EMI Health is pleased to offer dental plans in Utah’s Federal Health
Insurance Marketplace for Individuals and the Small Business Health Options Program (SHOP). The information below outlines some
important aspects of the EMI Health plans. Enrollees will receive a formal
policy and are encouraged to read it in its entirety.
Out-of-network liability and
The Plan uses a Preferred Provider Organization. A Participating
Provider is a Provider who has an agreement in effect with the Preferred
Provider Organization (PPO) to accept a reduced rate for services rendered to
Insureds. This is known as the negotiated rate or table of allowance. The
Participating Provider cannot bill the Insured for any amount in excess of the
negotiated rate. The Insured may obtain a copy of the directory of
Participating Providers at www.emihealth.com or by calling 801-262-7475.
Although benefits under the Plan are generally greater for services
provided by Participating Providers, the choice to use a Participating Provider
or Non-participating Provider is entirely up to the Insured. If the Insured elects to receive services from a Non-participating Provider, the Insured will be responsible for amounts exceeding the Table of Allowance.
In the unlikely
event that there is no Participating Provider available within the Insured’s
county to perform the services needed, Insureds may contact EMI Health’s customer
services department at 801-262-7475 for assistance finding a Participating
Provider near them. If there are no Participating Providers within the time and
distance requirements, claims will be paid as participating up to the table of
allowance for Non-participating Providers in closer proximity to the Insured
than the nearest Participating Provider of the same specialty. The Insured will
be responsible for amounts exceeding the table of allowance.
Enrollee claims submission
Except as otherwise provided in the policy or by Utah law, no benefits
provided under the policy shall be paid to, or on behalf of, an Insured unless
the Insured, or his authorized representative, has first submitted a written or
Electronic Data Interchange (EDI) claim for benefits to EMI Health. Claims may
be submitted at any time within 12 months of the date the expenses are
incurred. If, however, the Insured shows that it was not reasonably possible to
submit the claim within that time period, then a claim may be submitted as soon
as reasonably possible. Failure to give notice does not bar recovery under the Policy if EMI Health fails to show it was prejudiced by the failure.
provider fails to submit a claim for services directly to EMI Health, the
Insured may submit a properly completed and coded bill to the following
852 East Arrowhead Lane
Murray, Utah 84107-5298
A dental claim form may be downloaded from www.emihealth.com under Member Forms.
If the claim form is not properly completed, it cannot be processed, and it
will be returned. For additional information, contact EMI Health’s customer
service department at 801-262-7475 or toll free at 800-662-5851.
Grace periods and claims pending
policies during the grace period
A Grace Period is the period that shall be granted for the payment of
any policy charge, during which time the policy shall continue in force. In no
event shall the Grace Period extend beyond the date the policy terminates.
A 30-day Grace Period will be granted for payment of premiums accrued
after the first premium has been paid. EMI Health may discontinue coverage
under the policy at the end of the 30-day Grace Period or 30 days following the
date on which EMI Health mailed written notice of termination. Partial payment
will be treated as nonpayment, unless EMI Health, at its sole discretion,
indicates otherwise in writing. During the Grace Period, the policy will remain
in force, but the Insured will be liable to EMI Health for premiums accrued
during that period.
For recipients of advance payments of the premium tax credit,
nonpayment of premiums within a
90-day Grace Period following the due date specified above, EMI Health
may discontinue coverage under the policy at the end of the 90-day Grace Period
following 30 days written notice of termination.
During the Grace Period, the Policy shall continue in force, however,
any claims received for services rendered after the first month of the Grace
Period, will be held for processing (pended) until Policy charges are paid in
full. The Subscriber will remain liable to pay the premium including premium
for the Grace Period, and Insureds will continue to be responsible for paying
all Copayments, Coinsurance, and Deductibles, as applicable.
EMI Health will have the right to recover any payment made in excess of
the Plan’s obligations. Such recoveries must be initiated within 12 months (or
24 months for a Coordination of Benefits claim) from the date a payment is made
unless the recovery is due to fraud or intentional misrepresentation of
material fact by the Insured. This right of recovery applies to payments made
to the Insured or to the provider. If such overpayment is made to the Insured,
he or she must promptly refund the amount of the excess. If the overpayment is
made to a provider, and attempts to recover overpayments from said provider are
exhausted, the Insured may be responsible for reimbursement to EMI Health. EMI
Health may, at its sole discretion, offset any future benefits against any
overpayment. In order to avoid overpayments, it is important for the Insured to
take responsibility in paying premiums on time and reporting to EMI Health any
changes in the status of other insurance coverage.
Enrollee recoupment of
premium adjustments (whether the result of error, administrative delay, or any
other cause) requiring the return of unearned prepaid premiums to the Insured,
must be in writing and be received by EMI Health the month prior to the end of
coverage. Coverage will terminate at midnight on the last day of the month that
the written request for termination is received. Prepaid premiums for periods
extending after coverage ends may be refunded. EMI Health will not refund any
premiums paid for periods in which there was coverage. EMI Health may request
evidence that an adjustment is necessary. Requests for
refunds of premium should be sent to the following address:
852 East Arrowhead Lane
Murray, Utah 84107-5298
Medical necessity and prior authorization
timeframes and enrollee responsibilities
EMI Health dental plans do not require prior authorization of services;
however, before starting a dental treatment for which the charge is expected to
be $300 or more, a predetermination of benefits is recommended. To obtain a
predetermination, the dentist must itemize all recommended services and costs
and attach all supporting documents, including x-rays. EMI Health will notify
the dentist of the benefits payable under the Plan. The Insured and the dentist
can then decide on the course of treatment, knowing in advance how much the
Plan will pay. The Plan does not cover cosmetic treatment or services that are
not medically necessary.
Information on Explanations of
EMI Health will send an EOB to the Insured following the receipt and
adjudication of a claim. An EOB is a statement explaining the treatments for
which the Plan paid on behalf of the Insured, the amount of the Plan’s payment,
and the Insured’s financial responsibility pursuant to the terms of the policy.
For information on how to read your EOB, click here.
Coordination of benefits (COB)
When an Insured is covered by an EMI Health plan and another COB plan,
one plan is designated as the
Primary Plan. The Primary Plan pays first and ignores benefits payable
under the other plan. The Secondary Plan reduces its benefits by those payable
under the Primary Plan. Any COB Plan that does not contain a Coordination of
Benefits provision that is consistent with Utah Rule R590-131 (Non-conforming
Plan) will be considered primary, unless the provisions of both plans state
that the Conforming Plan is primary.
If a person is covered by two or more plans that have Coordination of
Benefits provisions, each plan determines its order of benefits using Utah Rule
R590-131. A COB Plan that does not include a Coordination of Benefits provision
may not take the benefits of another COB Plan into account when it determines