Transparency in Coverage 2023

On March 30, 2010, the Health Care and Education Reconciliation Act of 2010 (P.L.111-152) was signed into law. The two laws are collectively referred to as the Affordable Care Act. The Affordable Care Act established new competitive private health insurance markets called Marketplaces or Exchanges. By providing a place for one-stop shopping, Marketplaces make purchasing health insurance easier and more transparent, and put greater control and more choice in the hands of individuals and small businesses.

Sections 1311(e)(3)(A)-(C) of the Affordable Care Act, as implemented at 45 CFR 155.1040(a)-(c) and 156.220, establish new standards for qualified health plan (QHP) issuers to submit specific information related to transparency in coverage. QHPs are required to post and make data related to transparency in coverage available to the public.

Community Health Choice is providing all required data elements below. Please click on the links to obtain additional information about each data element.

Out-of-network liability and balance billing

In general, Community Health Choice (CHC) members must access benefits from participating physicians or providers. Community Health Choice has no obligation to issue payment to non-participating physicians or providers. However, there are some circumstances when CHC will authorize services and/or issue payment to non-participating physicians or providers (i.e. emergency services, inclusive of emergency transportation and Plan Directed Care) meaning when a participating physician or provider’s referral of a member is outside of Community’s network.

Payment of claims for Plan Directed Care requires prior authorization. Community Health Choice has created a usual and customary compensation payment for emergency services or services associated with Plan Directed Care to non-participating physicians or providers. The payment may vary by benefit program and by the county in which the member receives services. Community Health Choice has created a usual and customary (U & C) compensation payment for emergency services or services associated with Plan Directed Care to non-participating providers or physicians. Community Health Choice reviews its’ usual and customary rate annually. The rate is based on industry-accepted standards and practices related to the services provided and reflects fair and accurate market rates.

Non-participating providers should not balance bill Community Health Plan members as acceptance of the check/payment of the usual and customary rate is considered payment in full.

Enrollee claim submission

An enrollee who receives services by a provider outside of Community Health Choice’s service area may submit a claim for reimbursement consideration no later than 95 days after the date of service. Claims and/or encounter data must be submitted on the current Marketplace Medical Claim Form to the address designated on the Member’s ID card and include:

The member name
Member ID Number
Services Received
Date of Service
Provider Name and NPI Number
Diagnosis code(s)
Proof of payment

An enrollee who receives emergency care outside of the United States must provide the following:

Proof of payment to the foreign provider for the services provided
Complete medical information and or records
Proof of travel to the foreign country, such as airline tickets or passport stamps
The foreign provider’s fee schedule if the provider uses a billing agency
- Completed Claim Forms should be mailed to:
  Community Health Choice, Inc.
  Attention: Claims Department
  P.O. Box 301424
  Houston, TX 77230

Requests for claims reconsideration must be submitted within 180 days from date initial adverse determination date.

Grace periods and claims pending

You are required to pay your premium by the scheduled due date. If you do not do so, your coverage could be canceled. For most individual health care plans, if you do not pay your premium on time, you will receive a grace period.

A grace period is a time period when your plan will not terminate even though you have not paid your premium. Any claims submitted for you during that grace period will be pended. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full. If you do not pay your delinquent premium by the end of the grace period, your coverage will be terminated.

For members who receive Advance Premium Tax Credits (APTC), Community will provide a grace period of 3 consecutive months, who fail to timely pay premiums and receive APTC; Community will pay all appropriate claims for services rendered during the first month of grace period. Claims submitted in the second and third month of a subscriber’s grace period will be paid and recovered from the Provider should the subscriber terminate for non-payment. Community notifies HHS of such non-payment and Providers of the possibility of denied claims when the subscriber is in the second and third months of the grace period. Community will notify Providers within the first month of the grace period and through months two and three.

For Members who do not receive APTC, grace period will span one month. If the subscriber’s portion of premium payment is not received by the end of the month, coverage will be (are) terminated retroactively to the paid through date.

Retroactive denials

Retroactive denials occur when claims are paid during a member’s grace period and the member fails to pay their premium within the required timeline to continue coverage. Should this occur, Community Health Choice will terminate coverage effective the last day of the premium period for which the premium was paid after grace period expires. The member may be held liable for the cost of services received during the grace period.

All enrollments will be subject to the grace period and termination policy and procedures through system protocols as directed by Community Health Choice. To avoid retroactive denials, a member should ensure timely payment of their premiums.

Recoupment of overpayments

Refunds of Overpayments

If you believe you have overpaid for your premium and you would like to request a refund, please do so by calling toll free 1-855-315-5386 or local 1-713-295-6704, Monday through Friday (excluding State-approved holidays) 8:00 a.m. to 5:00 p.m.

You may also mail your request to Community Health Choice, Attn: Member Services, 2636 South Loop West, Suite 125, Houston, TX 77054 or send an email to [email protected].

Medical necessity and prior authorization timeframes and enrollee responsibilities

Some services or supplies require prior authorization or preservice review before you can receive then. This means a medical necessity review is conducted to ensure medically necessary services are the most appropriate level of service for the member considering potentials and harm. Also to ensure the services are known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes. Your provider must obtain prior authorization from us for these services. If your provider does not get prior authorization prior to providing the services, you may have to pay for the amount of charges.

After prior authorization has been requested, all supporting clinical documentation will be review to see if the request can be approved. We will notify your provider of the decision as follows:

For services that require prior authorization, within 3 business days of receipt.
For concurrent review services, within 24 hours of receipt of the request.
For post-stabilization treatment of life-threatening condition, within one hour of the receipt of the request.
For retrospective requests, within 30 calendar days of receipt of the request.

Failure to obtain prior authorization may result in rejection or denial of benefits.

Note: In extenuating, emergent situations, benefits will not be reduced for failure to comply with prior authorization requirements. However, you provider must contact us as soon as possible up after the emergent situation has occurred.

Drug exception timeframes and enrollee responsibilities

Drugs covered under Community Health Choice health plan

To check medications covered under your plan, please refer to the applicable formulary located under: Marketplace Formulary.

Drug Exception Request

Sometimes our members may need access to drugs that are not listed on the formulary (drug list). Request for non-formulary drugs are initially reviewed by Community Health Choice through the formulary exception review process. The member or provider can submit the request to us by faxing the Pharmacy Formulary Exception form to:

Navitus Health Solutions

PO BOX 999

Appleton, WI 54912-0999

Fax: 1-855-668-8551

Exception to Coverage Request Form

In support of your request, your doctor or other prescriber must provide us with an explanation to explain the clinical reasons for the exception request. If the drug is denied, you have the right to an external review.

If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case for an external review by an impartial, third-party reviewer known as an independent review organization (IRO). We must follow the IRO’s decision.

An IRO review may be requested by a member, member’s representative, or prescribing provider by mailing, calling, or faxing the request:

AOR and Review Form
HHS Federal External Review Process
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534
888-866-6205 ext. 3326
[email protected]

For standard exception review of medical requests, the timeframe for review is 72 hours from when we receive the request. For expedited exception review requests, the timeframe for review is 24 hours from when we receive the request. To request an expedited review for exigent circumstance, select Yes at the “Is this external review for urgent care?” option in the Request Form.

Explanation of benefits (EOB)

After a claim is received and processed by Community Health Choice, a detailed statement explaining what medical treatments and or services were paid or denied (an Explanation of Benefits (EOB) is mailed to the member. An EOB includes the type of service rendered, the amount billed, discount amount, the amount covered, copay/coinsurance/deductible amount, the amount paid by the health insurance company and any balance the member is responsible for paying the provider. The EOB also includes the member’s year-to-date out of pocket maximum amount. Note: An EOB is not a bill for services.

Coordination of Benefits

When an enrollee is covered by multiple health plans, the process of coordinating benefits allows two or more health plans to work together and determine the order of benefit (i.e. who pays first) as well as how much is owed by each plan. The combined payments of all plans cannot exceed more than the health plan covered expenses. This defines the coordination of benefits procedure. Coordination of Benefits help to avoid duplicate payments and reduce overall costs to an enrollee.

Community Health Choice is the payer of last resort when other insurance is in effect. When other primary insurance information is not identified, Community Health Plan will pay all covered medical services. Upon notification that other primary insurance exists, Community Health Plan shall employ all reasonable actions to pursue recovery of benefits paid as primary.

Why Choose Community?

As a local nonprofit health plan, Community Health Choice gives you plenty of reasons to join our Community. From the benefits and special programs we offer to the way our Member Services team helps you make the most of them, Community is always working life forward for you and your family.

“Community Health Choice is always there to answer my questions and help me and my family with our medical needs. I truly appreciate and value their customer support and service.”
– Cecily
Member of Community Health Choice