Transparency in Coverage

We recognize the value in sharing information with you. With the right information, 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. You can find information here about claims, cost-sharing, and coverage. 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. You or your health care provider submits claims to your health insurer. The claims are for costs for health care services and/or supplies from a hospital, doctor, or other health care facility.
Certain medical services may require additional information. This could be notes from the provider, or payment or rejection notices from other insurance carriers. (Other insurance could be Workers' Compensation, other health plans, Medicare, auto insurance, etc.). Other information also includes origin and destination points for ambulance transfers or accident information. Delays in submitting this special information, when required, may delay the claims from processing.

Generally, you do not need to submit claims for services received in-network. The situation changes if you choose to receive care from an out-of-network provider and/or your provider does not submit claims. In those cases, you must notify us of the claim as soon as possible after receiving covered services. You must notify us in writing or by calling Customer Service at 1-888-YOUR-AH1 (968-7241). When we receive a notice of your claim, we will send the necessary claim form. You must then send the completed claim form, with all itemized bills attached, within 90 days. Claim forms should be submitted to the following address:

AmeriHealth Insurance Company
P.O. Box 211184
Eagan, MN 55121

Please refer to the last section at the bottom of this page for more 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 on time. During the grace period a member can make 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. This occurs 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 about the payment of your claim you may contact Customer Service at 1-888-YOUR-AH1 (968-7241).

Member Recoupment of Overpayments

If you dispute a charge or payment, you may contact Customer Service for additional assistance by calling 1-800-313-9168.

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

AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey (collectively, AmeriHealth New Jersey) offer Health Maintenance Organization (HMO) and Exclusive Provider Organization (EPO) plans in the Individual Health Care (Consumer) market. These plans do not include coverage for services provided outside of our provider network. Therefore, you would be responsible for the full cost of the service if you are receiving out-of-network care. However, there are two types of exceptions to this. Emergency care is covered no matter where the service is obtained. Also, you may be covered if you inadvertently receive care from an out-of-network provider while being treated at a network facility. In both cases, applicable network cost-share would apply. Please see your benefit booklet for additional details on your coverage level.

Explanation of Benefits

Your Explanation of Benefits (EOB) helps you understand your out-of-pocket costs for covered services. This includes 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 1-888-YOUR-AH1 (968-7241).

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

Non-formulary Drug Exceptions

AmeriHealth New Jersey provides a Select Drug Program formulary. This is an open formulary. All FDA-approved drugs are covered at the designated cost-share. AmeriHealth New Jersey does not have a formulary exception process.

Preapproval for Coverage of Services

Certain services require preapproval from AmeriHealth New Jersey. (Preapproval is sometimes called precertification.) It is needed before the service is performed. Your doctor will submit the paperwork for this type of request. If your doctor has questions about our process, please share with them the process information here. We do not require members to submit a preapproval by a certain date.

If your doctor needs help with this type of request, they should call 1-888-YOUR-AH1 (1-888-968-7241) 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 in-network providers, the provider is responsible for obtaining the preapproval. Members with POS plans who need services out-of-network are responsible for obtaining the preapproval when necessary.

The Care Management and Coordination (CMC) department will evaluate the request. They will notify the member and provider once a decision has been reached for those cases that require clinical review. Failure to complete the required preapproval process may result in a reduction in payment or nonpayment.

A member or doctor may appeal our decision or provide additional information to support the request at any time during the evaluation process.

Additional Information

For Individual and/or Family Coverage:

Third-party Payment

The information on this page refers to the health plans offered to our Individual members. If you are enrolled in a 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 www.amerihealthexpress.com.