Backdating healthcare provider contracts
Use the Quick Links to access our Find a Doctor/Provider tool and our Find a Pharmacy tool.You must pay copayments, coinsurance and the annual deductible for most covered services.If you choose to receive a refund, please contact Member Services at 1-855-202-0622 (TTY: 1-800-982-8771 or 711)Medically necessary services are health care services that are determined to be medically appropriate in accordance with Care Source's medical policies and nationally recognized guidelines.These are services that are not experimental or investigational in nature, are necessary to meet the basic health needs of the covered person and are rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service.The grace period provisions above will not apply to you.You are responsible for the costs of any health care services that you receive for any period of time during the benefit year for which you did not pay a premium.Regardless of your household income, there is no cost sharing if you receive services from an Indian health care provider or through referral under the Contract Health Services program administered by the Indian Health Service.You must pay the cost of all health care services and items that exceed the limitations on payment of benefits or are not covered services.
Sometimes a member may have a drug allergy or intolerance.
Or, a certain drug may not be effective for a member.
In these cases, the member or the member’s representative may ask for an exception to a drug listed on the PDL.
A request for prior authorization must be made, decided and a benefit determination issued, as expeditiously as the member’s health condition requires, but no later than 15 calendar days following receipt of the complete request.
An urgent determination must be reviewed, completed, decided and a benefit determination issued as fast as is needed, but no later than 72 hours following receipt of the request.