Transparency in Coverage

What you need to know about using your Capital Health Plan (CHP) benefit plan

What is meant by out-of-network liability and balance billing?

A network is a group of health care providers that are contracted to treat CHP members at a specified rate that is usually much lower than the customary amount. Network providers include doctors, specialists, dentists, hospitals, surgical centers and other facilities. The member is responsible for the cost share based on their CHP benefit plan.

CHP is an HMO plan and offers very limited out-of-network benefits. Out-of-network care is covered only in an urgent care or emergency care situation or when prior authorized by CHP. Otherwise, you are responsible for the full cost of any care received out-of-network.

How can I find out how much a service or procedure will cost if I have not yet met my deductible?

For medical service cost estimates, we recommend you use a helpful online tool called Fair Health. It can be found at https://pricing.floridahealthfinder.gov. For specific estimates, unique to your situation and deductible status, you can contact CHP's Member Services Department via email at [email protected] or via telephone at (850) 383-3311, 8:00 am - 5:00 pm, Monday - Friday

If I am billed for a service that I think CHP should pay, what do I do?

There may come a time when you are billed for services you believe should have been covered by CHP or you are asked to pay for services at the time they are rendered. These could include emergency services or services received from non-contracted, out-of-network providers. There may also be a time when you feel a deductible, copayment, or co-insurance amount should not apply. Any time you receive a bill, or request reimbursement for a payment you have already made, you must submit these claims to CHP's Claims Department within six (6) months from the date service(s) were rendered. If it is not reasonably possible to submit a claim in the time required, CHP will not reduce or deny the claim for this reason if proof is filed as soon as possible. In any event, any claim for payment or reimbursement submitted by a member must be submitted no later than one (1) year after the date service(s) were rendered unless the member was legally incapacitated.

Capital Health Plan, Inc.
P.O. Box 15349
Tallahassee, FL 32317

To ensure a request for reimbursement is processed efficiently and accurately, the request must include the following:

  • A claim form, located here: Reimbursement Form
  • A copy of the paid receipt(s)
  • A copy of the billing statement reflecting the CPT codes and Diagnosis Code information

There may be situations when, in order to process your request, CHP will need additional information. This could include details regarding other Health Care or accident coverage you may have. It is important that you cooperate with CHP in any efforts made to obtain such information. These efforts include, but are not limited to, completion of a Coordination of Benefits form and/or signing Release of Information forms. Not cooperating with CHP in obtaining needed information related to your reimbursement request may result in a denial of your request.

What does it mean if there is a Retroactive Denial of a Claim?

A retroactive denial is the reversal of a previously paid claim where you may become liable for payment. Claims may be retroactively denied in certain situations including, but not limited to, the following:

  • If your coverage is retroactively terminated
  • If we determine you had other health care coverage that should have been the primary payer
  • If there was a provider billing error

There are things you can do to help prevent retroactive denials. You should be sure to pay your CHP premiums on time, be sure to let us know if there is other insurance (like health, auto, workers’ compensation) that should be the primary payer of your claim, or if you find that items on your bill do not match the services you actually received.

How do I obtain a refund of overpayment for drug costs?

If you have paid for a prescription drug and you think CHP should pay or you think you were overcharged for drugs, you should send your paid receipt and the Prescription Drug Reimbursement Form (located here: Form) to CHP's Claims Department within six (6) months from the date service(s) were rendered. When a member submits any request for medication reimbursement the request must include the following:

  • Copy of dated, paid cash register receipt.
  • Copy of the actual, dated, medication receipt indicating the name of the prescribing Physician, the patient's name, the name of the drug, quantity dispensed and the dosage

    CHP/Prime Therapeutics
    Commercial Claims Department
    P.O. Box 21870
    Lehigh Valley, PA 18002-1870

How do I obtain a refund if I overpay the amount I owe for my premium?

If you have paid for your monthly premiums and think you have overpaid and are due a refund, you should contact the CHP Premium Billing Department by telephone, email or in writing.

  • You can call (850) 383-3311 and press 2 to speak with a representative; or
  • Email us at [email protected]; or
  • Send your written premium refund request to:

    Capital Health Plan, Inc.
    Premium Billing
    P.O. Box 15349 Tallahassee, FL 32317-5349

Grace period for non-payment of premiums - FAQs

I understand that some exchange members qualify for a three-month "grace period" if they don't pay their premiums. What does that mean?

Some consumers who buy insurance on a public exchange will qualify for a subsidy to help pay the cost of their coverage. Once the consumer has paid at least one full month's premium during the benefit year, they'll qualify for a three-month grace period. This means that if any individual can't pay his/her premiums (after paying for at least one month in the benefit year) they will have three months to pay before insurers can cancel their coverage.

If I am an exchange member with a subsidy, and I stop paying my monthly premium, how will this affect payment of my claims?

Individual members who have not paid their monthly premium are considered delinquent.

  • The provider will be paid for services received during the first month of delinquency.
  • CHP will suspend payment of claims for services provided during the second and third months of the grace period.
  • If full payment is not received by the end of the third month, your coverage will be terminated retroactively to the end of the first month of the grace period, and CHP will not pay any suspended claims. We will deny payment.
  • You will be responsible for full payment of these denied claims. Any claims that CHP did pay will be re-opened and denied. We will ask the providers to pay us back what we paid and bill you instead.

What is an EOB?

EOB stands for "Explanation of Benefits." This is NOT a bill. The EOB is issued monthly in the CHP Member Portal, or you can request a copy by mail by calling the CHP Member Service Department at (850) 383-3311. Your monthly EOB includes information regarding all claims that CHP processed on your behalf during the previous month, regardless of the date the service was performed. It shows charges, CHP's payments and any amounts that you should pay to the provider along with how your claims have been applied to your year to date deductible and maximum out of pocket limits. CHP does not know whether or not you have paid your part of each claim to the provider. On the EOB, we are just telling you what you should have paid. If you paid the provider more than what is shown on your EOB, then the contracted provider must pay you back the difference. Providers receive the same payment information that appears on your EOB when we send them their payment, so they should be able to quickly refund your money if you paid them more than you should have. If you have not paid them what you owe, you will probably receive a bill from the provider. You should always pay the provider directly for any deductible, coinsurance or copayments that you owe.

If CHP has denied payment on a claim, the EOB will show that also. If we deny a claim and you are responsible for paying the provider for a service, we will send you a separate letter that fully explains why we denied the claim and how you can appeal our decision.

You should carefully review your EOB each month to make sure that any claims listed accurately reflect providers and services you have received under your CHP benefit plan. Please note that even if your plan allows you to obtain care from out-of-network providers through prior authorization, the services you receive still must be considered “medically necessary covered services” per your plans’ benefits. Otherwise, they will not be paid by CHP and you will be responsible for full payment of the services received. If you have a question about your EOB, or if you have trouble getting a refund from a provider that owes you money, you should call the CHP Customer Service number on the EOB for help and answers.

What does Coordination of Benefits (COB) mean?

COB stands for "Coordination of Benefits". Coordination of Benefits takes place between different insurance companies (health plans, auto insurance, worker's compensation, etc.). There are rules that all insurance companies follow (including CHP) when coordinating benefits with each other. These rules are used to decide which plan pays first for people who have more than one plan. This helps coordinate coverage and allows claim information to be shared by the plans. This way, the plans can avoid duplicate payments. If you have questions regarding COB, please call (850) 383-3311.

What does the term "medical necessity" mean?

Health plans like CHP provide coverage only for health-related services that we define or determine to be "medically necessary". These are services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.

Medical necessity also refers to a decision by CHP that your treatment, test, or procedure is necessary for your health or to treat a diagnosed medical problem. CHP will not pay for healthcare services that our review physicians deem to be not medically necessary. The most common example is a cosmetic procedure, such as the injection of medications (such as Botox) to decrease facial wrinkles or tummy-tuck surgery. CHP also will not cover procedures that our review physicians determine to be experimental, or not proven to work.

CHP will send you and your doctor a letter if we deny your request for coverage or payment because our review physician decided it was not medically necessary. We will tell you exactly what we denied and why. We will also provide you with information about how you can appeal our decision.

How can I know if CHP will cover a service or supply before the service is provided to me?

In order to be covered, certain referrals, requests for medical services/drugs or exceptions to CHP's drug formulary (list of covered drugs) must be reviewed by CHP before they are performed. Please click here for a list of items and services that require prior authorizations.

How long does it take for CHP to decide on coverage of medical services, drugs or exceptions to CHP's list of covered drugs requested by my doctor?

CHP will review these requests within the following timeframes:

Urgent Request - If your doctor feels that the service is needed urgently, they will tell CHP about the request and that it is needed quickly. CHP will approve, deny, or request an extension and notify your doctor of our decision about covering the requested service no later than 72 hours after the date the appropriate CHP Department receives the request.

Routine Request - If your doctor does not feel that the need for the service is urgent, they will tell CHP that the request is routine. CHP will approve, deny, or request an extension and notify you of our decision within 14 calendar days of the date the appropriate CHP department receives the request. We usually make these decisions faster than that.

Post-service Request - If you obtain services without the required prior review and a claim is received, this is considered a post-service request. CHP will approve, deny or request an extension within 30 calendar days of the date the appropriate CHP department receives the request. We usually make these decisions faster than that.

The time frame for both routine and urgent referral requests may be extended. Urgent referral requests may be extended an additional 48 hours, routine referral requests may be extended an additional 14 days, and a post-service request may be extended up to 45 days, for one or more of the following events:

  • CHP requires additional information that could be beneficial to the member
  • You or the requesting provider requests an extension up to 14 days to obtain additional information that he or she believes could be beneficial to the member

What are my responsibilities in the prior authorization process?

  • Provide accurate and complete information about your present complaints, past illnesses, medications, and unexpected changes in your condition.
  • Understand, ask questions, and follow recommended treatment plan(s) to the best of your ability.
  • Promptly respond to CHP's request for information regarding you and/or your dependents in relation to the prior authorization request.
  • If you are not sure about your role in the prior authorization process, you should speak with someone in the Member Services Department at (850) 383-3311 with questions regarding referrals and prior authorizations. The hours of operation are Monday -Friday, 8 a.m. - 5 p.m. Translation services are available to our non- English speaking members. For those with hearing impairment or speech loss, call TTY: (877) 870-8943.

What happens if I don't follow proper prior authorization procedures?

CHP will not pay for healthcare services that our review physicians deem to be not medically necessary. If you obtain services that we determine not to be medically necessary, you will have to pay the entire bill for these services. For members who do not have an out of network benefit, we also will not pay for routine covered services rendered by non- participating providers if you have not obtained proper CHP prior authorization. You will be financially responsible to pay the entire provider's bill. If you have an out of network benefit and choose to use a non-participating provider for routine care without prior CHP authorization, you will have to pay a higher out of pocket amount related to such services.

Important Information about Your Appeal Rights for Medical Services (Non-Pharmacy)

What if I need help understanding a denial? Contact us at 850-383-3311 or 1-877-247-6512 (TTY 850-383-3534 or 1-877-870-8943) if you need assistance understanding this notice or our decision to deny you a service or coverage.

What if I don’t agree with this decision? You have a right to appeal any decision not to provide or pay for an item or service (in whole or in part). You may appeal this decision up to 180 days after the date on your notification.

How do I file an appeal? Submit your appeal in writing, explaining the subject of the appeal and the reason you believe your request should be approved. Send the written appeal to CHP Appeals, P. O. Box 15349, Tallahassee, FL 32317 or submit in person to Member Services at 1264 Metropolitan Blvd, 3rd floor, Tallahassee, FL 32312. You may securely fax the information to 850-383-3413. See also the “Other resources to help you” section of this form for assistance filing a request for an appeal.

What if my situation is urgent? If your situation meets the definition of urgent under the law, your review will generally be conducted within 72 hours. Generally, an urgent situation is one in which your health may be in serious jeopardy or, in the opinion of your physician; you may experience pain that cannot be adequately controlled while you wait for a decision on your appeal. If you believe your situation is urgent, you may request an expedited appeal by following the instructions above for filing an internal appeal. You may also submit a simultaneous request for external review to the following location: Contact Medical Review Institute of America (MRIoA) at 1-800-654-2422. Written requests for external review should be mailed to Medical Review Institute of America, LLC, 2875 South Decker Lake Drive, Suite 300, Salt Lake City, UT 84119 or faxed to 1-801-261-3189.

Who may file an appeal? You, your treating provider or someone you name to act for you (your authorized representative) may file an appeal. If someone other than you or your treating provider files an appeal on your behalf, a signed Appointment of Representative (AOR) form must be included with the appeal. You may obtain a copy of the form by calling Member Services at 850-383-3311 or 1-877-247-6512 (TTY 850-383-3534 or 1-877-870-8943) or visiting our website at www.capitalhealth.com. The form is located here (Appointment of Representative Form).

Can I provide additional information about my claim? Yes, you may supply additional information by mail to CHP Appeals, P. O. Box 15349, Tallahassee, FL 32317 or submit in person to Member Services at 1264 Metropolitan Blvd, 3rd floor, Tallahassee, FL 32312 or by secure fax at 850-383-3413.

Can I request copies of information relevant to my claim? Yes, you may request copies (free of charge) using the Authorization to Use or Disclose Protected Health Information form. If you think a coding error may have caused this claim to be denied, you have the right to have billing and diagnosis codes sent to you, as well. You can request copies of this information by contacting us at 850-383-3311 or 1-877-247-6512.

What happens next? If you appeal, we will review our decision and provide you with a written determination. If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision.

Other resources to help you: You may contact the Florida Department of Financial Services, Division of Consumer Services at 1-877-693-5236.

Important Information about Your Appeal Rights for Pharmacy Services

How do I request an exception to the CHP ACA Compliant Formulary?

There are several types of exceptions that can be requested:

  • Exception to cover a drug that is not listed on the formulary (non-formulary drug)
  • Exception to waive a coverage restriction or limit on a drug (example: waive or increase quantity limit).

In the event your prescribing physician / provider determines that a drug that is not listed on the CHP Formulary (non-formulary drug) is a better choice to treat your condition, or a coverage restriction limit should be waived, the Prescribing Physician / Provider may request a Formulary Exception. Submit the request in writing, with the reason you believe your request should be approved or online here Coverage Exception Form. Send the written request to: CHP/Prime Therapeutics, LLC, Clinical Review, 2900 Ames Crossing Road, Eagan, MN 55121, or the request may be securely faxed to 1-855-212-8110.

What if I am not happy with CHP's decision regarding my formulary exception request?

If CHP denies the request, you, an authorized representative, or the prescribing provider, may appeal the decision.

What Do I Include With My Appeal?

You should include your name, address, member ID number, reasons for appealing, and any evidence that you wish to attach. You may include supporting medical records, doctors' letters, or other information that explains why we should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information per the instructions below, or present this information to our Member Services Department in person at 1264 Metropolitan Blvd, 3rd floor, Tallahassee, FL 32312.

How Do I File An Appeal?

For a Standard Appeal: You, your doctor, or your appointed representative (Appointment of Representative Form) should submit your request in writing, explaining the subject of the external review request and the reason you believe your request should be approved. Send the written request to CHP/Prime Therapeutics, LLC Clinical Review, 2900 Ames Crossing Road, Eagan, MN, 55121, or the appeal may be securely faxed to CHP/Prime Therapeutics, LLC, Clinical Review, 1-855-212-8110.

For a Fast Appeal:

If your situation meets the definition of urgent under the law, your review will generally be conducted within 24 hours. Generally, an urgent situation is one in which your health may be in serious jeopardy or, in the opinion of your physician; you may experience pain that cannot be adequately controlled while you wait for a decision on your external review. If you believe your situation is urgent, you may request an expedited external review by following the instructions above and documenting a request for a fast appeal.

What Happens Next?

If you request an external review, an Independent Review Organization (IRO) will review our decision and provide you with a written determination. For standard requests, the IRO will make a decision within 72 hours. If the independent review organization decides to overturn our decision, we will provide coverage or payment for your health care item or service.

As a CHP Member, you have the responsibility:

You Have a Right To:
  • Receive information about CHP, the services, benefits, member rights and responsibilities, and participating practitioners and facilities that provide care.
  • Receive medical care and treatment from practitioners and providers who have met the credentialing standards of CHP.
  • Expect CHP participating practitioners to permit you to participate in decision-making about your health care consistent with legal, ethical, and relevant patient- practitioner relationship requirements. If you are unable to fully participate in treatment decisions you have a right to be represented by your parents, guardians, family members, health care surrogates or other conservators to the extent permitted by applicable laws.
  • Expect health care practitioners who participate with CHP to provide treatment with courtesy, respect, and with recognition of your dignity and right to privacy.
  • Expect that CHP staff and services do not discriminate, exclude or treat people differently.
  • Expect that CHP provides services to assist people with disabilities.
  • Expect that CHP provides language services to assist members and providers to communicate effectively.
  • Communicate complaints or appeals about CHP or the care provided through the established appeal or grievance procedures found in your Member Handbook and the master policy or contract provided to your employer.
  • Have candid discussions with practitioners about the best treatment options for you no matter what the cost of the treatment or your benefit coverage.
  • Refuse treatment if you are willing to accept the responsibility and consequences of that decision.
  • Have access to your medical records, request amendments to your records, and have confidentiality of these records and member information protected and maintained in accordance with State and Federal law and CHP policies.
  • Make recommendations regarding CHP’s member rights and responsibilities policies.
  • Call or write us anytime with helpful comments, questions and observations, whether concerning something you like about our plan, or something CHP can improve upon. Expect to receive a response from CHP staff.
You Have a Responsibility To:
  • Seek all non-emergency care through your primary care physician (PCP), obtain a referral from your PCP for medical services by a specialist when required, and cooperate with those providing care and treatment.
  • Be courteous; respect the rights, needs and privacy of other patients, office staff and providers of care.
  • Supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care for you.
  • Understand your health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
  • Follow the plans and instructions for care that you have agreed to with your practitioners.
  • Ask questions and seek clarification to enable you to participate fully in your care.
  • Pay cost share and provide current information concerning your CHP membership status to any CHP participating practitioner or provider.
  • Follow established procedures for filing a complaint, appeal or grievance concerning medical or administrative decisions that you feel are in error.
  • Review and understand the benefit structure, both covered benefits and exclusions, as outlined in the Member Handbook. Cooperate and provide information that may be required to administer benefits.
  • Seek access to medical and member information through your Primary Care Physician, CHPConnect or through CHP Member Services.
  • Follow the coverage access rules in your Member Handbook.