Obligations of Contract Providers

Prohibition Against Balance Billing

Contract Providers may only collect from a member that member’s applicable cost-sharing responsibility for a covered service.  Contract Providers may not collect any amount from a member for a covered service that exceeds the applicable contracted rate.  This includes any covered service which a member is solely responsible to pay either as part of a deductible or after a payment cap has been reached.

Pending or Disputed Claims

Other than for an amount collected at the time of service, Contract Providers may not seek payment from a member or instigate any form of collection action while a claim is pending or disputed.  Until a pending or disputed claims has been adjudicated, Contracted Providers may only seek to resolve concerns about a pending or disputed claim with PEHP, which may include the submission of a formal appeal. 

Add/Provider Responsibility for Denied Claims

Contract Providers may not seek payment from a member for a claim that was denied in whole or in part due to the failure of a contracted provider to:

1. Submit the claim to PEHP within 12 months from the date of service unless the provider was unaware of PEHP coverage due to the member’s failure to disclose or a longer (15 month) COB rule applies.  
2. Obtain authorization for a covered service unless the provider disclosed to the member before rendering services that  PEHP had denied authorization and the member knowingly agreed to pay for the denied services.
3. Follow proper coding rules in submitting the claim. 

Non-covered Services  

Contract Providers may provide non-covered services to a member for which the member is solely responsible for payment, provided that the Provider discloses to the member before rending services that the services are not covered by PEHP, the member knowingly agrees to pay for the non-covered services, and the Provider does not submit a claim for payment for the non-covered services  to PEHP.   

Practicing at Different Locations

PEHP’s contract with providers extends to any location in which the provider practices with a few exceptions. Contract Providers remain obligated to notify PEHP of any practice location change.