PPO II - EmblemHealth

124 2013 Evidence of Coverage for PPO II
Chapter 7: Asking us to pay our share of a bill you have received
for covered medical services or drugs
2. When a network provider sends you a bill you think you should not pay
Network providers should always bill the plan directly, and ask you only for your share of the cost. But
sometimes they make mistakes, and ask you to pay more than your share.
• You only have to pay your cost-sharing amount when you get services covered by our plan.
We do not allow providers to add additional separate charges, called “balance billing.” Th is
protection (that you never pay more than your cost-sharing amount) applies even if we pay the
provider less than the provider charges for a service and even if there is a dispute and we don’t
pay certain provider charges. For more information about “balance billing,” go to Chapter 4,
Section 1.3.
• Whenever you get a bill from a network provider that you think is more than you should pay,
send us the bill. We will contact the provider directly and resolve the billing problem.
• If you have already paid a bill to a network provider, but you feel that you paid too much, send
us the bill along with documentation of any payment you have made and ask us to pay you back
the diff erence between the amount you paid and the amount you owed under the plan.
3. If you are retroactively enrolled in our plan.
Sometimes a person’s enrollment in the plan is retroactive. (Retroactive means that the fi rst day of
their enrollment has already passed. Th e enrollment date may even have occurred last year.)
If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your covered
services or drugs after your enrollment date, you can ask us to pay you back for our share of the costs.
You will need to submit paperwork for us to handle the reimbursement.
• Please call Customer Service for additional information about how to ask us to pay you back
and deadlines for making your request. (Phone numbers for Customer Service are printed on the
back cover of this booklet.)
4. When you use an out-of-network pharmacy to get a prescription fi lled
If you go to an out-of-network pharmacy and try to use your membership card to fi ll a prescription,
the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to
pay the full cost of your prescription. (We cover prescriptions fi lled at out-of-network pharmacies only
in a few special situations. Please go to Chapter 5, Sec. 3.5 to learn more.)
• Save your receipt and send a copy to us when you ask us to pay you back for our share of the
cost.
5. When you pay the full cost for a prescription because you don’t have your
plan membership card with you
If you do not have your plan membership card with you, you can ask the pharmacy to call the plan
or to look up your plan enrollment information. However, if the pharmacy cannot get the enrollment
information they need right away, you may need to pay the full cost of the prescription yourself.
• Save your receipt and send a copy to us when you ask us to pay you back for our share of the
cost.