Out-of-network liability and balance billing
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.
If the 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 address:
PO Box 21482
Eagan, MN 55121
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.
Upon the payment of a claim under this Policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom.
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.
A retroactive denial is the reversal of a previously paid claim, through which the insured may become responsible for payment. Claims can be denied retroactively for various reasons. The most common is because coverage was retroactively terminated. EMI Health will have the right to recover any payment made in excess of the Plan’s obligations, including retroactive denials. 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 and retroactive denials, 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 overpayments
Requests for 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. 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. In no case will EMI Health consider a refund for more than the 12-month period prior to the request. Requests for refunds of premium should be sent to the following address:
5101 S Commerce Drive
Murray, Utah 84107
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 Benefits (EOBs)
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 Administrative Code (U.A.C.) 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 U.A.C. 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 its benefits.