Summary of Coverage and Cost Information for Out-of-Network Treatment

Disclosures to Covered Persons Regarding Out-of-Network Treatment

This summary provides an overview of how your health plan covers out-of-network treatment. It is provided as guidance only and does not alter your coverage in any way.

Please refer to your individual policy, group policy, certificate/evidence of coverage (if employer group plan), or your summary of benefits and coverage for more information about your in- and out-of-network benefits and costs for in-network treatment.

If you have questions, please call us at 844-214-2381 (TTY: 711). This hotline operates from 7 a.m. – 11 p.m., 7 days per week.

  • To check if a health care professional or facility is in-network, search our Provider Finder.
  • For additional information, or to see your estimated out of network costs, visit amerihealthexpress.com for your specific benefits
  • To see examples of out-of-network costs and service estimates within your region, visit www.fairhealthconsumer.org.

The following information applies to all benefits plans through AmeriHealth New Jersey

Your Policy Covers
Medically necessary treatment by out-of-network health care professionals/facilities in an emergency or urgent situation

  • What this means
    Emergency — You are covered for out-of-network treatment for a medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain; psychiatric disturbances and/or symptoms of Substance Use Disorder such that a prudent layperson, who possesses an average knowledge of health and medicine, could expect the absence of immediate medical attention to result in: placing the health of the individual or unborn child in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. This includes any further medical examination and such treatment as may be required to stabilize the medical condition. This also includes if there is inadequate time to affect a safe transfer of a pregnant woman to another hospital before delivery or such transfer may pose a threat to the health or safety of the woman or unborn child.

    Urgent — You are covered for out-of-network treatment of a non-life-threatening condition that requires care by a health care professional within 24 hours.
  • How am I protected by NJ law?
    You should not be billed by an out-of-network health care professional or facility, for any amount that is more than what your cost-share (deductible, copayment, or coinsurance) would be for similar services received in-network. If you receive a bill for any other amount, please contact us at 844-214-2381 (between 7 a.m. – 11 p.m., 7 days per week) and/or file a complaint with the Department of Banking and Insurance at www.state.nj.us/dobi/consumer.htm.

    EXCEPTIONS
    AmeriHealth New Jersey and the out-of-network health care professional/facility may negotiate and settle on a different cost amount for the emergent/urgent medical services. If that negotiated amount exceeds what was indicated on the initial Explanation of Benefits (EOB), your out-of- pocket cost-sharing responsibility may be more than the amount indicated on the initial Explanation of Benefits.

    Your total final costs will be provided on the final EOB if settled.

    If an Agreement Cannot Be Reached
    If an agreement cannot be reached, AmeriHealth New Jersey or the out-of-network health care professional/facility may seek to determine the amount to be paid for the medical services with the help of a neutral third party.

    The amount decided by the third party could be more than what AmeriHealth New Jersey has already paid to the out-of-network health care professional/facility. Any additional payment made by AmeriHealth New Jersey toward the newly decided amount will not increase the cost you owe more than what was listed as your responsibility on the EOB sent with the last payment made to the health care professional/facility before third-party review. If a third-party review is required, you will receive a final EOB that will show the total maximum amount your plan will cover for the service(s), also known as the allowed amount.

Your Policy Covers
Inadvertent or accidental out-of-network services

  • What this means
    If you are admitted to an in-network health care facility (e.g. hospital, ambulatory surgery center, etc.) and, for any reason, in-network health care services are unavailable or provided by an out-of-network health care professional in that in-network facility your treatments are still covered at your in-network rates.

    This includes laboratory testing ordered by an in-network health care professional and sent to an out-of-network provider. Other examples of accidental or inadvertent services include imaging, x-rays and anesthesia performed at an in-network facility by an out-of-network provider.
  • How am I protected by NJ law?
    You should not be billed by an out-of-network health care professional or facility, for any amount that is more than what your cost-share (deductible, copayment, or coinsurance) would be for similar services received in-network. If you receive a bill for any other amount, please contact us at 844-214-2381 (between 7 a.m. – 11 p.m., 7 days per week) and/or file a complaint with the Department of Banking and Insurance at www.state.nj.us/dobi/consumer.htm.

    EXCEPTIONS
    AmeriHealth New Jersey and the out-of-network health care professional/facility may negotiate and settle on a different cost amount for the emergent/urgent medical services. If that negotiated amount exceeds what was indicated on the initial Explanation of Benefits (EOB), your out-of- pocket cost-sharing responsibility may be more than the amount indicated on the initial Explanation of Benefits.

    Your total final costs will be provided on the final EOB if settled.

    If an Agreement Cannot Be Reached
    If an agreement cannot be reached, AmeriHealth New Jersey or the out-of-network health care professional/facility may seek to determine the amount to be paid for the medical services with the help of a neutral third party.

    The amount decided by the third party could be more than what AmeriHealth New Jersey has already paid to the out-of-network health care professional/facility. Any additional payment made by AmeriHealth New Jersey toward the newly decided amount will not increase the cost you owe more than what was listed as your responsibility on the EOB sent with the last payment made to the health care professional/facility before third-party review. If a third-party review is required, you will receive a final EOB that will show the total maximum amount your plan will cover for the service(s), also known as the allowed amount.

Your Policy Covers
Treatment from out-of-network health care professionals/facilities if in-network health care professionals/facilities are unavailable

  • What this means
    Plans are required to have sufficient networks to provide you with access to professionals and facilities that you can access within certain time frames and distances. This allows you to receive medically necessary treatment of all illnesses or injuries covered by your plan.
  • How am I protected by NJ law?
    You can request treatment from an out-of-network health care professional/facility when an in-network health care professional/facility is unavailable through an appeal, often called a request for an “in-plan exception.” Please see the Department of Banking and Insurance’s guide at: nj.gov/dobi/appeal.