EMI Health is pleased to offer dental plans in Arizona’s Federal Health
Insurance Marketplace for Individuals. 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 negotiated rate.
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 negotiated rate.
Enrollee claims submission
EMI Health must receive written notice within 20 days after a claims
starts or as soon as reasonably possible. Except as otherwise provided in the
policy or by Arizona 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.
EMI Health will provide the Insured or the Provider with a claim form
within 15 days after receiving a notice of a claim. A dental claim form may also
be downloaded from www.emihealth.com
. To make a claim, the form should be completed and signed by the Provider
who performed the services and by the patient (or the parent or guardian if the
patient is a minor) and submitted to the address below. If EMI Health does not
send the Insured or the Provider a claim form within 15 days after notice
regarding a claim, the requirements for the proof of loss outlined in the Proof
of Loss section will be deemed to have been complied with, as long as the
Insured provides written proof that explains the type and extent of the loss
that he or she is making a claim for within the time established for filing
proof of loss.
5101 S Commerce Drive
Murray, Utah 84107
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.
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 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.
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. 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
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)
This plan does not include a Coordination of Benefits provision and
will not take the benefits of another plan into account when determining