Pay BillBelow we’ve summarized some important terms to help you understand your individual or family plan with Independent Health. Terms and conditions of your health insurance plan may vary based on your state and plan type. For more information, please refer to your member contract, located in the Documents section of your MyIH account. Please contact Member Services at (716) 631-8701 or 1-800-501-3439 if you have additional questions.
Out-of-network liability and balance billing
Out-of-network services are from doctors, hospitals, and other health care professionals that have not contracted with your plan. A health care professional who is out of your plan network can set a higher cost for a service than professionals who are in your health plan network. Depending on the health care professional, the service could cost more or not be paid for at all by your plan. Charging this extra amount is called balance billing. In cases like these, you will be responsible for paying for what your plan does not cover. Balance billing may be waived for emergency services received at an out-of-network facility.
Use our Find a Doctor tool to find an in-network, participating provider. For best results, log in to your MyIH account for coverage details based on your plan.
Submitting your own claim as a member
A claim is a request to your insurance company for payment of health care goods or services. Usually, providers file claims with us on your behalf. If you received services from an out-of-network provider, and if that provider does not submit a claim to us, you can file the claim directly. If you are on an individual or family plan, you have 120 days to file a claim in New York State (90 days for government plans).
Log in to your MyIH account to submit a claim online. Or submit a claim by filling out the Medical/Pharmacy General Claim Form. If you need additional help with a claim, please call Member Services at (716) 631-8701 or 1-800-501-3439.
Grace periods and claims pending
You are required to pay your premium by the scheduled due date. If you do not do so, your coverage could be canceled. For most individual health care plans, if you do not pay your premium on time, you will receive a 30-day grace period.
A grace period is a time period when your plan will not terminate even though you did not pay your premium. Any claims submitted for you during that grace period will be pended. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full. If you do not pay your delinquent premium by the end of the 30-day grace period, your coverage will be terminated. If you pay your full outstanding premium before the end of the grace period, we will pay all claims for covered services you received during the grace period that are submitted properly. If you have an individual HMO plan in [state], we will pay your claims during the 30-day grace period; however, your benefits will terminate if your delinquent premium is not paid by the end of that grace period.
If you are enrolled in an individual health care plan offered on the Health Insurance Marketplace and you receive an advance premium tax credit, you will get a 3-month grace period and we will pay all claims for covered services that are submitted properly during the first month of the grace period. During the second and third months of that grace period, any claims you incur will be pended. If you pay your full outstanding premium before the end of the 3-month grace period, we will pay all claims for covered services that are submitted properly for the second and third months of the grace period. If you do not pay all of your outstanding premium by the end of the 3-month grace period, your coverage will terminate, and we will not pay for any pended claims submitted for you during the second and third months of the grace period. Your provider may balance bill you for those services.
Retroactive denial of claims
A retroactive denial is the reversal of a claim we have already paid. If we retroactively deny a claim we have already paid for you, you will be responsible for payment. Some reasons why you might have a retroactive denial include having a claim that was paid during the second or third month of a grace period or having a claim paid for a service for which you were not eligible.
You can avoid retroactive denials by paying your premiums on time and in full and making sure you talk to your provider about whether the service performed is a covered benefit.
You can also avoid retroactive denials by obtaining your medical services from an in-network provider.
Recoupment of overpayments
If you believe you have paid too much for your premium and should receive a refund, please call Member Services at (716) 631-8701 or 1-800-501-3439.
Medical necessity and preauthorization timeframes and member responsibilities
We must approve some services before you obtain them. This is called preauthorization. Please visit our Member Preauthorization page for a list of services that require preauthorization.
If you require a service on Independent Health’s member preauthorization list, you are responsible for obtaining approval by calling Member Services at (716) 631-8701 or 1-800-501-3439. While your provider may also do this on your behalf, keep in mind that it is your responsibility to ensure preauthorization is obtained from Independent Health prior to receiving these services to avoid potential financial penalties. The request for member preauthorization should be made 15 calendar days in advance of the service(s) being rendered, or within 48 hours of the first business day following emergency services and/or admission.
Independent Health will review the member preauthorization request, which may take 3 to 5 business days. Once a decision is made, you will be notified in writing of the decision.
If you don’t get preauthorization, you may have to pay up to the full amount of the charges.
Drug exceptions timeframes and member responsibilities
Sometimes our members need access to drugs that are not listed on the plan’s formulary (drug list). These medications are initially reviewed by Independent Health through the formulary exception review process. The member or provider can submit the request to us using the Pharmacy Formulary Exception Request form. If the drug is denied, you have the right to an external review.
If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case for an external review by an impartial, third-party reviewer known as an independent review organization (IRO). We must follow the IRO’s decision.
- For initial standard exception review of medical requests, the timeframe for review is 72 hours from when we receive the request.
- For initial expedited exception review of medical requests, the timeframe for review is 24 hours from when we receive the request.
- For external review of standard exception requests that were initially denied, the timeframe for review is 72 hours from when we receive the request.
- For external review of expedited exception requests that were initially denied, the timeframe for review is 24 hours from when we receive the request.
If you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, you may request your case be handled as expedited.
An IRO review may be requested by a member, member’s representative, or prescribing provider by mailing, calling, or faxing the request. Please reach out to Member Services at (716) 631-8701 or 1-800-501-3439 for more information.
Explanation of Benefits (EOB)
Each time we process a claim submitted by you or your health care provider, we explain how we processed it on an Explanation of Benefits (EOB) form.
The EOB is not a bill. It explains how your benefits were applied to that particular claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you’re responsible for paying the provider. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.
This sample Explanation of Benefits (EOB) highlights each section of the form, providing you with helpful definitions and terms.
Coordination of Benefits (COB)
Coordination of Benefits (COB), is when you have other insurance under one or more health insurance plans. An important part of coordinating health care benefits is determining the order in which the plans pay for them. One plan provides benefits first. This is called the primary plan. The primary plan pays its full benefits as if there were no other plans involved. The other plans then become secondary.
If you or anyone on your plan has other insurance, including medical, pharmacy, veterans’ coverage, worker’s compensation or no-fault due to a motor vehicle accident, it only takes a few minutes to take this survey. As stated in your Independent Health member contract, you are required to provide us with this information.