The information below is for consumers who want insight into how they can access care under their health insurance plan. Providence Health Plan recognizes claims payment, out-of-network liability, balance billing and denial practices are key concerns for consumers.
Understand claims and payment processes ›
The links below are to the specific sections of the member handbook that describe how these subjects work and Providence Health Plan’s obligations to members. If you have questions about any of these topics, please call Customer Service at 800-878-4445.
Out-of-network liability and balance billing
Services provided by non-participating providers
Enrollee claim submissions
Timely submission of claims
Grace periods and claims pending
Claims payment, time frames for processing claims
Retroactive denials and recoupment of overpayments
Right of recovery
Medical necessity and prior authorization timeframes
Medical necessary services
Medical cost management
Claims payment, claims involving prior authorization
Drug exception timeframes and enrollee responsibilities
Prescription drug benefit
Explanation of benefits
Coordination of benefits
Glossary of claims terms and processes
Advance Premium Tax Credit (APTC): A tax credit you may be eligible for (go to www.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 Health Plan when you get items or services that are covered.
Coordination of Benefits: If you have two or more health insurance plans that are responsible for paying the same medical claim, Providence Health Plan will coordinate with the other plan to determine which plan will pay for medical services. If you are in a situation where benefits need to be coordinated, please contact your customer service representative (800-878-4445) to ensure the claim is paid appropriately.
Explanation of Benefits (EOB): You will receive an EOB from Providence Health Plan after we have processed your claim. An EOB is not a bill. An EOB explains how Providence Health Plan 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 Period: If you receive an advance premium tax credit, but do not pay your health insurance premiums in full, you will enter a 90-day "grace period." During the first month of the grace period, you will continue to have health insurance coverage, and Providence Health Plan will pay claims for your health care services during that time. However, if you do not pay by the second or third month of the grace period, Providence Health Plan 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 Health Plan will pay the pended claims. If you do not pay your health insurance premiums in full before the end of the grace period, you will need to pay for any health care services you received during the second or third months of the grace period, and your coverage will end (See Pended Claim).
If you do not receive advance premium tax credit, you will be given a notice if you have not paid your premium by the 10th of the month. Your policy will be terminated if you do not pay your premium before the end of the month, or if you only made a partial payment.
Medical Necessity: Health care 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.
Pended Claim: A claim that requires further information or premium payment before it can be fully processed and paid to the health care provider.
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.
Prescription Drug Formulary: A list of drugs covered by Providence Health Plan specific to your health insurance plan.
Prescription Drug Formulary Exception Process: If your physician recommends you take medications not offered through Providence Health Plan’s Prescription drug formulary, he or she may request Providence Health Plan to make an exception to its formulary. Your physician will need to make a statement supporting why this request is necessary, and the Providence Health Plan Pharmacy team will review and respond to your request within 3 business days, unless the pharmacy team requires further information from your physician before making a determination.
Requests for exceptions to the prescription drug formulary can be made through the Providence Health Plan Prior Authorization Form, or your physician can write or call Providence Health Plan 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.
Prior Authorization: For services that do not involve urgent medical conditions, Providence Health Plan 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 Health Plan 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 Health Plan 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.
Prior Authorization (Expedited): For services that involve urgent medical conditions: Providence Health Plan will notify your provider or you of its decision within 72 hours after the Prior Authorization request is received. If Providence Health Plan 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 Health Plan 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.
Retroactive Denial: If Providence Health Plan finds a problem with a claim (such as a duplicate or improperly coded claim) after the claim has been paid, Providence Health Plan can retroactively deny the claim to fix the problem. If you are being reimbursed directly for medical claims, or if you have claims pended 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 Health Plan 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 Health Plan 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) if you have more than one insurance company that Providence Health Plan needs to coordinate with for payment.