How an individual health plan works

We do not have contracted rates with health care providers who are out of network. That means an out-of-network health care provider sets the rate to charge you. We do not know in advance what that rate will be.

Your health plan covers network health care providers. Out-of-network health care providers are covered under your health plan only in the case of an emergency. Or, in cases where you are in a participating facility and have services delivered by certain types of non-participating providers whose bill is considered a surprise.

When an out-of-network provider bills you for charges other than copays, coinsurance or the amount remaining on your deductible, it is called balance billing. Under federal law and some state laws, you may be protected from balance billing during an emergency or when you receive services from an out-of-network health care provider in a participating facility.

If you enroll in an Illinois PPO, out-of-network covered services from doctors, hospitals and other health care professionals that have not contracted with your plan may charge you more or may not be covered at all by your plan. Charging the extra amount is called balance billing. In cases like these, you may be responsible for paying for what your plan does not cover. Balance billing may be waived for covered emergency services received from out-of-network providers.

If you have Aetna coverage, you can call Member Services at the toll-free number on your Aetna ID card to find out how your health plan reimburses out-of-network health care providers.

A claim is a request to an insurance company for payment of health care services. If you use a network health care provider or facility, that provider will submit your claims.
 

If you have a health plan that provides out-of-network benefits and see an out-of-network health care provider, you may need to submit the claim. You can submit a claim by completing and mailing a claim form or other documentation to us as soon as reasonably possible. The mailing address is on the claim form.

Find a health insurance form

Instead of completing a claim form, you may send us:

• Patient name
• Types of service(s) provided
• Date(s) of service
• Conditions being treated
• Member ID number
• Bill of charges from the health care provider
• Any medical documents you received from your health care provider
• Receipts for prescription drugs not covered under the health plan, including drug name, nature of illness or injury, purchase date, quantity, prescription number, charge, pharmacy name/address, strength, dose per/day, prescribing physician's name

Note: If required information is missing on the bill, write it on the bill and sign your name.
 

There are time limits to submit claims. You can find details on these time limits by state below. You can also check your plan’s claims filing time limit to determine when to submit your claim. To talk with customer service, call the number on the back of your ID card.

Maximum claim filing time limits by state

Arizona, California, Delaware, Florida, Georgia, Illinois, Indiana, Kansas, Maryland, Missouri, Nevada, New Jersey, North Carolina, Ohio and Utah

You have 12 months from the date of service to file a claim.

Texas

For plan year 2022, you have 24 months from the date of service to file a claim. For plan years 2023 and 2024, you have 95 days from the date of service to file a claim.

Virginia

You have 15 months from the date of service to file a claim.

Note: Review your policy documents for additional claim filing details.

Claim submission mailing address:
PO Box 981106
El Paso TX 79998

You’re required to pay your premium by the due date. If your premium isn’t paid by this due date, you’ll receive a grace period. A grace period is a time period when your coverage will not terminate even though you didn’t pay your premium.

For individual health plans, keep in mind:

• Premium payments are due in full each month.
• Partial payments will be refunded.
• Unfortunately, there are no exceptions.

If you’re enrolled in an individual health plan: If your premium isn’t paid by the due date, you’ll get a one-month grace period. During this period, your claim may be pended. If the total premium due isn’t paid by the end of the one-month grace period, your coverage will terminate back to your last paid-through date.

If you’re enrolled in an individual health plan offered on the Health Insurance Marketplace® and receive an Advance Premium Tax Credit (APTC): If your premium isn’t paid by the due date, you’ll get a three-month grace period. We’ll pay all claims for covered services that are properly submitted during the first month of the grace period. Your claims in months two and three of your grace period may be pended until full payment is received, if permitted by state law. If the total premium due is not paid in full by the end of the three-month grace period, your coverage will terminate back to the last day of the first month of the grace period. Your providers may balance bill you for services or the claims pended during the grade period if your coverage ends due to nonpayment. Members who have received APTC and enter the three-month grace period will receive a 30-day reminder letter about the outstanding premium. 

Claims pending

During a premium grace period, if a claim is pended, that means no claims will be paid until the outstanding premium is paid in full.

A retroactive denial reverses a previously paid claim. It happens when coverage of a service, procedure or drug is denied after the fact.

A retroactive denial can happen if premiums are not paid. For example, if your coverage lapses due to nonpayment of your monthly premiums, we may not cover services provided during the unpaid period.

You can avoid retroactive denials by:

• Paying your full premium amount on time
• Talking to your provider about whether the service performed is a covered benefit
• Receiving your medical services from an in-network provider 

If you have overpaid for your health plan coverage, you have the right to a refund. Call the number on your bill or member ID card to request a refund.

Medical necessity describes care that is reasonable, necessary, and appropriate, based on evidence-based clinical standards of care.

We must approve some services and drugs for medical need before you get them. This is called prior authorization or precertification. During this process, a health plan will review the medical need for a covered benefit (such as surgery or another medical procedure) before the member can access the benefit.

If a health care provider does not submit a request for prior authorization before the service or procedure is accessed, we may not cover the service, drug or procedure.

Requests should be made at least two weeks before the scheduled service or procedure. This table includes more details but may not apply to health plans in every state.

Request for prior authorization and medical necessity review

We typically decide on urgent prior authorization requests within 72 hours (15 days for non-urgent requests). These timeframes may vary by state.

Typical time frames to review prior authorization requests for prescription drugs

There are three types of prescription drug requirements. Exceptions can be requested for each type.

Precertification: Some drugs require precertification. This means that the health plan needs to approve the prescription before it is filled.

Your health care provider must request precertification and receive our decision before you can fill a prescription. Otherwise, we will not cover the cost of the drug.

Step therapy: Some drugs require step therapy. This means that you must try one or more other drugs before the step therapy drug is covered.

The other drugs are called prerequisite drugs. They have FDA approval and may cost less. They treat the same condition as the step therapy drug. If you don't try the other drugs first, you may need to pay full cost for the step therapy drug. If you don't try the other drugs first, you may need to pay full cost for the step therapy drug.

Quantity limits: This helps your health care provider and pharmacist make sure that you use your drug correctly and safely.

We use medical guidelines and FDA-approved recommendations from drugmakers to set quantity limits. The quantity limit program includes:

• Dose efficiency edits: Limits prescription coverage to one dose per day for drugs that have approval for once daily dosing.
• Maximum daily dose: If a prescription is less than the minimum dose, or higher than the maximum allowed dose, a message is sent to the pharmacy.
• Quantity limits over time: Limits prescription overage to a specific number of units over a specific amount of time.

Prescription drug exceptions

Covered services are based on the drugs in your plan’s formulary (drug guide). If your request for a drug or non-formulary drug is denied, and our decision involved medical judgement, you have the right to request a medical exception.

You or your health care provider can request exceptions to these requirements. To submit a request for review by Aetna:

• Call our Precertification Department at 1-855-240-0535 ${tty} or fax a request to 1-877-269-9916.

• You also can mail a written request to:

            CVS Health
            ATTN: Aetna PA
            1300 E. Campbell Rd.
            Richardson, TX 75081

You may be entitled to submit your case for review to an impartial organization outside of Aetna. This is called an Independent Review Organization (IRO). If our claim decision is one for which you can seek external review, it will be stated in the notice of adverse benefit determination. An IRO review may be requested by you, your representative, or your health care provider. The request can be submitted in writing to the address provided in the adverse benefit determination notice or by calling the number on your ID card. The IRO will send notification of its decision. We will stand by the IRO’s decision.

For a standard exception review that was denied, we will make our determination no later than 72 hours after receiving  the request. For an expedited exception review that was denied, we will make our determination no later than 24 hours after receiving the request. To request an expedited review for urgent circumstances, call the number on your ID card.

An Explanation of Benefits (EOB) is a statement a health plan provides to a member. It is not a bill.

An EOB shows:

• The date you received services
• The amount the health care provider billed
• The amount the health plan covers
• The amount the health plan paid
• The amount you are expected to pay the health care provider

An EOB is provided after the health plan considers a claim.

Coordination of benefit rules are used to decide which health plan pays first for people who have more than one health plan. This helps coordinate coverage and allows claim information to be shared by the health plans.

If you’re covered under an individual health plan, some states allow us to coordinate your benefits as described above. Other states do not allow coordination of benefits with an individual health plan. Your health plan documents will describe the process in your state.

If you have Medicare as your other health plan, Medicare will pay primary (before) your individual health plan.