AmeriHealth offers a variety of products that hold members responsible for cost-sharing amounts (i.e., copayments, coinsurance, and deductibles) for covered services they receive. In addition, we have introduced several new products on the Health Insurance Marketplace and benefit changes that will go into effect on January 1, 2014. As a result, we would like to take this opportunity to remind you that cost-sharing varies based on the member's type of coverage and benefit plan and can include applicable cost-sharing for both facility and professional services. It is imperative that you ask members for their current health plan ID card and verify not only member eligibility but also cost-sharing amounts each time a member is seen (e.g., in the doctor's office, outpatient facility, emergency room/department, or inpatient facility). AmeriHealth routinely audits the claims we adjudicate to ensure they are paid accurately and in accordance with the member's benefit plan. Audits include, but are not limited to, ensuring appropriate application of cost-sharing. If a claim adjustment is required based on audit findings, it will be noted on the Statement of Remittance that you receive through the normal course of business.

Verifying member eligibility and cost-sharing amounts

To verify member eligibility and cost-sharing amounts, providers should use the Eligibility and Benefits Inquiry transaction on the NaviNet^® web portal. For information on using this transaction, please review the Eligibility and Benefits Inquiry Guide, which is available in the Upcoming System and Process Changes section of our site. If you are not NaviNet-enabled, you can sign up by going to the NaviNet website and selecting Sign Up at the top of the page. Note: Cost-sharing amounts are available to members through their benefit plan documents or by logging on to our secure member website, amerihealthexpress.com.

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