Transparency in Coverage

We recognize the value in sharing information with you so you can make the best health-related decisions based on your needs. This page will give you a brief overview of some of our business practices with regard to claims, cost-sharing, and coverage. While much of this information is available in your member handbook or summary of benefits, this page reviews the basics so you can quickly understand commonly used terms and policies.

Member Claims Submission

A claim is a request for payment that you or your health care provider submits to your health insurer for costs for health care services and/or supplies provided to you by a hospital, doctor, or other health care facility.

Certain medical services may require additional information, such as notes from the provider, payment or rejection notices from other insurance carriers (including Workers' Compensation, other health plans, Medicare, auto insurance, etc.), origin and destination points for ambulance transfers or accident information. Delays in submitting this special information, when required, may delay the claims from processing.

If you are a Preferred Provider Organization (PPO) member, you do not need to submit a claim when services are received by an in-network provider. If you choose to receive care from an out-of-network provider and your provider does not submit the claim, you should submit written notice of the claim within 20 days after completion of the covered services. Upon receipt of a notice of claim, you will be sent the necessary claim form. You have 12 months from the date of service to submit a claim for payment. The claim form may also be found on the member portal. If you do not have portal access and need a claim form, you may contact Customer Service at 1-800-ASK-BLUE (275-2583). Claim forms should be submitted to the following address:

Personal Choice Claims
P.O. Box 69352
Harrisburg, PA 17106-9352

If you are a Health Maintenance Organization (HMO) member, you generally do not need to submit claims for services received in-network. If your provider does not submit claims, you must notify us of the claim as soon as possible after receiving covered services either in writing or by calling Customer Service at 1-800-ASK-BLUE (275-2583). Upon receipt of a notice of claim, you will be sent the necessary claim form. The completed claim form, with all itemized bills attached, must be received within 90 days. The claim form may also be found on the member portal. Claim forms should be submitted to the following address:

Claims Servicing Center
P.O. Box 69353
Harrisburg, PA 17106-9353

Please refer to the last section at the bottom of this page for additional information.

Nonpayment of Premium and Grace Periods for Members Receiving Premium Tax Credits

Per regulation 45 CFR 156.270(d), members who receive advance payments of the premium tax credit and have previously paid at least one full month's premium have a 90-day grace period when premium payments are not made timely. During the grace period a member may pay outstanding premium payments without losing coverage. If a member fails to make payment in full within 90 days, coverage will be terminated.

Claims received during the first 30 days of the grace period will be paid on schedule. Claims received during the remaining grace period may be pended as necessary, meaning we will neither pay nor deny the claim. If a member pays his or her outstanding premium in full during the 90-day grace period, claims will be paid accordingly. If the member fails to pay his or her outstanding premium, claims will be denied.

Retroactive Denial of Claims

A retroactive denial is the reversal of a previously paid claim, after services are rendered, where you may become liable for payment. Claims may be retroactively denied in certain situations, including, but not limited to the following:

  • If your coverage is retroactively terminated
  • If we determine you have other health care coverage that should have been the primary payer
  • If there was a provider billing error

Ways to prevent a retroactive denial include the following:

  • Ensure that premium payments are made on time
  • Do not sign up for Marketplace coverage when you are eligible for Medicare, Medicaid, or other insurance that qualifies as Minimum Essential Coverage
  • Ensure that you are not intentionally misrepresenting any material facts when signing up for health care coverage
  • Review and understand your benefits
  • Review your Explanation of Benefits (EOB) thoroughly

If you have any questions regarding the payment of your claim you may contact Customer Service at 1-800-ASK-BLUE (275-2583).

Member Recoupment of Overpayments

If you dispute a charge or payment, you may contact Customer Service for additional assistance by calling 1-888-879-4891.

Coordination of Benefits

If you have more than one health insurance plan, those plans need to work together to make sure you're getting the most out of your coverage. That process is referred to as Coordination of Benefits. Coordinating your benefits helps us process your claims faster and maximizes your benefits, which can lower your out-of-pocket costs. One plan becomes your primary plan and pays your claims first. Then the second plan pays toward the remaining cost.

Please refer to the last section at the bottom of this page for additional information.

Liability for Non-Network Coverage and Balance Billing

The coverage and cost-sharing for care received outside of our network varies by plan type. PPO members that decide to receive care from a provider not within the plan network, or HMO members who receive care from an in-network provider without receiving a referral from their primary care physician, will incur significantly higher out-of-pocket expenses including deductibles and coinsurance. In some instances, the out-of-network provider also may charge you for the balance of their bill (balance billing). HMO and Exclusive Provider Organization (EPO) members do not receive any benefits when they decide to receive care from a provider not within the plan network. The exception is Emergency Care Services, which are covered no matter where they are obtained. To see the exact cost-sharing responsibilities for out-of-network coverage for your plan, review your plan's Summary of Benefits.

Please refer to the last section at the bottom of this page for additional information.

Explanation of Benefits

Your Explanation of Benefits (EOB) helps you understand your out-of-pocket costs when receiving covered services, including how much your provider charged for the services, how much your health care plan paid, and what amount you owe. You will only receive an EOB if you are liable for any charges after the claim is adjudicated.

Find out how to read and understand your EOB here. If you have any questions about your EOB, contact Customer Service at 1-800-ASK-BLUE (275-2583).

Please refer to the last section at the bottom of this page for additional information.

Non-formulary Drug Exceptions

Independence provides a Select Drug Program formulary. Independence does not have a formulary exception process because this is an open formulary and all FDA-approved drugs are covered at the designated cost-share.

Preapproval for Coverage of Services

Certain services require preapproval/precertification from Independence prior to being performed. Your doctor will take care of submitting the paperwork for this request. If your doctor has questions about our process, please share with them the process information. We do not require a timeframe within which a member must submit a preapproval/precertification.

If you or your patient needs services that require preapproval/precertification, please call 1-800-ASK-BLUE and select the prompt for authorizations. Providers registered with the NaviNet® web portal may submit requests electronically for services to be rendered at an acute care facility or ambulatory surgical center.

When obtaining services from participating network physicians/providers, preapproval/precertification is the responsibility of the physician/provider. Members with Personal Choice plans who plan to obtain services from out-of-network physicians/providers are responsible for assuring that preapproval/precertification is obtained where necessary.

The Care Management and Coordination (CMC) department will evaluate the request and will notify the member and provider once a decision has been reached for those cases that require clinical review. Failure to complete required preapproval/precertification may result in a reduction in payment or nonpayment for the services not preapproved/precertified.

A member or doctor may appeal our decision or provide additional information to support the request at any time during the evaluation process. Please refer to the CMC section of the Provider Manual for Participating Professional Providers for more information. The Manual can be accessed by registered providers through the NaviNet® web portal.

Additional Information

For Individual and/or Family Coverage:

For Small Business Health Options Program (SHOP) Coverage:

The information on this page refers to the health plans offered to our Individual and Small Business Health Option members. If you are enrolled in a large group plan provided by your employer, please refer to your specific plan benefit booklet or Summary of Benefits and Coverage documents for additional information available on ibxpress.com.