Transparency in Coverage
Qualified Health Plan issuers participating in the Federally Facilitated Marketplace are required to provide the following disclosures. If you have questions about the information below, please call Customer Service toll-free: 1-844-508-4677.
Out-of-Network Liability and Balance-Billing
Definition of balance-billing: Balance-billing occurs when an out-of-network provider bills an enrollee/member for charges other than copayments, deductible, coinsurance, or any amounts that exceed the Usual, Customary, and Reasonable (UCR) reimbursable rate.
Claims Payment: Member Responsibility
In-network providers agree to accept the allowed amount as full payment for covered services and will only bill you for any copayments, coinsurance, or deductibles under your health benefit plan. The allowed amount is the maximum amount your plan will reimburse a doctor or hospital for a given service.
When receiving care from an out-of-network provider, you still may be responsible for the cost of your care over the allowed amount minus any applicable copayment, deductible, and/or coinsurance amounts, depending on the provider.
If the out-of-network provider charges more than this allowed amount, you may have to pay the difference up to the provider’s full charge. If you have any questions, call Customer Service at the number on the back of your ID card.
All covered services are subject to contract benefits, limitations, and exclusions. For more information, please refer to the Evidence of Coverage (member handbook) for your plan.
Financial Liability for Out-of-Network Services
If you, as a True Health New Mexico HMO plan member, receive non-emergent care, services, and/or supplies from an out-of-network (non-participating) provider, those services/supplies will not be covered unless prior approval is obtained from True Health New Mexico before the services occur. If you do not receive prior approval, you may be responsible for the charges.
Exceptions to Out-of-Network Liability, Such as Emergency Services
Definition of medical emergency: Health care procedures, treatments, or services delivered to a covered person after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain. The absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: danger to the person’s health, serious harm to bodily functions and any bodily organ or part, or disfigurement to the person.
If you reasonably believe you have an emergency medical condition, the initial treatment of that condition is paid at the in-network benefit level, even if you receive care from an out-of-network provider.
For follow-up care (which is no longer considered an emergency), you will need to visit an in-network provider to receive in-network benefits. If you receive follow-up care from an out-of-network provider, you may be responsible for the charges.
For more information, please refer to the Evidence of Coverage (member handbook) for your plan.
Enrollee Claims Submission
Definition: An enrollee/member, instead of the provider, submits a claim to the health plan, requesting payment for services received.
How to submit a claim if the provider did not submit the claim
If a provider or facility is in-network, the provider must file claims on the member’s behalf. Claims for benefits or services rendered by an out-of-network provider must be submitted to True Health New Mexico within one (1) year (365 days) from the date of service. If an out-of-network provider does not file a claim for you, you are responsible for filing the claim within the one-year deadline.
Claims submitted after the deadline are not eligible for reimbursement. If a claim is returned to you because True Health New Mexico needs more information, you must resubmit it with the information requested within ninety (90) days of receipt of the request.
Mail claim forms and itemized bills to:
True Health New Mexico
P.O. Box 211468
Eagan, MN 55121
Once received, reviewed, and approved, True Health New Mexico will reimburse you for covered benefits and services, less any required deductibles and coinsurance or copayment amounts you are required to pay as stated in the Summary of Benefits and Coverage for your plan. You will be responsible for services not specifically covered by your Plan.
Medical Necessity and Prior Authorization Time Frames and Enrollee Responsibilities
- Medical necessity is used to describe care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care.
- Prior authorization is a process through which a health plan approves a request to access a covered benefit before the enrollee/member accesses the benefit.
Some services require True Health New Mexico’s approval before care is received.
- The first step in the prior approval process is for you to confirm whether a treatment or service is a covered benefit under your Plan.
- If the service is not a covered benefit, the prior approval process cannot change this.
- You can confirm whether a treatment or service is covered by the Plan by reviewing your Plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (member handbook) or by calling True Health New Mexico Customer Service. We can answer questions that you or your provider may have about this process.
- Failure to obtain prior approval may cause a delay of the service or denial of claim. This means you will be responsible for the full amount charged by the provider.
When Does Prior Approval Review Occur?
Three types of prior approval review can occur:
- When we receive an approval request before you receive care. True Health New Mexico makes standard/non-urgent service decisions within seventy-two (72) hours of receiving the request for approval for prescription drugs and within five (5) business days for all other standard/non-urgent service decisions. We will send notice of the coverage decision in writing to you and your provider.
- Concurrent review occurs when we receive a request for approval while you are receiving care – for example, in a hospital, skilled nursing facility, or rehabilitation facility. True Health New Mexico will make a decision within twenty-four (24) hours of receipt of the review request. We will send notice of the coverage decision in writing to you and your provider.
- Retrospective review occurs when we receive a request for prior approval after you have received care. True Health New Mexico makes decisions related to these services within thirty (30) days of receiving all of the needed information.
Definition: The reversal of a previously paid claim, in which case the enrollee/member then becomes responsible for payment. Retroactive denials can occur if there is a correction or change made to an enrollee/member’s eligibility, causing coverage to be terminated as of an effective date that is in the past. Any claims from the period after the termination effective date will be denied.
The Exchange may start the termination of a member’s coverage in a Qualified Health Plan (such as their True Health New Mexico plan) and must allow True Health New Mexico to terminate such coverage in the following circumstances:
- The member is no longer eligible for coverage in a Qualified Health Plan;
- The member has not paid their premiums;
- The member performs an act, practice, or omission that constitutes fraud, or makes an intentional misrepresentation of material fact.
To avoid retroactive denials of claims, you should tell True Health New Mexico immediately about any changes to your eligibility and pay your premiums on time.
Enrollee Recoupment of Overpayments
Definition: The refund of a premium overpayment by the enrollee/member due to the over-billing by the issuer.
If you believe True Health New Mexico has billed you for the wrong premium amount, our Customer Service department will start a reconciliation of your statements. If we identify a refund amount, you will see it reflected on your next invoice and/or we will mail the difference to you.
For help, please contact True Health New Mexico.
Grace Periods and Claims-Pending Policies During the Grace Period
Definition: True Health New Mexico will grant a grace period of ninety (90) days to enrollees/members who have paid at least one month’s worth of premiums and are receiving advance payments of the Premium Tax Credit. If True Health New Mexico does not receive your premium payment within that grace period, True Health New Mexico will terminate your coverage as of the last day of the first month during the grace period.
True Health New Mexico will continue to pay all appropriate claims for covered services provided during the first month of the grace period and will pend (halt) claims for covered services provided in the second and third month of the grace period. Pending claims halts the process of reviewing and paying submitted claims.
If you have not paid your premiums, True Health New Mexico will notify you and the Exchange. True Health New Mexico also will notify providers of the possibility of denied claims when you are in the second and third month of the grace period. True Health New Mexico will continue to collect Advance Premium Tax Credits on your behalf from the Department of the Treasury and will return the Advance Premium Tax Credits on your behalf for the second and third month of the grace period if you exhaust your grace period as described above.
Drug Exception Time Frames and Enrollee/Member Responsibilities
Formulary exceptions, prior approvals, and appeals
All requests for approval of formulary exceptions should be sent by the prescribing provider (prescriber) to True Health New Mexico Pharmacy Services. In all cases, True Health New Mexico Pharmacy Services will perform the review and approval/denial of formulary exceptions as quickly as possible, but generally will not take longer than three (3) business days for a non-urgent request. Our procedures include an expedited (urgent) process for exigent (immediate) circumstances that requires a health plan to make its coverage determination within no more than twenty-four (24) hours after it receives the request, and that requires a health plan to provide the drug for the duration of the exigency.
If you are dissatisfied with True Health New Mexico’s initial expedited decision in a pharmacy urgent care situation, you may request an expedited review of the decision by both True Health New Mexico and an external reviewer called an Independent Review Organization (IRO). When an expedited review is requested, True Health New Mexico must review its prior decision and respond to your request with seventy-two (72) hours. If you request that an IRO also perform an expedited review simultaneously with True Health New Mexico’s review, the IRO must also provide its expedited decision within seventy-two (72) hours.
- Prospective review procedures and guidelines for formulary exceptions are developed and updated by and in conjunction with the Evolent Health Pharmacy and Therapeutics Committee and other specialist providers who have agreed to work with True Health New Mexico and Evolent Health to provide expert guidance.
- In the event that a request for a coverage determination cannot be approved with the available clinical information, the prescriber and the member are notified by phone and in writing of the coverage determination.
- The written notification to the provider and the member will contain the rationale for the determination and a description of the appeal process.
- Additionally, medication use by True Health New Mexico members is reviewed periodically to determine if use is appropriate, safe, and meets current medication therapy standards.
The prescribed drug will be considered for coverage under the pharmacy benefit program when the following criteria are met:
- A formulary alternative is not appropriate for the patient (e.g., patient has a contraindication or intolerance to the formulary alternative, etc.); and
- The drug is being prescribed for a U.S. Food and Drug Administration (FDA)-approved indication, or the patient has a diagnosis that is considered medically acceptable in the approved compendia* or a peer-reviewed medical journal; and
- The patient does not have any contraindications or significant safety concerns with using the prescribed drug.
- An approval will be granted for patients who meet the above criteria. If the patient does not meet the above criteria, the prescribed use is considered experimental/investigational for conditions not listed here.
*The approved compendia include:
- American Hospital Formulary Service (AHFS) Compendium
- IBM Micromedex® Compendium
- Elsevier Gold Standard Clinical Pharmacology Compendium
- National Comprehensive Cancer Network Drugs and Biologics Compendium
Definition: A chemically and pharmaceutically equivalent (equal) version of a brand-name drug whose patent has expired. A generic drug meets the same FDA standard for bio-equivalency that brand-name drugs must meet. However, a generic drug is usually less costly. Your pharmacist will substitute a generic drug for you automatically when one is available, even if your provider writes a prescription for the brand drug. If the generic drug does not meet your needs, your provider can start a pharmacy exception. You may then receive the brand drug, depending on the drug’s clinical criteria and if True Health New Mexico approves the exception.
Definition: The practice of substituting one drug for another (a therapeutic alternative) when both drugs work the same way and have the same therapeutic effects (benefits). This substituted drug is called the therapeutic alternative. When you get your prescription filled, your pharmacist will tell you if a therapeutic alternative has been made for you. The pharmacist can do this only with your provider’s approval.
- Determining copay or coinsurance amount for a medication
- Starting the exception process
- Ordering a refill for an existing, unexpired mail order prescription
- Locating in-network pharmacies
- Learning potential drug interactions or side effects
- Looking for generic substitutes
Explanations of Benefits (EOBs)
Definition: A statement that a health plan sends to the enrollee/member to explain what medical treatments and/or services it paid for on an enrollee/member’s behalf, the issuer’s payment, and the enrollee/member’s financial responsibility pursuant to the terms of the policy.
True Health New Mexico will send an EOB to you to once we have received a claim from your provider and have completed the review for payment. You should read your EOB to understand how much True Health New Mexico has paid a provider on your behalf. EOBs are not bills for services rendered. Bills will come from the rendering provider.
Coordination of Benefits (COB)
Definition: COB refers to enrollees/members who have coverage under more than one health insurance plan. A plan may be another group or individual health insurer, or it may be another type of insurance, such as Medicaid, Medicare, or certain types of automobile insurance. The insurance industry has developed “order of benefit determination rules” that govern the order in which each plan will pay a claim for benefits. This ensures that plans will apply consistent rules and that the maximum amount will be paid under each applicable plan.
The insurer that pays first is called the primary plan. The primary plan must pay benefits in accordance with its policy terms without regard to the possibility that another plan may cover some expenses.
The insurance company that pays after the primary plan is the secondary plan. The secondary plan may reduce the benefits it pays so that payments from all plan benefits do not exceed one hundred (100) percent of the total allowable charge. (Note: In some cases, an enrollee/member may be covered under three or more plans. In that case, benefits can be coordinated among all the applicable plans to ensure that the maximum benefits are paid by each plan).
Benefits under your True Health New Mexico plan will pay after payment is made by a health plan; group or individual automobile insurance policy; or homeowner’s or premises insurance, including medical payments, personal injury protection, or no-fault coverage.
In order to be able to coordinate benefits with another insurance carrier, we must know what other health insurance coverage you have. This could reduce the out-of-pocket and/or “not-covered” amounts for which you are liable. It is in your best interest to provide us with the most current information about other coverage that you and/or your dependents have. When your other health insurance coverage begins or ends, you should call Customer Service immediately at 1-844-508-4677.
If you are enrolled in Medicare, the Covered Benefits provided by your True Health New Mexico plan are not designed to duplicate any benefit to which you are entitled under the Social Security Act. True Health New Mexico does not coordinate benefits with Medicare. We will not pay any additional amounts above your Medicare plan’s benefit coverage as a secondary payor to Medicare.