Understanding claims and billing processes

The following information is provided to help you access care under your health insurance plan. If you have questions about any of the information listed below, please call customer service at 800-878-4445. If any information listed below conflicts with your Contract, your Contract is the governing document.

Please note: Capitalized words are defined in the Glossary.

Click below to learn about how Providence handles the following topics:

Coordination of benefits

If you have coverage under two or more health insurance plans, Providence will coordinate with the other plan to determine which plan will pay for your Services. If you are in a situation where benefits need to be coordinated, please contact your customer service representative (800-878-4445) to ensure your Claims are paid appropriately.

Enrollee claim submissions

Payments for most Services are made directly to Providers. If your Provider bills you directly, and you pay for Services covered by your plan, we will reimburse you if you send us your claims information in writing. See your Contract for details and exceptions. Payment will be made to the Policyholder or, if deceased, to the Policyholder’s estate, unless payment to other parties is authorized in writing.

Time frames for processing claims

If Providence denies your Claim, we will send an Explanation of Benefits (or EOB, see below) to you with an explanation of the denial within 30 days after we receive your Claim. If we need additional time to process your Claim for reasons beyond our control, we will explain those reasons in a notice of delay we will send you within 30 days after we receive your Claim. We will then complete our processing and send an EOB to you within 45 days after we receive your Claim. If we need additional information from you to complete processing your Claim, we will send you a separate request for information, and you will have 45 days to submit the additional information. Once we receive the additional information, we will complete processing the Claim within 30 days.

Prior authorization of claims for medical conditions not considered urgent

Providence will let your Provider or you know if the Prior Authorization request is granted within two business days after it is received. If Providence needs additional information to process the request, we will notify your Provider, who will have 45 days to submit the additional information. After receiving the additional information, Providence will complete its review and notify your Provider or you of its decision within two days. If the information is not received within 45 days, the request will be denied.

Prior authorization for services that involve urgent medical conditions

Providence will notify your Provider or you of its decision within 72 hours after the Prior Authorization request is received. If Providence needs additional information to complete its review, it will notify your Provider or you within 24 hours after the request is received. Your Provider or you will then have 48 hours to submit the additional information. Providence will complete its review and notify your Provider or you of its decision by the earlier of (a) 48 hours after the additional information is received or, (b) if no additional information is provided, 48 hours after the additional information was due.

Claims involving concurrent care decisions

If an ongoing course of treatment for you has been approved by Providence and it then determines through its medical cost management procedures to reduce or terminate that course of treatment, you will be provided with advance notice of that decision. You may request a reconsideration of that decision by submitting an oral or written request at least 24 hours before the course of treatment is scheduled to end. Providence will then notify you of its reconsideration decision within 24 hours after your request is received.

Timely submission of claims

Providence will not pay for Claims received more than 365 days after the date of Service. We will make an exception if we receive documentation that you were legally incapacitated during that time. Payment of all Claims will be made within the time limits required by Oregon law.

Explanation of benefits (EOB)

You will receive an explanation of benefits (EOB) from Providence after we have processed your Claim. An EOB is not a bill. An EOB explains how Providence processed your Claim, and will assist you in paying the appropriate member responsibility to your Provider. Copayment or Coinsurance amounts, Deductible amounts, Services or amounts not covered and general information about our processing of your Claim are explained on an EOB.

Grace periods

Premium payment due date and grace periods

The Premium is due on the first day of the month. If you do not receive Advance Premium Tax Credits (see below) and do not pay the Premium within 10 days after the due date, we will mail you a Premium delinquency notice. If the Premium is not paid by the last day of the grace period specified in the notice, your coverage will be terminated with no further notice on the last day of the month through which Premium was paid. We reserve the right to suspend Claims processing for members who have not paid their Premiums. Making a partial Premium payment is considered a failure to pay the Premium. If we do not send you the Premium delinquency notice specified above, we will continue the Contract in effect, without payment of Premium, until we provide such notice.

Advance premium tax credit grace periods

If you have a Marketplace plan and receive tax credit that helps you pay your Premium (Advance Premium Tax Credits), and do not pay your Premium in a given month, you will enter a “grace period” for three months. During the first month of the grace period, you will continue to have health insurance coverage, and Providence will pay Claims for your Covered Services during that time. However, if you do not pay by the second or third month of the grace period, Providence will pend Claims for Services you receive during that time.

If you pay your Premiums in full before the end of the grace period, you will still have health insurance coverage for the second and third months of the grace period, and Providence will pay the Pended Claims. If you still have unpaid Premiums at the end of the grace period, you will need to pay for any Covered Services you received during the second or third months of the grace period, and your coverage will end. 

Medical necessity

Medically necessary services

We believe you are entitled to comprehensive medical care within the standards of good medical practice. Our medical directors and special committees of Network Providers determine which Services are Medically Necessary. Services that are not considered Medically Necessary will not be covered.

  • Example: Your Provider suggests a treatment using a machine that has not been approved for use in the United States. We probably would not pay for that treatment.
  • Example: You go to a hospital emergency room to have stitches removed, rather than wait for an appointment in your doctor’s office. We would not pay for that visit.
  • Example: You stay an extra day in the hospital only because the relative who will help you during recovery can’t pick you up until the next morning. We may not pay for the extra day.

Although a treatment was prescribed or performed by a Provider, it does not necessarily mean that it is Medically Necessary under our guidelines. Calling customer service to obtain confirmation of coverage from Providence beforehand is always recommended.

Medical cost management

Coverage is subject to the medical cost management protocols established by us to make sure Covered Services are cost effective and meet our standards of quality. Such protocols may include Prior Authorization, concurrent review, case management and disease management.

  • We may use or share your information with others to help manage your health care. For example, we might talk to your Provider to suggest a disease management program that may improve your health.
  • We reserve the right to deny payment for Services that are not Medically Necessary in accordance with our criteria. When more than one medically appropriate alternative is available, we will approve the least costly alternative.
  • We reserve the right to make substitutions for Covered Services; these substituted Services must:
    • Be Medically Necessary;
    • Have your knowledge and agreement while receiving the Service;
    • Be prescribed and approved by your Provider; and
    • Offer a medical therapeutic value at least equal to the Covered Service that would otherwise be performed or given.

Out-of-network liability and balance billing

Services provided by out-of-network providers

Typically, Providence individual plans do not pay for Services performed by Out-of-Network Providers. However, benefits for Covered Services by an Out-of-Network Provider will be provided when we determine in advance, in writing, that the Out-of-Network Provider possesses unique skills which are required to adequately care for you and are not available from Network Providers. Under no circumstances (with the exception of Emergency and Urgent Care) will we cover Services received from an Out-of-Network Provider/Facility unless we have Prior Authorized the Out-of-Network Provider/Facility and the Services received. Providence will only pay for Medically Necessary Covered Services. Please see your Benefit Summary for a list of Covered Services. You can check to see if a provider is in-network or Out-of-Network by checking the Provider Search page.

Balance billing

Your Plan only pays for Covered Services received from approved, Prior Authorized Out-of-Network Providers at rates allowed under your plan. If an Out-of-Network Provider charges more than your plan covers, that Provider may bill you directly for the additional amount. That amount is in addition to any Deductible, Copayment, or Coinsurance for which you may be responsible, and does not count towards your Out-of-Pocket Maximum.

Prescription drugs

Prescription drug benefit

The Prescription Drug Benefit provides coverage for prescription drugs which are Medically Necessary for the treatment of a covered illness or injury and which are dispensed by a Network Pharmacy pursuant to a prescription ordered by a Provider for use on an outpatient basis, subject to your Plan’s benefits, limitations, and exclusions. A list of covered prescription drugs can be found in the Prescription Drug Formulary.

Prescription drugs must be purchased at one of our network pharmacies

You have broad access to over 34,000 Network Pharmacies and their services at discounted rates. A list of our Network Pharmacies is available here, or you can contact customer service. You also may contact Customer Service if you need help locating a Network Pharmacy near you or when you are away from your home. Providence Network Pharmacies maintain all applicable certifications and licenses necessary under state and federal law. Please present your Member ID Card to the Network Pharmacy at the time you request Services. If you have misplaced or do not have your Member ID Card with you, please ask your pharmacist to call us. All Covered Services are subject to the Deductible, Copayments or Coinsurance and benefit maximums listed in your Benefit Summary.

Use of out-of-network pharmacies

On rare occasions, such as urgent or emergency situations, you may need to use an Out-of-Network Pharmacy. If this happens, you will need to pay full price for your prescription at the time of purchase.

To request reimbursement, you will need to fill out and send Providence a Prescription Drug reimbursement request form. Please include any itemized pharmacy receipts along with an explanation as to why you used an Out-of-Network Pharmacy. Sending us the form does not guarantee payment.

Using your prescription drug benefit

If you choose a brand-name drug when a generic-equivalent is available, any difference in cost for Prescription Drug Covered Services will not apply to your Calendar Year Deductibles and Out-of-Pocket Maximums.

Network Pharmacies may not charge you more than your Copayment of Coinsurance, subject to Deductible and coverage limitations. Please contact customer service if you are asked to pay more or if you, or the pharmacy, have questions about your Prescription Drug Benefit or need assistance processing your prescription.

When purchasing a Prescription Drug, you may have to pay Coinsurance or make a Copayment. If the cost of your Prescription Drug is less than your Copayment, you will only be charged the cost of the Prescription Drug. You may need to make multiple Copayments for a multi-use or unit-of-use container or package depending on the medication and the number of days supplied.

You may purchase up to a 90-day supply of prescription drugs at one time using a Network mail-order Pharmacy or preferred retail Pharmacy. Not all drugs are covered for more than a 30 day supply, including compounded medications, drugs obtained from specialty pharmacies, and limited distribution pharmaceuticals. To obtain prescriptions by mail, your physician or Provider can call in or electronically send the prescription, or you can mail your prescription along with your Providence Member ID number to one of our Network mail-order Pharmacies.

Upon Member or Provider request, the Plan will coordinate with Members, Providers, and the dispensing pharmacy to synchronize maintenance medication refills so Members can pick up maintenance medications on the same date. Members will be responsible for applicable Copayments, Coinsurances, and Deductibles.

Prescription drug formulary exception process

If your physician recommends you take medication(s) not offered through Providence’s Prescription drug Formulary, he or she may request Providence make an exception to its Prescription Drug Formulary. Your physician will need to make a statement supporting why this request is necessary, and the Providence Pharmacy team will review and respond to your request within three business days, unless the pharmacy team requires additional information from your physician before making a determination.

Requests for exceptions to the Prescription Drug Formulary can be made using the Providence Prior Authorization Form, or your physician can write or call Providence to request an exception directly. Your physician may send in this statement and any supporting documents any time (24/7).

Expedited coverage determinations will be made if waiting the standard timeframe would cause serious harm to your health. Expedited determinations will be made within 24 hours of receipt.

Services that involve prescription drug formulary exceptions

For standard requests, Providence will notify your Provider or you of its decision within 72 hours after receipt of the request. For expedited requests, Providence will notify your Provider or you of its decision within 24 hours after receipt of the request. To qualify for expedited review, the request must be based upon exigent circumstances.

Prior authorization timeframes

Prior authorization

A request you or your provider makes to Providence to determine if a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Providence may require preauthorization for certain Services before you receive them, except in an emergency. Prior Authorization is not a guarantee of coverage.

For Services that do not involve urgent medical conditions, Providence will notify you or your Provider of its decision within two business days after the Prior Authorization request is received. If additional information is needed to process the request, Providence will notify the Provider and the Provider will have 45 days to submit the additional information. Within two days of the receipt of the additional information, Providence will complete its review and notify your Provider or you of its decision. If the information is not received within 45 days, the request will be denied.

Expedited prior authorization

For Services that involve urgent medical conditions: Providence will notify your Provider or you of its decision within 72 hours after the Prior Authorization request is received. If Providence needs additional information to complete its review, it will notify the requesting Provider or you within 24 hours after the request is received. The requesting Provider or you will then have 48 hours to submit the additional information. Providence will complete its review and notify the requesting Provider or you of its decision by the earlier of (a) 48 hours after the additional information is received or, (b) if no additional information is provided, 48 hours after the additional information was due.

Services requiring prior authorization

All inpatient admissions to a hospital (not including emergency room care), skilled nursing facility, or a rehabilitation facility, all emergency hospitalizations (we need to be notified within 48 hours, or as soon as reasonably possible) and all hospital and birthing center admissions for maternity/delivery Services; all outpatient surgical procedures; and certain infused Prescription Drugs administered in a hospital based infusion center.

Providence will provide a Prior Authorization form upon oral or written request. If you want more information on how to obtain Prior Authorization, please call Customer Service.

Prior authorization requests for out-of-network services

The Member or the Out-of-Network Provider must call us at 800-638-0449 to obtain Prior Authorization. Please have the following information ready when calling to request a Prior Authorization:

  • The Member’s name and date of birth.
  • The Member’s Providence Member number and plan number (these are listed on your Member ID card).
  • The Provider’s name, address and telephone number.
  • The name of the Hospital or treatment facility.
  • The scheduled date of admission or date Services are to begin.
  • The Service(s) to be performed.

Claims involving prior authorization (pre-service claims)

For Services that do not involve urgent medical conditions: Providence will notify your Provider or you of its decision within two business days after the Prior Authorization request is received. If additional information is needed to process the request, Providence will notify the Provider and the Provider will have 45 days to submit the additional information. Within two days of the receipt of the additional information, Providence will complete its review and notify your Provider or you of its decision. If the information is not received within 45 days, the request will be denied.

For Services that involve urgent medical conditions: Providence will notify your Provider or you of its decision within 72 hours after the Prior Authorization request is received. If Providence needs additional information to complete its review, it will notify the requesting Provider or you within 24 hours after the request is received. The requesting Provider or you will then have 48 hours to submit the additional information. Providence will complete its review and notify the requesting Provider or you of its decision by the earlier of (a) 48 hours after the additional information is received or, (b) if no additional information is provided, 48 hours after the additional information was due.

Claims involving care decisions

Providence will notify you if an approved ongoing course of treatment is reduced or ended because of a medical cost management decision. You may submit a request to reconsider that decision at least 24 hours before the course of treatment is scheduled to end. Providence will then notify you of its reconsideration decision within 24 hours after your request is received. You can make this request by either calling customer service or by writing the medical management team.

Retroactive denials and recoupment of overpayments

Retroactive denial

If Providence finds a problem with a Claim (such as a duplicate or improperly coded Claim) after the Claim has been paid, Providence can retroactively deny the Claim to fix the problem. If you are being reimbursed directly for medical Claims, or if you have Pended Claims during a grace period, you may be impacted by retroactive denials. Also, if you are insured by more than one insurance company, there may be a dispute between Providence and the other insurance company which can also lead to a retroactive denial of your Claim (see Coordination of Benefits).

A retroactive denial may result in Providence asking you or your Provider to refund the Claim payment. You can avoid retroactive denial by making timely Premium payments, and by informing your customer service representative (800-878-4445) know if you have more than one insurance company that Providence needs to coordinate with for payment.

Premium overpayment

If you have made a payment in advance and then cancelled your insurance, or have made an accidental double-payment, please contact your Membership representative (888-816-1300) to request a refund.

Right of recovery

Providence has the right, upon demand, to recover from a recipient the value of any benefit or Claim payment that exceeded the benefits available under your Contract. Our right of recovery applies to any excess benefit, including, but not limited to, benefits obtained through fraud, error, or duplicate coverage relating to any Member. If timely repayment is not made, we have the right, in addition to any other lawful means of recovery, to deduct the value of the excess benefit from any future benefit that otherwise would have been available to the affected Member(s) from us under any Contract.

Glossary

Advance Premium Tax Credit (APTC): A tax credit you may be eligible for (go to healthcare.gov to get a determination) to lower your monthly health insurance payment (or “Premium”). When you apply for coverage in the Health Insurance Marketplace, you estimate your expected income for the year. If you qualify for a Premium tax credit based on your estimate, you can use any amount of the credit in advance to lower your Premium. If you receive APTC, you are also eligible for an extended grace period (see Grace Period).

Claim: A request for payment that you or your health care Provider submits to Providence when you get drugs, medical devices, or receive Covered Services.

Coinsurance: Coinsurance means the dollar amount that you are responsible to pay to a health care Provider, after your Claim has been processed by us. Your Coinsurance for a Covered Service is shown in the Benefit Summary, and is a percentage of the charges for the Covered Service.

Contract: The agreement between you and Providence that defines the obligations of both parties to maintain health insurance coverage. You can find your Contract here.

Copayment: Copayment means the fixed dollar amount that you are responsible for paying to a health care Provider when you receive certain Covered Services, as shown in the Benefit Summary.

Covered Services: a Service that is:

  • Listed as a benefit in the Benefit Summary and in your Contract;
  • Medically Necessary;
  • Not listed as an Exclusion in the Benefit Summary or in your Contract; and
  • Provided to you while you are a Member and eligible for the Service under your Contract.

Deductible: Your Deductible is the dollar amount shown in the Benefit Summary that you are responsible to pay every Calendar Year for Covered Services before benefits are provided by us. Deductible amounts are payable to your Qualified Practitioner after we have processed your Claim.

Certain Covered Services, such as most preventive care, are covered without a Deductible. Please see your Benefit Summary for information about these Services.

The following costs do not apply towards your Deductible:

  • Services not covered by your Contract;
  • Services in excess of any maximum benefit limit;
  • Balanced bills;
  • Copayments or Coinsurance specified as not applicable toward the Deductible in the Benefit Summary.

Marketplace: The Oregon Health Insurance Marketplace, where people can shop for plans and receive tax credits, including Advance Premium Tax Credits, to help pay for their Premiums and Covered Services. You can obtain Marketplace plans by going to Healthcare.gov

Medical Necessity: Services or supplies your medical care Provider needs to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Network Pharmacy: A pharmacy that has a signed a contractual agreement with Providence Health Plan to provide medications and other Services at special rates. There are four types of Network Pharmacies:

  1. Retail: A Network Pharmacy that allows up to a 30-day supply of short-term and maintenance prescriptions.
  2. Preferred Retail: A Network Pharmacy that allows up to a 90-day supply of maintenance prescriptions and access to up to a 30-day supply of short-term prescriptions.
  3. Specialty: A Network Pharmacy that allows up to a 30-day supply of specialty and self-administered chemotherapy prescriptions. These prescriptions require special delivery, handling, administration and monitoring by your pharmacist.
  4. Mail Order: A Network Pharmacy that allows up to a 90-day supply of maintenance prescriptions and specializes in direct delivery to your home.

Out-of-Network Provider: Out-of-Network Provider means an Outpatient Surgical Facility, Home Health Provider, Hospital, Qualified Practitioner, Qualified Treatment Facility, Skilled Nursing Facility, or Pharmacy that does not have a written agreement with Providence Health Plan to participate as a health care Provider for this Plan.

Out-of-Pocket Maximum: The total amount you will pay Out-of-Pocket in any Calendar Year for Covered Services received. The following Out-of-Pocket costs do not apply toward your Out-of-Pocket Maximum:

  • Services not covered by your Contract;
  • Services not covered because Prior Authorization was not obtained;
  • Services in excess of any maximum benefit limit;
  • Fees in excess of the Usual, Customary and Reasonable (UCR) charges; and
  • Deductibles, Copayments or Coinsurance for a Covered Service if indicated in any Benefit Summary as not applicable to the Out-of-Pocket Maximum.

Pended Claim: A Claim that requires further information or Premium payment before it can be fully processed and paid to the health care Provider.

Policyholder:The person to whom this Contract has been issued. A Policyholder shall be age 18 or older. If enrollment under this Contract consists solely of one child who is under age 21, the adult person who applied for such coverage shall be deemed to be the Policyholder until such child reaches the age of 21 when this Contract shall be reissued to show the 21 year old Member as the Policyholder.

Premium: The monthly rates set by us and approved by the Director as consideration for benefits offered under this Contract. Premium rates are subject to change at the beginning of each Plan Year.

Prescription Drug Formulary: A list of drugs covered by Providence specific to your health insurance plan. You can find the Prescription Drug Formulary here.

Prior Authorization: A request to us by you or by a Provider regarding a proposed Service, for which our prior approval is required. Prior Authorization review will determine if the proposed Service is eligible as a Covered Service or if an individual is a Member at the time of the proposed Service. To facilitate our review of the Prior Authorization request, we may require additional information about the Member’s condition and/or the Service requested. We may also require that a Member receive further evaluation from a Qualified Practitioner of our choosing. Prior Authorized determinations are not a guarantee of benefit payment unless:

  • A determination that relates to benefit coverage and Medical Necessity is obtained no more than 30 days prior to the date of the Service; or
  • A determination that relates to eligibility is obtained no more than five business days prior to the date of the Service.

Provider: A physician, Women’s Health Care Provider, nurse practitioner, naturopath, clinical social worker, physician assistant, psychologist, dentist, or other practitioner who is professionally licensed by the appropriate governmental agency to diagnose or treat an injury or illness and who provides Covered Services within the scope of that license. A Provider may be in-network for Providence members on a certain plan but Out-of-Network for other plans. You can find in-network Providers using the Providence Provider search tool.

Service: A health care related procedure, surgery, consultation, advice, diagnosis, referrals, treatment, supply, medication, prescription drug, device or technology that is provided to a Member by a Qualified Practitioner.