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Individual & Family Products

Transparency in Coverage - Claims Payment and Policies

The Affordable Care Act (ACA) requires that all health plans provide information that will help consumers understand how reliably the plan reimburses claims for covered services and other practical information.  Health care transparency provides consumers with the information necessary to choose their health care plan.

 

Medical
Dental
Claims/Appeals Data
  • Out of network liability and balance billing
    Enrollee claim submission
    Grace periods and claims pending
    Retroactive denials
    Recoupments of overpayments
    Medical necessity and prior authorization timeframes and enrollee responsibilities
    Drug Exception timeframes and enrollee responsibilities
    Explanation of benefits
    Coordination of Benefits
  • Out of network liability and balance billing
    Enrollee claim submission
    Grace periods and claims pending
    Retroactive denials
    Recoupments of overpayments
    Medical necessity and prior authorization timeframes and enrollee responsibilities
    Explanation of benefits
    Coordination of Benefits
  • On Market Only Capital Advantage Assurance Company® Keystone Health Plan® Central
    Number of Claims Received in Calendar Year 2015 47,073 59,081
    Number of Claims Denied in Calendar Year 2015 11,089 20,793
    Number of Internal Appeals Filed in Calendar Year 2015 7 46
    Number of Internal Appeals Overturned from Calendar Year 2015 Appeals 3 34
    Number of External Appeals Filed in Calendar Year 2015 0 0
    Number of External Appeals Overturned from Calendar Year 2015 Appeals 0 0