Explanation of Benefits
To learn more about EOBs, please view our Understanding your Explanation of Benefits (EOB) statement video.
Claims payment information
Individual and family plans through HAP
To get the most you can from your health plan, it's important to know how your coverage works. You should also be aware of special rules - like when you need to contact us before you receive certain services and what happens if you don't pay your premium on time.
For details about your benefits, refer to your plan documents. These may include your contract, policy or booklet, applicable riders and your Summary of Benefits and Coverage. To view your plan documents, log in at hap.org. For more help understanding your coverage, contact Customer Service.
The information below applies to HAP Personal Alliance® plans bought through HAP.
Filing claims
A claim is the invoice your health care provider sends to HAP once you receive a service. When you get covered services from a provider who has a contract with HAP, you shouldn't have to pay for those services in advance. The provider should bill us within 12 months from the date of service.
Providers who do not have a contract with HAP may require you to pay in advance. When this happens, you can request reimbursement for covered services from us within 12 months of the date of service. You will need to submit proof of payment, an itemized bill and a completed Direct Member Reimbursement form. To access the form, log in and click on Member Resources under Quick Links.
For claims reimbursements for health care provided outside of the U.S., please use the Foreign Claims Reimbursement form. Medicare members must use the Medicare Foreign Claims Reimbursement form. For more information on foreign claims, please see this helpful FAQ.
Please mail these items to:
HAP Claims Division
Attention: Member Reimbursement
1414 E. Maple Rd.
Troy, MI 48083
You must follow any prior authorization requirements described in your plan materials. This is true whether we pay as the primary insurer or otherwise. If we are not your primary insurer, you are responsible for making sure your claims are submitted to your primary insurer before they are submitted to us.
Explanation of Benefits
You may get an Explanation of Benefits statement once your claim is processed. The EOB will show:
- Date of service
- Amount the provider charged for the service(s)
- Amount HAP paid
- Costs you are responsible for (copay, coinsurance, deductible)
- Any services that were not covered
The EOB is not a bill. It's an explanation of how your claim was processed. If you have questions about your EOB or how a claim was paid, call Customer Service at the number on your ID card. You can check your claims, view your EOBs or sign up for paperless EOBs by logging in.
Once logged in:
- Check your claims or view your EOBs by selecting My Claims and EOBs
- Sign up for paperless EOBs by selecting Paperless Options
To learn more about EOBs, please view our Understanding your Explanation of Benefits (EOB) statement video.
What to know before you receive care: Prior authorization and medical necessity
It's important to understand your health plan's approval process before you have any services performed.
Your plan has requirements that must be followed before scheduling certain medical treatments and inpatient admissions. These requirements apply whether or not the provider has a contract with HAP. If you don't follow these requirements, we may not pay your benefits for these services.
Inpatient services
- Elective inpatient hospital admissions: Your provider must contact HAP before you are admitted to obtain prior authorization. For elective admissions, HAP will make a decision within 15 days of the request. For medically urgent requests, HAP will make a decision within 72 hours of the request.
- Emergency hospitalizations: The facility or provider must notify HAP within 48 hours after your admission.
- Care after a hospitalization (such as inpatient rehabilitation, skilled nursing facility and long-term acute care): The discharging facility or provider will obtain authorization prior to your discharge.
Outpatient services
HAP or its designated representative will provide a decision within 15 calendar days from the date of the request. If the request is submitted as urgent, a decision will be made with 72 hours of the time of the request.
Medical necessity
Medical necessity is based on well-established professional medical standards, as reflected in scientific and peer-reviewed medical literature. It means covered services are:
- Consistent with, and essential for, diagnosis and treatment of your condition or injury
- The most appropriate supply or level of service that can be provided safely
- Provided for the diagnosis or direct care and treatment of your condition or injury
- Not provided primarily for your convenience or the convenience of your family, doctor or other caretaker
- More likely to result in benefit rather than harm
A medically necessary hospitalization means we've determined you require acute care as an inpatient due to the nature of your condition or the services given.
You may request the criteria we used to make this decision. All requests must be sent in writing to:
Customer Service
Attention: Correspondence
1414 E. Maple Rd.
Troy, MI 48083
Pre-authorization
Certain services require pre-authorization from us before they will be covered. See your plan materials for more details. If you do not follow these requirements or you obtain services in excess of what is approved, those services may not be covered.
Paying for care outside of your network
Your out-of-network coverage depends on the specific plan you choose. Some plans cover care outside of your network with higher out-of-pocket costs. Other plans don't cover care received outside of your network except for medical emergencies.
In the event of an emergency, you don't need to be concerned. As a member, you have 24/7 coverage at any emergency room around the world.
Emergency medical condition: Starts suddenly and includes signs and symptoms so severe, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to your health or to a pregnancy in the case of a pregnant woman, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part.
Emergency services: Medically necessary services provided to diagnose, treat and stabilize an emergency medical condition. Emergency services end when your emergency medical condition is stabilized.
Coverage for dependents away at school: Children ages 17 to 25 on your plan who are off at school are covered through our “Students Away at School” program. Dependents away at school have access to emergency or urgent care services. While your student is outside of HAP’s service area, authorization is needed for all services, except emergency or urgent care. Because we don’t cover routine doctor visits while your child is away at school, make sure to schedule these appointments during holidays, summer breaks or other times when your child is home. To learn more, click here.
If your plan doesn't cover out-of-network care but you can't get the treatment you need in your network, HAP may approve you to see an out-of-network doctor or facility. Even though we pay allowable charges, you may still be required to pay the difference between the allowable charges and the provider's actual charge for services you receive from an out-of-network provider. This is referred to as balance billing. Balance billing does not include your copays, coinsurance or deductibles.
No charges in excess of allowable charges will be reimbursed for covered services. Covered services are subject to copays, coinsurance, deductibles and out-of-pocket limits as described in your plan materials. Covered services may be limited by maximum benefits allowed under state and federal law.
Grace periods
To access your benefits and maintain coverage, you must pay your first premium payment before the effective date of your coverage or as otherwise indicated on your initial invoice.
Once your coverage is effective, monthly premium payments are due the first of each month of the coverage period to which they apply. Your plan provides a grace period for payment of premiums. The type of grace period depends on the type of plan you are enrolled in.
One-month grace period
If you are enrolled in a HAP Personal Alliance plan through you are entitled to a grace period of one month.
| If: | Then: |
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You have medical or pharmacy claims during the grace period |
Medical: Your claims are pended, which means they are put on hold until you pay your premiums in full. Doctors and other medical providers may require you to pay the full cost for all services up front. Pharmacy: Your claims are denied. You pay for the full cost of all services. Save your receipts so you can submit them for reimbursement after your full balance is paid. |
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You make a full payment of your outstanding premiums before the last day of the one month grace period |
HAP pays all outstanding claims that occurred during the grace period. Submit your pharmacy receipts to HAP for reimbursement. |
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Termination of coverage:If you do not pay your premiums in full before the end of the grace period, your coverage will be retroactively terminated to the last day of the month prior to the beginning of the grace period. You will then be responsible for the full cost of all health care services received after the termination date. If you return to HAP, you may be responsible for premium payments owed within the last 12 months. |
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Retroactive denials
A retroactive denial is the reversal of a previously paid claim. Other than during the grace period, you are not entitled to any covered services during any period of time in which you have not paid your premium. If you receive covered services during such a time, you must pay the provider for the full cost of these services.
If your coverage is terminated, we reserve the right to offset any premium refunded to you by an amount equal to what we have paid for covered services.
You can prevent a retroactive denial by paying your premium in full by the due date listed on your invoice. If you do not pay the full amount on time, you will also receive a letter(s) from HAP with important information about how to avoid losing your coverage and having your claims retroactively denied.
In addition to not paying your premium, there are several other reasons why we may retroactively deny a claim that we’ve already paid:
- Your HAP Personal Alliance plan was retroactively terminated because you obtained other coverage during an open or special enrollment period, or you’re no longer eligible for coverage
- Your HAP Personal Alliance health plan has been rescinded (cancelled) due to fraud or misrepresentation on your part
- After paying a claim, we discover that we incorrectly paid the claim due to a system error
- After paying a claim, we discover fraud, waste or abuse by a provider or someone other than the member and must retroactively deny the claim
Premium overpayments
Premium payments are due on the first of the month or as otherwise indicated on your monthly invoice. If you were overbilled for any reason or are due a refund as a result of retroactive changes, you may be entitled to a refund or a credit toward future premium payments.
- If your policy is terminated, you will be refunded any overpaid premiums.
- If your policy is active, overpayments will be shown as a credit on your account. The credit will be applied to future premium payments. If you would prefer to receive a refund of those overpaid premiums, you can contact Customer Service at the number on your ID card to request a refund.
Pharmacy prior authorization and exceptions
Some medications included on our drug formulary (list of covered drugs) require us to decide that the drug is appropriate to use. This is called a medical necessity determination.
How to request a medical necessity determination
To request coverage for a drug that requires a determination, please ask your doctor to fill out a form and send it to:
HAP
Attention: Pharmacy Care Management
1414 E. Maple Rd.
Troy, MI 48083
Or you can fax the form to (313) 664-8045. If you need help with this process or want to learn which drugs are covered for you, call Customer Service at the number listed on your ID card or log in.
If you or your doctor requests coverage for a medication, we must make a decision within 15 calendar days. If you or your doctor thinks waiting for a standard decision could seriously harm your health or your ability to function, you can request an urgent decision. We must respond to your request for an urgent decision within 72 hours.
If a drug your doctor prescribed is not on our list of covered drugs, you or your doctor can request a formulary exception. We will evaluate this request based on the medical necessity and your specific benefits.
This request must include a supporting statement that the requested drug is medically necessary to treat your condition because other covered drugs aren’t as effective for you or would harm you.
How to request a formulary exception
To request coverage for a medication not included on our formulary, please ask your doctor to fill out a form and send it, along with a supporting statement, to:
HAP
Attention: Pharmacy Care Management
1414 E. Maple Rd.
Troy, MI 48083
Or you can fax the form to (313) 664-8045. If you need help with this process or want to learn which drugs are covered for you, call Customer Service at the number listed on your ID card or log in.
If you or your doctor requests coverage for a drug that is not on our list of covered drugs, we must make a decision within 72 hours. If you or your doctor thinks waiting for a standard decision could seriously harm your health or your ability to function, you can request an urgent decision. We must respond to your request for an urgent decision with 24 hours.
How we coordinate benefits
If you have health coverage through more than one source, we need to know who should pay your claims first. This process is called coordination of benefits. It helps you get the benefits you're entitled to while reducing health care costs.
In most cases, the health plan that should pay first is the plan offered to you by your employer. Usually, if your spouse is employed and has health care coverage, your spouses' health plan will pay second for you. Both health plans offering you coverage coordinate how your benefits are paid. This means each plan needs to know you have other health care coverage. It is best to contact your health plan to find out which plan should pay first for you and your dependents.
Let us know about your other health care
If you are covered under another plan besides HAP, log into the HAP member portal and download the Membership COB Data Collection and let us know about your other health care coverage. You can find the form under My Care → Coordinating with Other Coverage.
Other resources available
Auto Related Coverage
Contact your automobile insurer for information about health coverage on your automobile insurance policy. Depending on the type of automobile coverage you selected, your auto insurance may by your primary coverage for related health care expenses.
Liability
Contact your liability insurer. Your liability insurer may be responsible for some of your medical or prescription coverage.