Transparency in Coverage

Transparency in Coverage

CHRISTUS Health Exchange HMO plans require that you select an in-network Primary Care Provider (PCP) to coordinate all of your care. We will pay for covered services that our members receive from our in-network providers. Members who receive care from an in-network provider without receiving a referral from their PCP will incur higher out-of-pocket expenses including deductibles and coinsurance.

Services from an out-of-network provider are not covered, and providers may bill you for their services. Except for emergency services, members who go to an out-of-network provider will have to pay all charges out of pocket for the health services they receive. Emergency services are covered whether or not members use an in-network or out-of-network provider or emergency room. Members will pay in-network cost sharing (copayment, coinsurance and deductible) for covered emergency services.

CHRISTUS Health Exchange in-network plan providers will usually file claims for members after they receive services. In the event a provider is unable to file a claim, the member must notify CHRISTUS Health Plan within 20 days after receiving covered services in writing or by calling Member Services at the number on the back of your ID card. CHRISTUS will send a claim form for the member to complete. The claim form will then need to be returned to CHRISTUS Health Plan with all itemized bills attached. The claim form and attachments should be returned CHRISTUS within 365 days to the following address:

CHRISTUS Health Plan
Attn: Claims Department
919 Hidden Ridge
Irving, Texas 75038

Members must pay all monthly premiums to CHRISTUS Health Plan when they are due. If payments are late, CHRISTUS Health will provide a notice to members with information on how to keep coverage by paying all premiums owed by the end of the grace period defined below.

For members not receiving APTCs, CHRISTUS Health provides a grace period of 30 days for payment of monthly premiums except for the first binder premium payment. During the 30 day grace period coverage will continue. If CHRISTUS doesn’t receive the entire premium amount that is due by the end of the grace period, coverage will be cancelled back to the last day of the grace period. Members may be responsible to CHRISTUS Health Plan for the payment of the portion of the premium for the time coverage was in effect during the grace period.

For members receiving APTCs, CHRISTUS Health provides a grace period of ninety days if member has previously paid at least one full month’s premium during the benefit year. During the grace period CHRISTUS Health will:

  • Pay all appropriate claims for services rendered to the member during the first month of the grace period and may pend (hold) claim payment for services rendered to the member in the second and third months of the grace period;
  • Notify Health and Human Services (HHS) of such non-payment; and
  • Notify providers of the possibility of denied claims when a member is in the second and third months of the grace period.

If a member receiving APTCs reaches the end of their ninety day grace period without paying all outstanding premiums we will notify the member that coverage will be cancelled. The last day of coverage will be the last day of the first month of the ninety day grace period. Members will be responsible for payment of all charges for claims that were pended during the second and third month of the grace period.

In some situations, a claim may be denied after a member has already received services from a provider. This may happen when coverage is cancelled for non-payment or loss of eligibility under our plan due to a change in circumstance. This may also happen if our Medical Management team does a retrospective review of a member’s medical records after services have been provided to determine if the services were medically necessary.

Emergency care services may be reviewed retrospectively to determine if a true medical emergency did exist. These types of retrospective reviews are designed to protect members from the high costs associated with unnecessary use of emergency departments and urgent care centers. A member’s treatment of non-emergencies as if they are emergencies at an emergency department or urgent care center when a visit to a doctor’s office would have been appropriate could result in the member’s responsibility to pay a greater portion or all of the charges.

Prompt premium payment can also help members prevent retroactive denials. Members must always notify Healthcare.gov of a change in circumstance that might affect coverage. Members should also review all of our requirements to have health care services pre-authorized before receiving them.

If a member disputes a premium charge or payment, they may call Member Services by calling the number on the back of the ID card.

Some health care services require prior authorization before members receive them. If members do not follow our requirements for prior authorization, CHRISTUS Health Plan may not pay for the services. In most cases, physicians and other providers will be responsible for getting the prior authorization from the health plan. We have instructions and procedures in place for providers to request prior authorization.

The clinical department will evaluate the request to assess the Medical Necessity and coverage of proposed treatment. CHRISTUS Health Plan will also check that the treatment is being provided at the appropriate level of care. Prior authorizations are approved or denied based on current evidence- based clinical standards of care and guidelines and not on incentives or bonus structures. The member and provider will receive notification of CHRISTUS Health Plan’s decision, whether approved or denied.

Generally, the following types of services require prior authorization:

  • Surgery
  • Durable Medical Equipment (DME)
  • Home Health Care
  • Skilled Nursing Facility Care
  • Physical, occupational, and speech therapy
  • Cardiology Procedures
  • Hospice Services
  • Clinical Trial Services
  • Transplant Services
  • Certain drug and medications
  • Nuclear medicine
  • Non-emergency ambulance transport
  • Pain management
  • Prosthetic appliances and orthotics
  • Sleep studies

Note: This list may not include all services requiring Prior Authorization. If you need help determining if a service requires Prior Authorization, please contact Member Services at 1-844-282-3100.

Non-Emergent/Non-Urgent (Routine) Services are evaluated within 5 working days of receiving the request.

Ongoing Services (Concurrent) are done while member is receiving care, for example during a hospital stay. These requests are evaluated within 5 working days of receipt.

Expedited Requests for urgent services are evaluated within 24 hours of receipt of written or verbal request for a Prior Authorization.

You can ask CHRISTUS Health Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

•You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

•You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, CHRISTUS Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, CHRISTUS Health Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

For requests for benefits that do not involve exceptions, the Plan will provide notice of its decision within 24 hours after receiving an expedited request or 72 hours after receiving a standard request. For requests for benefits that involve exceptions, the adjudication timeframes do not begin until the member’s prescriber submits his or her supporting statement to the Plan for review.

For payment requests, including payment requests that involve exceptions, CHRISTUS Health Plan will provide written notice of its decision (and make payment when appropriate) within 14 calendar days after receiving a request. If CHRISTUS Health Plan coverage determination is unfavorable, the decision will contain the information needed to file a request for appeal/redetermination with the Plan.You can ask CHRISTUS Health Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, CHRISTUS Health Plan limits the amount of drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, CHRISTUS Health Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

For requests for benefits that do not involve exceptions, the Plan will provide notice of its decision within 24 hours after receiving an expedited request or 72 hours after receiving a standard request. For requests for benefits that involve exceptions, the adjudication timeframes do not begin until the member’s prescriber submits his or her supporting statement to the Plan for review.

For payment requests, including payment requests that involve exceptions, CHRISTUS Health Plan will provide written notice of its decision (and make payment when appropriate) within 14 calendar days after receiving a request. If CHRISTUS Health Plan coverage determination is unfavorable, the decision will contain the information needed to file a request for appeal/redetermination with the Plan.

You can ask CHRISTUS Health Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, CHRISTUS Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, CHRISTUS Health Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

For requests for benefits that do not involve exceptions, the Plan will provide notice of its decision within 24 hours after receiving an expedited request or 72 hours after receiving a standard request. For requests for benefits that involve exceptions, the adjudication timeframes do not begin until the member’s prescriber submits his or her supporting statement to the Plan for review.

For payment requests, including payment requests that involve exceptions, CHRISTUS Health Plan will provide written notice of its decision (and make payment when appropriate) within 14 calendar days after receiving a request. If CHRISTUS Health Plan coverage determination is unfavorable, the decision will contain the information needed to file a request for appeal/redetermination with the Plan.

After a member receives a health care service, CHRISTUS Health Plan will send an Explanation of Benefits (EOB) notice to the member. An EOB is a statement to explain what medical treatments and/or services a plan paid for on a member’s behalf, the plan’s payment and the member’s financial responsibility (out of pocket costs) pursuant to the terms of the policy. If you have questions about your EOB, please contact Member Services at the number on the back of your ID card.

Coordination of benefits exists when a member is also covered by more than one health plan. Benefits can be coordinated to establish proper payment of services. CHRISTUS Health Plan can assist with COB, but we will need you to complete the Other Health Insurance (OHI) Form. CHRISTUS Health Plan sends this form out annually; however you may contact Member Services at the number on the back of the ID card to request the form sooner if needed. One plan becomes your primary plan and pays your claim first. Then the second plan pays toward the remaining cost according to your policy.


MM161 & MM162
Last Updated: 2/23/17