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Claims and Your Financial Responsibility

Health Choice Insurance Co. (Health Choice) is a health maintenance organization (HMO). This means you must receive covered benefits from in-network providers. Your Primary Care Physician (PCP) must refer you to a specialist and the referral must be on file with Health Choice before you visit the specialist. Some covered benefits require prior authorization by Health Choice in order to be an eligible expense. If these conditions are not met, you may be responsible for the cost of services received be billed by your provider.

See your Evidence of Coverage (EOC) for more information on referrals and prior-authorizations, as well as the prior authorization information found here. To find an in-network provider for your plan, please visit our online directory.

Emergency services are a covered benefit, even if received from an out-of-network provider. Emergency services do not require prior authorization.

If you are required to pay for out-of-network emergency care at the time of services, submit your claim to the following address:

Health Choice Insurance Co.
Attn: Claims Department
410 N. 44th Street
Suite 927
Phoenix, AZ 85008

If you receive a bill for covered benefits from an in-network provider please contact Member Services at 855-452-4242.

If you paid your own claim directly to your provider but your provider also submitted a claim to Health Choice, then you will need to contact your provider's billing office and request a refund upon receiving your Explanation of Benefits. Health Choice can only pay the provider directly, we do not pay claims to our members.

Health Choice pays clean claims within 30 days of receipt of the claim. A clean claim is a claim for covered benefits that may be processed without obtaining additional information, including coordination of benefits information, from the health care provider, the enrollee or a third party, except in cases of fraud.

In Arizona, coordination of benefits does not apply to individual health plan coverage. This means that other health plan coverage you may have is not considered in the payment of your claims under a Health Choice Insurance Co. plan.

Retroactive Denials

There are circumstances under which Health Choice may retroactively deny coverage for emergency and prior-authorized non-emergency treatment. A service or claim may be retroactively denied if:

  • There is no documentation supporting the medical necessity of the services rendered.
  • Records do not substantiate medical necessity and will be reviewed by our Medical Director to determine the following:
    • Emergency Services
    • Appropriate level of care post-stabilization
    • Consistent application of InterQual Criteria Guidelines has been utilized
    • The services rendered could have been provided at a lower level of care.

All denials are reviewed and approved by the Chief Medical Officer and/or Medical Director. If you would like further information, please see your Evidence of Coverage.

Premiums

Grace Period for Members Receiving Advance Premium Tax Credit (APTC)

Members who receive APTC have a ninety (90) day grace period. During the first month of the grace period, we will continue to pay claims incurred for eligible expense. During the second and third months of the grace period, we may suspend payment of any claims until we receive the past due premiums. If payment is not received for all outstanding premiums by the end of the grace period, your health plan coverage will be terminated effective at 11:59pm on the last day of the first month of the grace period. You will be responsible for the cost of any healthcare services you receive after the last day of the first month of the grace period.

Members without APTC

Members without APTC do not have a grace period. After the first due premium payment, if a premium is not paid on or before the date it is due, your enrollment will automatically terminate.

No benefits will be payable for services incurred during a coverage period (month) if the premium was not paid by the due date.

Premium Auto-Pay

You may set up auto-pay for your monthly premium as long as your current premium balance is $0.

To set up auto-pay please follow these steps:

  1. Log onto ChooseHealthChoice.com
  2. Sign into your account
  3. Click “Manage Recurring Payments”
  4. Choose “Automatic Payments” and fill in your information
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