Ambetter Balance Billing Reminder

Balance billing occurs when a participating provider bills a member for charges above and beyond a member’s copayment, coinsurance and/or deductible  for covered services under the member’s benefit program, or for services denied by Ambetter of Illinois (“Ambetter”).

Payments made by Ambetter to providers less any copays, coinsurance, or deductibles which are the financial responsibility of the member, will be considered payment in full. Providers may NOT seek payment from Ambetter of Illinois members for the difference between the billed charges and the contracted rate paid by Ambetter.

Network providers may also not balance bill members for covered services when the provider fails to obtain an authorization and the claim is denied by
Ambetter.

No Balance Billing:Out of Network – ER Services

DO: if a member goes to Out of Network - ER and if it is NOT a true emergency, then the member is responsible for any
amount above what Ambetter IL plan covers and CAN be balance billed.
DON’T: If a member goes to Out of Network - ER and if it IS a true emergency, then the member CANNOT be balance billed for any amount above what Ambetter IL plan covers.

Emergency (Medical, Behavioral Health, and Substance Use) Services

This means covered inpatient and outpatient services that are (1) furnished by a provider qualified to furnish these services and (2) needed to evaluate or stabilize an emergency medical/behavioral health condition. An emergency medical/behavioral health condition means a medical, mental health, or substance use-related condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following: (1) Placing the physical or behavioral health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part; (4) Serious harm to self or others due to an alcohol or drug use emergency; Injury to self or bodily harm to others; or with respect to a pregnant woman having contractions: (1) that there is inadequate time to effect a safe transfer to another hospital before delivery, or (2) that transfer may pose a threat to the health or safety of the woman or the unborn child.

Eligible Service Expense

This means a covered service as determined below.

  1. For network providers: When a covered service is received from a network provider, the eligible service expense is the contracted fee with that provider.
  2. For Non-Network providers: 
    • When a covered service is received from a non-network provider as a result of an emergency, the eligible service expense is the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full (member may not be billed for the difference between the negotiated fee and the provider’s charge). Emergency care received from a non-network provider will be paid at no greater out-of-pocket to the member than had a network provider been utilized. However, if the provider has not agreed to accept a negotiated fee as payment in full, the eligible service expense is the greatest of the following (member MAY NOT be balance billed by the provider)
    • When a covered service is received from a non-network provider as approved or authorized by us that is not the result of an emergency, the eligible service expense is the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full (member MAY NOT be billed for the difference between the negotiated fee and the provider’s charge).
    • When a covered service is received from a non-network provider because the service or supply is not available from any network provider inmember’s service area and is not the result of an emergency, the eligibleservice expense is the negotiated fee, if any, that the provider has agreedto accept as payment in full (member MAY NOT be billed for the difference between the negotiated fee and theprovider’s charge).

2021 Provider Manual (PDF) 

Provider Toolkit