Commercial - Administrative Procedures
Billing of Members
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.
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
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.
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.
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.