Exchange Notices

The information on this page applies to health plans with a January 1, 2017 effective date. This information is subject to change pending review by state and federal regulators.

Nevada - Health Insurance Marketplace/Exchange Notices – Claims Payment Policy Information

Out-of-network liability and balance billing

Health Plan of Nevada does not cover out-of-network services except as specifically described in your Schedule of Benefits. If you see a provider outside of our network, you may be responsible for the full cost of any medical services and/or pharmacy prescriptions.

When you are outside of our service area or network, Health Plan of Nevada covers emergency services or urgently needed services up to the allowed allowance from the Health Plan of Nevada reimbursement schedule.

You may also be responsible for the difference between the amount billed by any out-of-network provider and the amount Health Plan of Nevada would pay a network provider. This is called balance billing. The difference will not apply to your out-of-pocket maximum or your coinsurance maximum.

Claims Submission

Most providers will bill Health Plan of Nevada directly. If you see a provider outside of our network, you may have to submit the claim yourself.

All claims must be submitted to Health Plan of Nevada within sixty (60) days from the date expenses were incurred. If you're asked to submit the claim, please only complete Section 1 of the Nevada claim form. Your provider must fill out Section 2.

In addition, please include copies of any applicable itemized bills and/or receipts from your provider. The itemized bill must include the following information:

  • Name, address, and tax ID number
  • Date of service
  • Diagnosis
  • Description of services and/or standardized codes rendered
  • Itemized charges for each service

Non-Plan Provider Claim Forms can be obtained by contacting the Member Services Department at 1-877-752-8026, TTY 711, Monday through Friday, 8 a.m. to 5 p.m. local time.

Send the completed form and copies of corresponding bills and/or receipts to:

Health Plan of Nevada
Claims Department
P.O. Box 15645
Las Vegas, NV 89114-5645

Grace periods and claims pending during the grace period

Your coverage can end if you fall behind in paying your monthly health insurance premium. But before your coverage can end, you have a short period of time to pay called a “grace period.”

How the grace period works

If you get federal financial assistance in the form of an Advance Payment of Tax Credit (APTC), and have paid at least one month’s premium during the benefit year, you will be given a 3-month grace period to pay your premium. To keep your coverage, you must pay all premiums owed in full before the 3-month grace period ends. Your coverage will end if you don’t pay your premiums in full before the grace period ends.

Health Plan of Nevada will pay claims for covered health services during the first month of the grace period. In the second and third months of the grace period, claims will be pended. This means that no claims will be paid or processed in these months unless full premium payment is received by the end of the 3-month grace period.

If you don’t qualify for an APTC, you’ll have a grace period of one month but only if you paid your first premium. During the grace period, you will still have coverage. If full payment is not received within this one month grace period, your coverage will be canceled, and you will be responsible for the cost of services received during the grace period. 

Retroactive denials

Claims are processed when a provider sends Health Plan of Nevada a claim for payment and is based upon eligibility at the time of processing. If your coverage ends after a claim is processed, the claim may be reprocessed and denied if the services were completed after the date your coverage ended.  This could happen if coverage has ended because payment was not received on time or if your subsidy amount changes and the full premium payment were not received.

Retroactive denials can be prevented by paying premiums on a timely basis.

Getting your money back if you overpaid

If you have paid too much on your premium, please call 1-877-752-8026, TTY 711, Monday through Friday, 8 a.m. to 5 p.m. local time.

Medical necessity and prior authorization timeframes and member responsibilities

Your provider may prescribe a health care service, treatment, equipment or medication which requires review and approval. This process is called prior authorization, and the goal is to ensure you receive the most appropriate, medically necessary care. All requests for prior authorization must be initiated by your provider.

If you don’t get prior authorization as required, you may be responsible for paying for certain benefits and services. Prior authorization must be obtained before a scheduled service as soon as reasonably possible. 

All requests requiring a medical or clinical decision are reviewed by a licensed physician or under the supervision of one. Furthermore, only a physician may deny a request. Prior Authorizations may take up to fifteen calendar days or longer if additional information is needed. Review your plan documents to determine which services require prior authorization.

You or your provider may file an appeal if coverage is denied. To appeal a decision, mail a written request within 180 days from the date of the denial to: 

Health Plan of Nevada
Member Services
P.O. Box 15645
Las Vegas, NV 89114-5645

Drug exceptions timeframes and member responsibilities

When a prescription drug isn’t covered, you may submit a medical necessity request form or your provider may call 702-242-7050

A standard request will be responded to within 72 hours. If your request needs immediate action and a delay could significantly increase the risk to your health, or the ability to regain maximum function, call us as soon as possible. We’ll provide a written or electronic determination within 24 hours.

Information on Explanations of Benefits (EOBs)

The Explanation of Benefits (EOB) is a statement sent to you that shows what medical treatments and services were paid on behalf of the member. These statements are not bills.

An EOB describes:

  • The provider that was paid
  • The service that was provided to the member
  • The Date of Service or date of the visit
  • The date the claim was processed and paid
  • The charges of the provider
  • The amount that is allowed
  • The member’s cost share: Copay, Coinsurance and/or Deductible based upon the benefit
  • Reasons for adjustments
  • Appeals options or next steps if the member

If you have any questions, please call Member Services at 1-877-752-8026, TTY 711, Monday through Friday, 8 a.m. to 5 p.m. local time.

Coordination of Benefits (COB)

Coordination of Benefits is a way to figure out who pays first when two or more health insurance plans are responsible for paying the same medical claim. If you have more than one health plan, your plan documents will tell you which plan pays first, called the primary plan, and which plan pays second, called the secondary plan.