Claims payment information

Individual and family plans through the Health Insurance Marketplace

Get important information about HAP Personal Alliance® plans purchased through the Marketplace – from receiving care to filing claims.

For specific details about your benefits, please refer to your plan documents, which may include your contract, policy or booklet, any applicable riders and your Summary of Benefits and Coverage. To view your plan documents, log in at hap.org or request hard copies by calling Customer Service.

Filing claims

When you receive covered services from a HAP-affiliated provider, you should not have to pay for those services in advance. The provider is responsible for billing us directly within 12 months from the date of service.

Nonaffiliated providers may require you to pay in advance for services. When this happens, you can request reimbursement from us within 12 months of the date of service. You will need to submit proof of payment and an itemized bill or a completed Direct Member Reimbursement form to:

HAP Claims Division
Attention: Member Reimbursement
2850 West Grand Boulevard
Detroit, MI 48202

The form is available online. Log in and click on Member Resources under Quick Links.

You are responsible for satisfying all referral and precertification requirements described in your plan materials, regardless of whether we pay as the primary insurer or otherwise. If we are not your primary insurer, you have a responsibility to ensure that claims are submitted to your primary insurance carrier before they are submitted to us.

Explanation of Benefits

You may get an Explanation of Benefits statement in the mail after your claim is processed. The EOB will show your copay or coinsurance amounts, the eligible amounts applied to your deductible and 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 the back of your ID card. You may also view your EOBs, get claim processing details or sign up for paperless EOBs by logging in.

For more information about your EOB, 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 to affiliated and nonaffiliated providers. Failure to follow these requirements may result in nonpayment of benefits.

Inpatient services

You or your authorized representative must notify HAP within 48 hours of your admission. HAP will make a decision within 24 hours of the request.

  • For an emergency hospitalization, the facility or provider is responsible to notify HAP within 48 hours of your admission.
  • For care after a hospitalization (such as inpatient rehabilitation, skilled nursing facility, and long-term acute care), the facility 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, that 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 that a determination has been made that you require acute care as an inpatient due to the nature of the services rendered or your condition.

You may obtain clinical review criteria used to determine medical necessity. All requests must be sent in writing to:

Customer Service
Attention: Correspondence
2850 West Grand Blvd.
Detroit, MI 48202

Precertification

Certain services require precertification 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

Balance billing occurs when an out-of-network provider bills you for charges other than copays, coinsurance or deductibles.

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.

An emergency medical condition (including severe pain) starts suddenly and includes signs and symptoms so severe that a layperson with average knowledge of health and medicine could reasonably expect that the absence of immediate medical attention could 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 are medically necessary services provided to diagnose, treat and stabilize an emergency medical condition. Emergency services end when your emergency medical condition is stabilized.

In the event of an emergency, you don't have to be concerned about your coverage. As a member, you will have 24/7 coverage at any emergency room around the world.

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 go to an out-of-network doctor of facility. Even though we pay allowable charges, you may still be required to pay the balance between the allowable charges and the provider's actual charge for services you receive from an out-of-network provider.

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 on the first of each month of the coverage period to which they apply. Your plan provides a grace period for payment of premiums, depending on the type of plan you are enrolled in.

Three-month grace period

If you are enrolled in a HAP Personal Alliance plan through the Marketplace and you are receiving Advance Payments of the Premium Tax Credit, you are entitled to a grace period of three consecutive months.

Guidelines for three-month grace period
If: Then:

You have medical or pharmacy claims during the first month

HAP pays all claims for covered services. You are responsible for out-of-pocket costs (such as copays, coinsurance and deductibles).

You have medical or pharmacy claims during the second and third months

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.

You make a full payment of your outstanding premiums by the last day of the three month grace period

HAP pays all outstanding claims that occurred during the grace period.

Submit your pharmacy receipts to HAP for reimbursement.

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 first month of the grace period. You will then be responsible for the full cost of all health care services received in months two and three of the grace period.

One-month grace period

If you are enrolled in a HAP Personal Alliance plan through the Marketplace and you are not receiving APTC or you are enrolled in a HAP Personal Alliance plan outside of the Marketplace you are entitled to a grace period of one month.

Guidelines for one-month grace period
If: Then:

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.

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.

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.

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 or reimburse us in the event that we paid for 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 your coverage and what you need to do to restore it. All past due amounts must be fully paid by the due date to avoid losing your coverage and having your claims retroactively denied.

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, any overpayments will be shown as a credit on your account and 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 the back of your ID card to request a refund.

Pharmacy prior authorization and exceptions

Some medications included on our drug formulary (list of covered drugs) require that a determination is made as to the appropriateness of use, also called a medical necessity determination.

How to request a medical necessity determination

To request coverage for a drug that requires a determination, you must fill out a form and send it to:

HAP
Attention: Pharmacy Care Management
2850 W. Grand Blvd.
Detroit, MI 48202 

Or you can fax the form to (313) 664-8045. You may also call Customer Service at the number listed on your ID card if you need assistance with this process or to learn which drugs are covered for you. You can also get more information by logging 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 that 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 formulary, you or your doctor can request a formulary exception. We will evaluate this request based on the appropriateness of use (medical necessity) and availability of coverage (benefit determination). 

This request must include a supporting statement that the requested drug is medically necessary to treat your condition because the covered drugs on the formulary available to treat your condition are not as effective for you as the nonformulary drug or would harm you.

How to request a formulary exception

To request coverage for a medication not included on our formulary, you must complete a form and send it, along with a supporting statement, to:

HAP
Attention: Pharmacy Care Management
2850 W. Grand Blvd.
Detroit, MI 48202

Or you can fax the form to (313) 664-8045. You may also call Customer Service at the number listed on your card or log in if you need assistance with this process or to learn which drugs are covered for you.

If you or your doctor requests coverage for a nonformulary drug, we must make a decision within 72 hours. If you or your doctor thinks that 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

Do you currently have coverage for health care through more than one source? Coordination of benefits involves determining which health insurer or party will be responsible to pay for your health care services first. This is necessary for services you receive that are a benefit under more than one health plan or insurance carrier. This helps you maximize your coverage without duplicating payment for your health care, reduces the cost of health care and lowers out-of-pocket costs.

In most instances, the health plan with primary payment responsibility is the plan offered to you by your employer. Usually, if your spouse is employed and has health care coverage, your spouses' health care coverage has secondary payment responsibility for you. Both health plans offering you coverage coordinate how your benefits are paid. This means each health plan needs to know you have other health care coverage. It is best to contact your health plan to determine which plan has primary payment responsibility for your dependents.

Show me:

  • HAP's 5K Challenge

    Get a discount to run one of our 5K Challenge races.

  • New Member Orientation

    Learn how to get the most out of your HAP membership.

View all events
View all news

Contact us

  • Customer service

    (800) 422-4641

     

    Email

     

    More options

  • Individual and family plans

    Ready to join?

    (855) 948-4427

    HMO Plans

    (800) 759-3436

    PPO Plans

    (800) 944-9399

  • Insurance through your employer

    Alliance Health and Life Insurance Company®

    (888) 999-4347

    Self-funded / ASO

    (866) 766-4709

    HAP HMO

    (800) 422-4641

    HAP Midwest Health Plan

    (888) 654-2200

  • Medicare

    Ready to join?

    (800) 868-3153 TTY: 711

    HAP Senior Plus®

    (800) 801-1770 TTY: 711

    HAP Senior Plus® (PPO)

    (888) 658-2536 TTY: 711

    Alliance Medicare Supplement:

    (800) 873-7526 TTY: 711