Medical Necessity and Prior Authorization

Prior authorization is approval from Peak Health that may be required before you receive certain health care services, treatments, supplies, medical devices, prescription drugs, or care in certain settings.

The prior authorization review is used to determine whether the requested service, treatment, supply, device, or prescription drug meets the medical necessity requirements outlined in your plan or policy.

Receiving prior authorization does not guarantee that benefits will be covered or payable under your plan. Coverage is subject to your plan’s terms, conditions, exclusions, and limitations.

You, a family member, or your health care provider can request prior authorization by calling the number on the back of your Peak Health member ID card.

To verify whether prior authorization is required for inpatient services, please call the number on the back of your member ID card.

How do you submit a claim?

Notice of  Claim

You do not need to complete or submit claim paperwork when you receive covered services from a participating provider. Simply present your Peak Health member ID card and pay any applicable copayment. Your participating provider will submit the claim to Peak Health for payment.

For emergency services received from a non-participating provider, the provider may submit the claim on your behalf if they are able and willing to do so. If the non-participating provider does not submit the claim on your behalf, you must submit a completed claim form along with itemized bills to the claims address listed on your member ID card.

You can obtain the required claim forms by contacting Peak Health Member Service at 1-833-695-7325 (1-833-5MYPEAK).

How do you file a Complaint, Grievance, or Appeal with Peak Health?

Complaints, Grievances and Appeals

Member Complaints, Grievances and Appeals – Medical

If you have a concern about a person, service, quality of care, initial eligibility denial, contractual benefits, or a rescission of coverage, please call 1-833-695-7325 (1-833-5MYPEAK).

We’ll make every effort to resolve your concern during your initial call. If additional time is needed to review or investigate the matter, we’ll contact you as soon as possible and no later than 30 days.

If you are not satisfied with a coverage decision, you may file an appeal.

Member Complaints, Grievances and Appeals – Prescription Drugs

If you have a concern about a person, service, quality of care, initial eligibility denial, contractual benefits, or a rescission of coverage, please call 1-833-695-7325 (1-833-5MYPEAK). A Peak Health Member Service representative will listen to your concern and help you understand your options.

We’ll make every effort to resolve your concern during your initial contact. If additional time is needed to review or investigate the matter, we’ll contact you as soon as possible and no later than 30 days.

If you are not satisfied with the outcome of a coverage decision, you may file an appeal through the appeals process.

Did you overpay your premium?

Member Recoupment of Overpayments

If you paid more than the amount due for your health insurance premium, you may be eligible for a refund. If you believe you have overpaid, please call Peak Health Member Service at 1-833-695-7325 (1-833-5MYPEAK). We can help answer questions about your premium payment and whether you may be eligible for a refund.

Nonpayment of Premium and Grace Period for Premium Tax Credits

Your premium must be paid to Peak Health by the due date specified in your policy for each coverage period. If your premium is not paid on time, a grace period may apply depending on how you purchased your coverage.

Plans Not Purchased Through the Marketplace or Plans Without an Advanced Premium Tax Credit

If you did not purchase your plan through the Marketplace, or you purchased your plan through the Marketplace but did not receive an advanced premium tax credit (APTC), you have a 30-day grace period to pay your premium and keep your coverage.

Your coverage will remain active during the grace period. Claims submitted during this time may be held or denied until your outstanding premium is paid.

If we do not receive your full premium payment by the end of the 30-day grace period, your coverage will end as of the last day of the grace period.

The grace period does not apply to your initial premium payment required to start your coverage.

Plans Purchased Through the Marketplace With an Advanced Premium Tax Credit

If you purchased your plan through the Marketplace and receive an advanced premium tax credit (APTC), you have a 90-day consecutive grace period to pay your outstanding premium and keep your coverage.

Your coverage will remain active during the grace period. However, claims for services received after the first 30 days of the grace period may be held or denied until your premium is paid.

If we do not receive your full premium payment by the end of the applicable grace period, your coverage will end as of the last day of the first month of the grace period.

Grace periods do not apply to your initial premium payment required to start your coverage.

What should you know about Out-of-Network Services and Balance Billing?

Out-of-Network Services and Balance Billing

If you have an HMO plan, you generally need to receive covered services from a network provider to receive benefits under your plan. However, if you receive care from an out-of-network provider because of a medical emergency, your services will be covered at the applicable in-network benefit level.

Peak Health provides members with a list of network providers in the Peak Health service area. You are responsible for choosing the doctors and other health care providers you use for your care.

If you have a PPO plan, you can receive covered services from out-of-network providers. However, out-of-network providers may not be required to accept Peak Health’s payment as payment in full.

If you choose to receive non-emergency services from an out-of-network provider, the provider may bill you for the difference between their charge and the amount Peak Health pays. This is commonly known as balance billing.

For out-of-network provider claims, Peak Health’s allowed amounts are generally based on 125% of the applicable CMS reimbursement rates and methodologies in effect at the time of service. This includes medications covered under the medical benefit. For services that do not have a rate listed on the CMS Medicare Fee Schedule, reimbursement is based on the current Peak Health Payer Fee Schedule, less any applicable copayment, deductible, or coinsurance.

If you have questions about out-of-network services or balance billing, please call Peak Health Member Service at 1-833-695-7325 (1-833-5MYPEAK).

Emergency Services and Certain Out-of-Network Providers

For covered emergency services, both HMO and PPO members pay the same cost sharing that would apply to in-network services, including applicable copayments, coinsurance, and deductibles.

You will also pay in-network cost sharing for certain services provided by out-of-network providers at a network hospital or facility. This may include providers such as anesthesiologists or pathologists. This protection may also apply when an out-of-network provider provides certain services at a network hospital or facility without notifying you that they are out of network.

When these protections apply, the out-of-network provider cannot bill you for more than your applicable in-network cost-sharing responsibility.

How can you request an exception for a prescription drug that is not on the Prescription Drug List?

Prescription Drug Exception and Expedited Process

If your doctor prescribes a prescription drug or related supply that is not included on Peak Health’s prescription drug list, your doctor may request an exception. An exception allows Peak Health to consider covering the drug or supply for your specific medical condition.

Your doctor must follow Peak Health’s prescription drug exception request process to request an exception.

Prescription Drug Exception Request Process

Your doctor can request an exception by calling Peak Health or completing the appropriate form and sending it to us by fax.

Your doctor may also provide written confirmation that you have previously tried a drug or related supply that is included on the prescription drug list or required under a step therapy protocol and that:

• The drug or supply was ineffective in treating your condition or was harmful to your health; and

• In your doctor’s opinion, using the drug or supply again is likely to be ineffective or harmful.

Peak Health will review and complete the exception request within 72 hours after receiving the request.

Requesting an Expedited Review for a Prescription Drug Exception or Prior Authorization

Your doctor may request an expedited review if waiting for a standard decision could seriously jeopardize your life, health, or ability to regain maximum function. An expedited review may also be requested if you are currently receiving treatment with a prescription drug or related supply that is not on the prescription drug list.

Peak Health will review and complete an expedited request within 24 hours after receiving it.

If the request is approved, your doctor will receive confirmation, and the authorization or exception will be processed through the pharmacy claims system so the medication or related supply can be covered.

The authorization or exception will remain in effect for as long as you continue to use the prescription drug or related supply for which approval was granted.

Once your doctor tells you that coverage has been approved, you can contact your pharmacy to fill your prescription.

If the request is denied, you and your doctor will be notified that coverage was not authorized.

Appealing a Prescription Drug or Prior Authorization Denial?

If you, someone acting on your behalf, or your prescribing doctor disagrees with a coverage decision, you may appeal the decision.

To appeal, you must submit a written request explaining why the prescription drug or related supply should be covered. Your appeal will be reviewed according to the requirements in your policy.

For information about the appeal process and external independent review, please see the “When You Have a Complaint or an Appeal” section of your policy.

If you have questions about prescription drug exceptions, prior authorization, or step therapy, call Peak Health Member Service at 1-833-695-7325 (1-833-5MYPEAK).

Which prescription drugs require prior authorization?

Prescription Drugs Requiring a Prior Authorization

Prior Authorization

Some prescription drugs and related supplies, including certain high-cost and specialty medications, require prior authorization before they can be covered.

When prior authorization is required, your doctor must request approval before the prescription or supply can be filled. Your doctor should follow the prescription drug authorization and exception request process described above.

Step Therapy

Step therapy is a type of prior authorization. Under a step therapy requirement, you may need to try one or more other prescription drugs or related supplies before Peak Health will cover the requested medication.

Step therapy may apply to certain higher-cost and specialty medications. You can find medications subject to step therapy requirements on the prescription drug list or formulary.

Your doctor can request step therapy authorization by following the prescription drug authorization and exception request process.

Special rule for certain advanced cancers: Step therapy or a history of failing another drug will not be required for prescription drugs used to treat stage four, advanced metastatic cancer when both of the following apply:

• The U.S. Food and Drug Administration (FDA) has approved the drug for the specific indication; and

• The prescription is consistent with accepted clinical practices for treating stage four, advanced metastatic cancer or a severe adverse health condition resulting from stage four, advanced metastatic cancer, and is supported by peer-reviewed medical literature.

Standard Requests

Standard organization determinations are made as quickly as your health condition requires and no later than 15 calendar days after Peak Health receives the request.

If additional time is needed because of circumstances beyond Peak Health’s control, we will notify you or your representative within 15 days of receiving the request. The notice will explain when you can expect a decision. The decision will be made no later than 30 days after the request was received.

Expedited Requests

An expedited organization determination may be requested when you or your health care provider believes that waiting for a standard decision could seriously jeopardize your life, health, or ability to regain maximum function.

Peak Health will make an expedited determination as quickly as your health condition requires and no later than 72 hours after receiving the request.

If information needed to make the decision is missing, Peak Health will notify you or your representative within 24 hours and explain what additional information is needed. Once the requested information is received, we will notify you or your representative of the determination within 48 hours.

What is a Retroactive Denial of a Claim?

Retroactive Denial of Claims

A retroactive denial occurs when Peak Health reverses a claim that was previously paid. If a claim that was already paid is later denied, you may become responsible for the amount that was previously paid.

A retroactive denial may occur for reasons such as:

• A claim was paid during the second or third month of a premium grace period.

• A claim was paid for a service received when you were not eligible for coverage.

• A claim was paid as a result of fraud or an intentional misrepresentation of facts.

You can help reduce the risk of a retroactive denial by:

• Paying your premiums in full and on time.

• Asking your doctor whether a service is a covered benefit before receiving care.

• Using in-network doctors and other health care providers whenever possible.

What are your Rights and Responsibilities as a Peak Health Member?

Rights and Responsibilities

As a Peak Health member, you have certain rights and responsibilities related to your health care and health plan coverage.

Please review the Rights and Responsibilities section of your policy or member materials to learn more about your rights and responsibilities as a Peak Health member.

If you have questions about your coverage, please call Peak Health Member Service at 1-833-695-7325 (1-833-5MYPEAK).