Claims Payment Information

 

ENROLLEE CLAIM SUBMISSION - click to expand

There is no reason for you to pay a provider for covered services under your Certificate (other than copayments, coinsurance and deductible), but if circumstances require that you do, and you can prove that you have, MHP Community will reimburse you for those covered services. You must provide written proof of the payment within 12 months of the date of service and complete a Direct Member Reimbursement Form. You can find the form below or you can obtain a copy by calling Customer Service at (888) 327-0671. 

NOTE: The proof of payment documentation must include the procedure code, diagnosis code, charges, the amount you paid and the Provider Tax ID number. Claims submitted more than 12 months after the date of service will not be paid. 

Direct Member Reimbursement Form

 

GRACE PERIODS AND CLAIMS PENDING POLICIES DURING THE GRACE PERIOD - click to expand

If you purchased an individual plan through the health insurance marketplace and you are receiving advance payments of tax credits in accordance with the Affordable Care Act, each of your monthly periodic payments is due on the first day of the month for that coverage period. There is a grace period of three months for all monthly premium payments after the initial premium payment.

 If you pay a monthly payment later than the first day of the coverage period to which it applies, but before the end of the grace period for the coverage period, any claim you submit for benefits will be placed in a pending status (suspended) on the first day of the second month of the grace period and then processed by the plan only when all periodic monthly payments due during the grace period are received. If you fail to pay in full all periodic monthly payments due and payable before the end of the grace period for those coverage periods, your coverage under the plan will be retroactively canceled back to the last day of the first month of the grace period. Failure to timely pay premium payments is not a special open enrollment event for later coverage under the plan.

RETROACTIVE DENIALS - click to expand

A retroactive denial is the reversal of a previously paid claim. If the claim is denied, the Member becomes responsible for payment. Retroactive denial of claims can be avoided by paying premiums on time.

RECOUPMENT OF OVERPAYMENTS - click to expand

If you believe you have overpaid your premium due to our overbilling, please contact us by calling Finance Department at (810) 733-9528.

COORDINATION OF BENEFITS (COB) - click to expand

Coordination of Benefits or COB means determining which Certificate or policy is responsible for paying Benefits for Covered services first (primary carrier) when a member has dual coverage. Benefit payments are coordinated between the two carriers to provide 100% coverage whenever possible for services Covered in whole or in part under either plan, but not to pay in excess of 100% of the total amounts to which providers or Members are entitled. Except as otherwise stated in this Certificate, MHP Community will coordinate benefits in accordance with Michigan law, and specifically PA 275 of 2016; MCL 550.251, et seq.

If the carriers that issued plans cannot agree on the order of benefits within 30 days after the carriers have received all of the information needed to pay the claim, the carriers shall immediately pay the claim in equal shares and determine their relative liabilities following payment.  A carrier is not required to pay more than it would have paid had the plan it issued been the primary plan.

Coordination of Benefits Form 

FAILURE TO PAY INITIAL PREMIUM - click to expand

Whether you purchase your MHP Community individual coverage on or off the Michigan Marketplace, your enrollment is not complete until you have paid your first month’s premium.  This is referred to as your “Initial Premium”. It must be paid directly to MHP Community – not to the Michigan Marketplace.  This payment must be paid no later than 30 calendar days from the intended effective date of coverage in order for your coverage to begin.

You will usually not have a payment coupon booklet before your Initial Premium is due, so please do one of the following:

  • Call Customer Service at (888) 327-0671 for instructions on how to pay your Initial Premium;
  • Hand deliver your Initial Premium to the McLaren Health Plan Community office at G-3245 Beecher Road, Flint, Michigan; or
  • Mail your Initial Premium to P.O.Box 771983, Detroit, MI 48277-1983

If we do not receive your payment within the 30-day time period your coverage will not be effective.

TERMINATION OF COVERAGE - click to expand

TERMINATION FOR NONPAYMENT OF PREMIUM

If the Subscriber fails to pay any premium other than the Initial Premium – whether in whole or in part, by the due date - the contract is in default.

A.  MEMBERS WHO RECEIVE ADVANCED PREMIUM TAX CREDITS (APTC):

If you purchased your Coverage on the Michigan Marketplace and receive APTC and you have paid at least one full month of premium during the current benefit year, you will be given a three (3) month grace period during which the premiums must be brought up to date. If you need health care services at any time during the second and third months of the grace period, MHP Community will hold payment for claims beginning on the first day of the second month of the grace period and notify the Participating Provider that we are not paying these claims during this time.  If premiums are not brought up to date within the three month grace period, your Coverage will be cancelled.  Your last day of Coverage will be the last day of the first month of the three-month grace period. All claims for any health services that were provided after the last day of Coverage will be denied, and any Benefits incurred by a Member and paid by MHP Community after the Termination effective date may be charged to the Subscriber or the Member who received the Benefit.

B.  MEMBERS WHO DO NOT RECEIVE ADVANCED PREMIUM TAX CREDITS (APTC):

If you purchased your Coverage on or off the Michigan Marketplace, you do not receive APTC and you have paid at least one full month of premium during the current benefit year, a grace period of 31 days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force.  If premiums are not brought up to date within the one month grace period, your Coverage will be cancelled.  Your last day of Coverage will be the last day of the last month in which a full monthly premium was received by MHP Community.  All claims for any health services that were provided after the last day of Coverage will be denied, and any Benefits incurred by a Member and paid by MHP Community after the Termination effective date may be charged to the Subscriber or the Member who received the Benefit. 

C.  TERMINATION OR NON-RENEWAL OF A MEMBER’S COVERAGE – ADDITIONAL CAUSES

Coverage for a Member may also be Terminated or Non-Renewed for any of the reasons listed below.  Such Termination or MHP Community’s decision to Non-Renew Coverage is subject to thirty days’ notice (including the reason for the Termination or Non-Renewal) and, if applicable, grievance rights, and is effective on the date specified by MHP Community or the Michigan Marketplace.

  • The Member enrolled in a Michigan Marketplace plan is no longer eligible for Coverage through the Michigan Marketplace;
  • The Member enrolledwith MHP Community off the Michigan Marketplace no longer meets MHP Community eligibility requirements;
  • The MHP Community Michigan Marketplace plan is terminated or decertified by state or federal regulators;
  • The MHP Community plan is withdrawn from the marketplace by MHP Community in accordance with state and federal laws;
  • A contract is cancelled for nonpayment of premium;
  • The Member changes products;
  • The Member moves out of the MHP Community Service Area;
  • The Member enrolled with MHP Community off the Michigan Marketplace ceases to be a member of an association through which the Member has achieved eligibility; or
  • The Member commits fraud against MHP Community or a provider of Benefits.

A Member wishing to Terminate Coverage must provide at least fourteen (14) days’ notice to MHP Community or the Michigan Marketplace (as applicable) of his or her wish to Terminate.

D.  RESCISSION OF MEMBER’S COVERAGE

Rescission of Coverage means the Member’s Coverage ends retroactive to the date a Member committed fraud against MHP Community or a provider of Benefits, or intentionally misstated or intentionally withheld a material fact. MHP Community will provide at least 30 days’ notice of a rescission. A Member may appeal a Rescission of Coverage by following the MHP Community Complaint and Appeals Procedure. Fraud or intentional misstatement or withholding of a material fact includes:

  • Intentional misrepresentation of the eligibility of a Member;
  • Fraudulent use of the MHP Community ID card; or
  • Fraudulent use of the MHP Community system.

NOTE:  Any amounts paid by MHP Community after the event are due and owing from the Member.

For retroactive denials, recoupment of overpayments and/or any other information regarding claims, please contact Customer Service at (888) 327-0671.

OUT-OF-NETWORK PROVIDER AND BALANCE BILLING  - click to expand

An out-of-network provider or facility does not have a contract with MHP Community. They are paid at a reasonable and customary rate.* The out-of-network provider or facility can charge you the difference between what their total charged amount is and what MHP Community paid. This is called “balance billing.” Your deductible and coinsurance may be higher when you see an out-of-network provider. 

*HMO Plan members only have out-of-network coverage for urgent and emergent care. All other out-of-network services are not covered unless preauthorized by MHP Community.

ENROLLEE RESPONSIBILITIES AND MEDICAL NECESSITY - click to expand

At the time of enrollment and if requested by MHP Community thereafter, Members are required to disclose to MHP Community whether they have health coverage under any other certificate or policy. Members must also immediately notify MHP Community if there are any changes in such coverage. If a member fails to provide such information when requested, or to notify MHP Community upon any changes to the Member’s other health coverage, MHP Community may deny payment for individual claims.

Members have the right to request and ask for and be given, without cost, a copy of the actual benefit provisions, guidelines, protocol, clinical review criteria or other information used to determine Medial Necessity, All requests must be sent in writing to MHP Community Customer Service, G-3245 Beecher Road, Flint, MI 48532.

Prior authorization requests are processed within 14 days of receipt for non-urgent requests, and between 24-72 hours for urgent needs.

DRUG EXCEPTION - click to expand

MHP Community has placed a Prior Authorization (PA) restriction on certain medications within the drug formularies. PA means the medication requires special approval before it will be considered for coverage under MHP Community. A medication may require a PA due to safety concerns or to ensure a more cost-effective formulary alternative cannot be used.

If a prescribing provider feels a medication that requires a PA is medically necessary, then a prior authorization form should be completed by the prescribing provider and faxed to the number indicated on the form. Please contact MHP Community at (888) 327-0671, if you have questions regarding the PA process or the status of a PA request. Note: If the member needs an emergency supply of a medication that requires prior authorization, please contact Customer Service at (888) 327-0671 for assistance.

Prior authorization requests are processed within 14 days of receipt for non-urgent requests, and between 24-72 hours for urgent needs.

EXPLANATION OF BENEFITS (EOB) - click to expand

MHP Community does send you an Explanation of Benefits (EOB) that details the amount of charges for health care services you have received, the amount we paid, the amount we denied and any copay, coinsurance or deductible you may owe. If a bill from your provider does not match the information on your EOB, you can either call Customer Service at (888) 327-0671, TTY 711, for an explanation of the charge, or you can call your provider.

Explanation of Benefits Sample