Billing of Members

Copayments:
Participating providers are required to collect copayments from members for services performed in the office setting for which the provider submits a claim, and when ConnectiCare is the primary plan. (The copayment amount/applicable services, as stated on the ID card, are governed by the member’s Membership Agreement or other legal documents, as applicable.) Services that require a copayment include, but are not limited to, office visits, pain management services, and diagnostic/therapeutic procedures.

Some examples of services that generally do not take a copayment are as follows:

• care related to pregnancy, after the initial office visit copayment is made;
• certain antepartum care: amniocentesis, biophysical profile, fetal ultrasound examinations, and fetal stress/non-stress test;
• chemotherapy administration services, billed as a single service and not part of an office visit;
• immunization codes;
• laboratory codes and/or venipuncture, if no other service is billed; and
• mammography screening

Note: In any case, the member is only responsible for one copayment per day, per billing provider/group in the same specialty, for applicable services provided. For example, when physicians bill for a preventive visit in addition to an office visit, on the same date of service, only one copayment should be collected.

Coinsurance:
ConnectiCare offers plans that have coinsurance requirements. To ensure a more efficient billing process, bill ConnectiCare for services rendered prior to taking any cost-sharing payments from members.  This will allow you to verify whether the member has coinsurance requirements.  When you receive your Explanation of Payment (EOP) from us, you may then bill the member for the portion of the bill for which he/she is responsible, as indicated on the EOP.

Deductibles:
ConnectiCare also offers plans that have deductible requirements. To ensure a more efficient billing process, you should bill ConnectiCare for services rendered prior to taking any cost-sharing payments from members.  This will allow you to verify whether the member has met the deductible and/or has copayment or coinsurance requirements. When you receive your EOP from us, you may then bill the member for the portion of the bill for which he/she is responsible, as indicated on the EOP.

Covered Services:
Participating providers may not bill members for any service that is covered under the member’s ConnectiCare plan. Nothing in this section is intended to restrict or prohibit providers from billing a member for any applicable copayment, coinsurance, or deductible for certain covered services, as required under the member’s Plan.

Denied Services:
Members should not receive a statement or be billed, unless the service has been denied with an “EX” code that allows the member to be billed. If you’re not sure of whether member liability exists, contact Provider Services before billing a member.

Note:  Prior to initiating services that are not covered under a member’s plan, the physician or other health care provider must advise the member that the service is not covered, that the member will be held responsible for the associated costs, and the member must agree to be financially liable for those costs prior to receiving the services.

Refunds/Overpayments by Members:
If you receive an overpayment from a member that exceeds the cost share for which they are responsible according to their benefit plan, we request that you refund the appropriate amount back to the member in a timely manner.   You can verify whether or not a member is due a refund by referring to your Explanation of Payment and reconciling it against your patient accounts.