Ascension_Personalized_Care_ACA_health_plan_transparency_in_coverage

Transparency in coverage

Ascension Personalized Care is dedicated to delivering compassionate, personalized care. We are here to help you get the information you need to make the right health care decisions for you and your family. We offer all of our plan members complete transparency in healthcare coverage.
  • Out-of-network services and balance billing

    To receive benefits from coverage, members must use a network doctor. However, payment will be made at the network doctor level of benefits for services provided by an out-of-network doctor when the services are provided for a medical emergency. Ascension Personalized Care will provide the member with listings of in-network doctors in the Ascension Personalized Care service area. The member is responsible for choosing their doctors for health care services.  


    For covered emergency services, members will pay in-network cost sharing (copayment, coinsurance and deductible).  Members will also pay in-network cost sharing for services provided by some out-of-network doctors (such as anesthesiologists or pathologists) that provide services at a network hospital or if the out-of-network doctor provides certain services at in a network hospital or facility and does not notify the member of their out-of-network status.  These out-of-network doctors are also prohibited from billing the member for any amounts in excess of the member’s cost sharing responsibility. 

  • Nonpayment of premium and grace period for premium tax credits

    Members must pay all monthly premiums to Ascension Personalized Care when they are due. If payments are late, Ascension Personalized Care will provide a notice to members with information on how to keep coverage. This includes paying all premiums owed by the end of the grace period as defined below.


    For members not receiving advanced premium tax credits (APTC), Ascension Personalized Care provides a grace period of 30-days for payment of monthly premiums (this does not include the first binder premium payment). Coverage will continue during the 30-day grace period. If Ascension Personalized Care does not receive the entire premium amount that is due by the end of the grace period, coverage will be cancelled back to the last day of the grace period. Members may be responsible to Ascension Personalized Care for the payment of the portion of the premium for the time coverage was in effect during the grace period.


    For members receiving an APTC, Ascension Personalized Care provides a grace period of 90-days if the member has previously paid at least one full month’s premium during the benefit year. During the grace period Ascension Personalized Care will:

    •       • Pay all appropriate claims for services rendered to the member during the first month of the grace period and may pend (hold) claim
              payment for services rendered to the member in the second and third months of the grace period;
    •       • Notify Health and Human Services (HHS) of such non-payment; and
    •       • Notify doctors of the possibility of denied claims when a member is in the second and third months of the grace period.

    If a member receiving APTC reaches the end of their 90-day grace period without paying all outstanding premiums, we will notify the member that coverage will be cancelled. The last day of coverage will be the last day of the first month of the 90-day grace period. Members will be responsible for payment of all charges for claims that were pended or paid during the second and third month of the grace period.

  • Member claims submissions

    Ascension Personalized Care in-network plan doctors file claims for members after they receive services.  Claim forms can only be submitted to Ascension Personalized Care by doctors for Ascension Personalized Care members.  


    To contact customer service, please call 833-600-1311.

  • Member recoupment of overpayments
    Members can dispute premium charges or payments by contacting customer service at 833-600-1311. 
  • Medical necessity and prior authorization

    A prior authorization is an approval from your health plan. It may be required before you are able to fill a prescription or receive a medical service. Please call us at 844-995-1145 to obtain a prior authorization.


    Prior authorization review is intended to confirm the medical necessity, as defined in your policy, of a setting, service, treatment, supply, device, or prescription drug. If a setting, service, treatment, supply, device, or prescription drug is listed below, prior authorization review must be obtained before incurring any claims for that setting, service, treatment, supply, device, or prescription drug. You are responsible for obtaining prior authorization review when required. You can obtain prior authorization review by contacting us at:


    Seton Health Plan Medical Management

    1345 Philomena St., Suite 305

    Austin, TX 78723

    Phone: 844-995-1145

    Fax: 512-380-7507

    Email: SHP-Authorization@ascension.org

    Prior authorization is not a guarantee that benefits will be payable. All benefits payable are subject to all of the terms, conditions, provisions, exclusions, and limitations of the Policy.


    The following settings, services, treatments, supplies, devices, or prescription drugs require prior authorization review:

    •       • Inpatient admissions (including acute care, long term acute care- behavioral health and/or substance abuse use disorder rehabilitation,
              residential treatment and partial hospitalization; skilled nursing facility).
    •       • Emergency admissions within 48 hours following admission
    •       • High risk maternity (routine that exceeds federal requirements)
    •       • Outpatient surgical procedures
    •       • Oral pharynx procedures
    •       • Spinal procedures
    •       • Diagnostic radiology
    •       • Therapeutic radiology
    •       • Neuropsychological testing
    •       • Orthotics and prosthetics
    •       • Durable medical equipment (including DME items more than $1000)
    •       • Hearing (EAR) devices
    •       • Transplants (other than corneal transplants)
    •       • Home health care
    •       • Home infusion therapy
    •       • Rehabilitative and habilitative outpatient therapy
    •       • Injectable medications (administered by a healthcare doctor)
    •       • Genetic testing

    *Potential experimental or investigational treatment, testing or procedures

    *List of services requiring prior authorization is not all inclusive.


    Failure to utilize or abide by the decisions of the Utilization Management Program will result in the denial of the claim for failing to prior authorize in advance of the proposed procedure or admission.

  • Information of Explanation of Benefits (EOB)

    An EOB is a helpful tool for keeping track of your Ascension Personalized Care healthcare benefits. It shows you how your health plan processed a healthcare claim. EOBs look similar to a bill, but they function differently. The EOB will be in the form of a letter that includes a chart showing how your claim was processed. Always check your EOB, and make sure the information displayed is accurate. If any information is missing or if you have questions regarding your EOB, contact the customer service number located on the back of your member ID card.


    See the list below of key elements included in your EOB:

    •       • Name of patient: Make sure your name or the name of another person who is covered by your health plan is displayed on the EOB. 
    •       • Insured ID number: This should match the number on your member ID card. 
    •       • Claim number: The number by which you and your health plan will be able to refer to a claim should you have questions or concerns. 
    •       • Provider: The name of the healthcare provider who provided this service. This could be the name of a specific doctor, or of a hospital or
              other location. 
    •       • Date of service: The start and end date of the service. 
    •       • Type of service: A description of the service received. 
    •       • Healthcare provider charge: The amount billed to your health plan by the healthcare provider. 
    •       • Cost covered by your health plan: The total your health plan paid for your services. 
    •       • What you owe: Any balance the healthcare provider billed that was not covered by your health plan.
  • Coordination of Benefits (COB)
    The Coordination of Benefits (COB) provision applies when a person has health care coverage under more than one plan. The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits in accordance with its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. The secondary plan may reduce the benefits it pays so that payments from all plans does not exceed 100% of the total allowable expense.