If you receive services from a provider that isn’t on your network, you may be responsible for more charges than had you received the same services from an in-network provider. Out-of-network providers may bill you directly for charges that aren’t covered by your plan. For more information related to out-of-network liability, click here
We work hard to manage costs while protecting the quality of care. Our care managers review three aspects of medical care:
- Is the care setting
- Are the services medically
- Is the length of time spent in
the hospital appropriate?
By making sure your care is provided in the most appropriate manner, we can lower medical expenses for everyone and maintain reasonable premium rates.
Approval from SelectHealth for certain services is called preauthorization. If preauthorization is not obtained when required, your benefits may be reduced or denied. Generally preauthorization is needed prior to receiving services. However, in some cases we may perform a post-service review to determine coverage. Please allow 14 days for preauthorization for non-admission-based procedures. For information on what services require preauthorization, click here
and browse to “What services require preauthorization?”
You may also request a list or speak to Member Services by calling 800-538-5038
weekdays, from 7:00 a.m. to 8:00 p.m., and Saturdays, from 9:00 a.m. to 2:00 p.m. TTY users please call 711.
If you request more services—in addition to services already approved—we will work with you and the facility or providers to make sure that care is received in an appropriate setting. We will also help you plan for the return home or to another care setting.
Claims Denials and Appeals
If you want to submit a claim to SelectHealth, rather than the provider
submitting the claim for you, you may fill-out a claim form located here. Follow the instructions on page
2. Generally claims must be submitted within one year from the date of
service, though longer time limits do exist in certain circumstances.
If your policy is canceled due to nonpayment or for other reasons, claims submitted during the grace period, or before your plan is canceled, will be denied after SelectHealth receives them. You can prevent this by always paying your full premium. For more information about retroactive denials, click here.
You or your representative can
appeal any decision. You may submit an appeal in writing to:
P.O. Box 30192
Salt Lake City, UT 84130-0192
Pharmacy benefits are included with all of our Individual medical plans.
All Individual plans include our RxCore formulary. A formulary is a list of covered prescription drugs. In an effort to help keep your costs as low as possible, RxCore excludes more expensive brand-name drugs when there is a lower-cost generic option or over-the-counter equivalent available. A generic drug is a medication with the same active ingredients, safety, dosage, quality, and strength as its brand-name counterpart. Providers and pharmacists agree that generic medications are as safe and effective as brand-name drugs.
Individual plan RxCore pharmacy benefits have four tiers (levels) of coverage. Each tier includes different drugs and copays/coinsurance. Tier 1 medications are available at the lowest cost. On some plans, the pharmacy deductible does not apply to these drugs.
Certain medications are not covered. If you have questions before applying for coverage or using your pharmacy benefits, call Member Services
If you need a prescription for a medication that is normally not covered under your plan, you may ask for an exception to your plan’s prescription drug coverage. Obtaining an exception decision takes between 24 (emergent) and 72 hours (standard). Many requests can be handled over the phone by calling 800-538-5038, or by filling out the Exception Request Form
. Some requests may need to be submitted by your physician. If the exception is denied, you have the right to appeal that decision as with any other denial.
Access your prescription drug benefits conveniently through a network of more than 39,000 pharmacy locations nationwide, with 400 locations in Utah. Most of our partner pharmacies are national chains, so you are covered while traveling.
Pick up a 90-day supply of your maintenance medications at participating Retail90
pharmacies or by mail order through Intermountain Home Delivery. This program offers both convenience and cost savings. Register for Intermountain Home Delivery
Individual Plans and Premiums
If you receive an Advanced Premium Tax Credit (APTC) to assist in paying your monthly premiums, you will receive a 3-month grace period in the event that you become delinquent in payment. In the event that claims are submitted for services received during the second or third months of the grace period, they will be pended (held without final determination or payment) until you pay your portion of premium or are terminated for nonpayment. For more information, click here
If you do not receive financial assistance for your coverage, premiums are due the first day of the month your coverage begins. If you do not pay your premium in full by the last day of the month, your coverage will be terminated the first day of that month.
Recoupment of Overpayments
If you pay too much (overpay)
toward your premium and your policy is still active, we will apply this
overpayment to the next month’s premium. If your policy has been terminated,
the overpayment will be refunded—unless benefits were used after the
termination date, in which case, the refund will be offset by the benefits used
and we will refund any remaining amount. If you have questions, please call
Accounts Receivable at 844-442-4106, option 1.
Explanation of Benefits (EOB)
An EOB explains what services have been paid for by your plan and what
services you will be responsible for. SelectHealth sends EOBs to members after
claims are received and processed. For more information on how to read and
understand an EOB, click here to see a sample.
Coordination of Benefits (COB)
COB occurs when a member is
enrolled in more than one plan and is used to determine which plan processes
claims first. For more information about coordination of benefits, click here.