-0977.

Explanation of Benefits (EOB) & Coordination of Benefits (COB)

An Explanation of Benefits (EOB) is a summary of services you've received during a specific period — it is not a bill. EOBs are sent at least once a month after you receive services and the claim is processed.

Coordination of Benefits (COB) applies when you or a family member on your plan is covered by two different health plans. Both plans need to know about it so we can coordinate the right benefits — let us know as soon as possible if this applies to you.

Formulary exceptions

Sometimes members need medications that are not on the plan's drug formulary. These requests are reviewed through a formulary exception review process. Standard review takes 72 hours from receipt; expedited (fast) review takes 24 hours.

If your exception request is denied, you have the right to an external review. You have 60 days from the date of the written denial notice to request this review.

How to request an external review

If you feel we have denied your exception request incorrectly, you may ask us to submit the case for an external review by an independent review organization (IRO). We must follow the IRO's decision. You have 60 days from the date of the written denial notice to request an external review.

Contact us by phone at 1-800-595-0619 (TTY: 711), by fax at 1-626-737-0989, or by mail:
Imperial Insurance Companies, Inc.
Attn: Appeals & Grievances
PO Box 60567, Pasadena, CA 91116

To learn more about the Coverage Determination/Exception process, refer to your Evidence of Coverage (EOC), Section 9.