- Out-of-network liability and balance billing
Out-of-network services are from doctors, hospitals, and other health care professionals that have not contracted with IEHP. A health care professional who is out of the IEHP Covered California network can set a higher cost for a service than professionals who are in your health plan network. Depending on the health care professional, the service could cost more or not be paid for at all by IEHP. Charging this extra amount is called balance billing. In cases like these, you will be responsible for paying for what IEHP does not cover. Balance billing may be waived for emergency services received at an out of-network facility.
- Enrollee claim submission
A claim is a request to an insurance company for payment of health care services. Usually, providers file claims with IEHP on your behalf. If you received services from an out-of-network provider, and if that provider does not submit a claim to IEHP, you can file the claim directly with IEHP. There are time limits on how long you have to submit claims, with details on the limit by state below. You can also check with IEHP to determine the specific time limit for submitting your claim.
Enrollee medical claim submission and claim filing time limit information:
The State (Maximum Claim Filing Time Limit) for CA is 180 Days
To file a claim, follow these steps:
1) Complete a claim form: Forms (iehp.org)
2) Attach an itemized bill from the provider for the covered service.
3) Make a copy for your records.
4) Mail your claim to the address below
Inland Empire Health Plan
P.O Box 4409
Rancho Cucamonga, CA 91729-1800
- Retroactive denials
A retroactive denial is the reversal of a claim we have already paid. If we retroactively deny a claim we have already paid for you, you will be responsible for payment. Some reasons why you might have a retroactive denial include having a claim that was paid during the second or third month of a grace period or having a claim paid for a service for which you were not eligible.
You can avoid retroactive denials by paying your premiums on time and in full, and making sure you talk to your provider about whether the service performed is a covered benefit. You can also avoid retroactive denials by obtaining your medical services from an in-network provider.
- Recoupment of overpayments
If you believe you have paid too much for your premium and should receive a refund, please call the IEHP member service number on the back of your ID card.
- Explanation of benefits (EOB)
Each time we process a claim submitted by you or your health care provider, we explain how we processed it on an Explanation of Benefits (EOB) form.
The EOB is not a bill. It explains how your benefits were applied to that particular claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you're responsible for paying the provider. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.
- Coordination of benefits (COB)
Coordination of benefits, or COB, is required when you are covered under one or more additional group or individual plans, such as one sponsored by your spouse's employer. An important part of coordinating benefits is determining the order in which the plans provide benefits. One plan provides benefits first. This is called the primary plan. The primary plan provides its full benefits as if there were no other plans involved. The other plans then become secondary. Coordination of Benefits (COB) is not applicable to Covered California plan members. Individuals eligible for group, Medicare, Medi-Cal, or other state or federal programs are not eligible for Covered California plans.
- 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 30-day grace period. A grace period is a time period when IEHP plan will not terminate even though you did not pay your premium. Because you have an individual HMO plan in CA, IEHP will pay your claims for covered services during the 30-day grace period; however, your benefits will terminate if your delinquent premium is not paid by the end of that grace period.
If you are enrolled in an individual health care plan offered through Covered California and you receive an advance premium tax credit, you will get a 3-month grace period and we will pay all claims for covered services that are submitted properly during the first month of the grace period. During the second and third months of that grace period, any claims you incur will be pended. If you pay your full outstanding premium before the end of the 3-month grace period, we will pay all claims for covered services that are submitted properly for the second and third months of the grace period. If you do not pay all of your outstanding premium by the end of the 3-month grace period, your coverage will terminate, and we will not pay for any pended claims submitted for you during the second and third months of the grace period. Your provider may balance bill you for those services.
- Medical necessity and prior authorization and enrollee responsibilities
We must approve some services before you obtain them. This is called prior authorization or preservice review. For example, any kind of inpatient hospital care (except maternity care) requires prior authorization. If you need a service that we must first approve, your in-network doctor will submit a request to us for the authorization. If you don’t get prior authorization, you may have to pay up to the full amount of the charges. Please refer to the specific coverage information you receive after you enroll.
We typically decide on requests for prior authorization for medical services within 72 hours of receiving an urgent request or within 15 days for non-urgent requests.
- Drug exception timeframes and enrollee responsibilities
- Issuers’ exceptions processes allow enrollees to request and gain access to drugs not listed on the plan’s formulary, pursuant to 45 CFR 156.122(c).
- An explanation of the internal exceptions process for people to obtain non-formulary drugs.
- An explanation of the external exceptions process for people to obtain non-formulary drugs through external review by an impartial, third-party reviewer, or Independent Review Organization (IRO).
- Timeframes for decisions based on standard reviews and expedited reviews due to exigent circumstances.
- Instructions on how to submit required information to start the exceptions process. This includes a request form link, address, phone number, or fax number for the enrollee to contact.
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:
For initial standard exception review of medical requests, the timeframe for review is 72 hours from when we receive the request.
For initial expedited exception review of medical requests, the timeframe for review is 24 hours from when we receive the request.
For external review of standard exception requests that were initially denied, the timeframe for review is 72 hours from when we receive the request.
For external review of expedited exception requests that were initially denied, the timeframe for review is 24 hours from when we receive the request. To request an expedited review for exigent circumstance, select the “Exigent Circumstances” option in the Request Form
Sometimes our members need access to drugs that are not listed on the plan's formulary (drug list). These medications are initially reviewed by [plan name] through the formulary exception review process. The member or provider can submit the request to us by faxing the Pharmacy Formulary Exception Request form link provided here. If the drug is denied, you have the right to an external review.