Transparency in Coverage and Cost-Sharing

Paramount Insurance Company (Paramount) is a health maintenance organization (HMO) licensed in Ohio. When you enrolled in Paramount, you selected or were assigned a Primary Care Provider (PCP) for yourself, and for each Member of your family. Your PCP will coordinate your medical care with other Participating Providers in the Paramount network. If your Primary Care Provider believes you need to see a specialist - a cardiologist, orthopedist or others - your Primary Care Provider will recommend a Participating Specialist. Or you may choose the Participating Specialist you wish to see from those listed in the Participating Physicians and Facilities directory (also available on the website) and make an appointment. You will be held financially responsible if your selected Specialist (and/or hospital/facility where services are rendered) is non-Participating and an out-of-plan Prior Authorization was not obtained. If a medically necessary covered service or procedure is not available from any Participating Providers, Paramount will make arrangements for an “out-of-plan Prior Authorization”. It is the responsibility of the Participating Provider to obtain Prior Authorization from Paramount in advance. It is the Member’s responsibility to make sure procedures and services are provided by a Participating Provider or that an out-of-plan Prior Authorization is obtained.

Out-of-network services are from doctors, hospitals, and other health care professionals that have not contracted with your plan. A health care professional who is out of your plan network can set a higher cost for a service than professionals who are in your health plan network. Depending on the health care professional, the service could cost more or not be paid for at all by your plan. Charging this extra amount is called balance billing. In cases like these, you will be responsible for paying for what your plan does not cover. Balance billing may be waived for emergency services received at an out-of-network facility.

Most network providers will submit a claim for you. If you go to a doctor, hospital or provider that is not in your network, ask them to submit a claim for you on a standardized claim form. If the provider will not submit the claim for you, contact our Contact Member Services or log into Paramounthealthcare.com for a claim form. Complete the claim form and attach an itemized bill that includes the diagnosis, procedure, date of service, charge and provider’s or facility’s name and address as well as proof of payment.  In most cases, the time limit for a member to submit a claim is 365 days, but this can vary. Please reference your Certificate or Benefit book to determine the specific time limit for submitting your claim.

If you go to a hospital or provider outside the country, get a copy of all your records and an itemized bill. If needed, have your records and bills translated to English. Submit your claims forms, bills, medical records, and proof of payment to the address listed on your ID card or mail to:

Paramount Insurance Company 
P.O. Box 928 
Toledo, OH 43697-0928 

Please remember that benefit coverage and limitations still apply. Refer to your Certificate or Benefit Book for details.

To access claims forms, please visit this page, or call 419-887-2525 Toll-free: Phone 800-462-3589 for more information.

Per regulation 45 CFR 156.270(d), if an enrollee receives advance payments of the premium tax credit and has paid at least one full month’s premium, the enrollee will observe a 3 month grace period.

During this grace period Paramount will:

• Pay covered services during the first month of the grace period
• Claims received the second and third months of the grace period may be pended (held awaiting payment) as necessary
• Notify network providers that the member is in the second and/or third month of the grace period and the claims currently pended (held awaiting payment) may possibly deny

If you have any questions concerning the grace period, contact the Member Services Department.

Member Services Department

419-887-2525

Toll-Free 800-462-3589

TTY 419-887-2526

TTY Toll-Free 888-740-5670

A retroactive denial is the reversal of a previously paid claim. If we retroactively deny a claim we have already paid for you, you will be responsible for payment. Some reasons why you might have a retroactive denial include having a claim that was paid during the second or third month of a grace period or having a claim paid for a service for which you were not eligible. You can avoid retroactive denials by paying your premiums on time and in full and making sure you talk to your provider about whether the service performed is a covered benefit.

If you dispute a premium payment or need to request a refund of premium overpayment, you may contact Member Services for additional assistance.

Prior Authorization is required for certain procedures or services. It is the responsibility of the Participating Provider to obtain Prior Authorization from Paramount in advance of these procedures or services.

If a medically necessary covered service or procedure is not available from any In-network providers, Paramount will make arrangements for an “out-of-plan Prior Authorization”. Your Primary Care Provider must request an “out of plan Prior Authorization” in advance. Consultations with Participating Specialists will be required before an “out-of-plan Prior Authorization” can be considered. If Paramount approves the “out-of-plan Prior Authorization”, written confirmation will be sent to you, your PCP and the non-in-network provider. All eligible authorized services will be covered subject to appropriate Deductible and Copayments/Coinsurance. Services received without obtaining prior authorization will be denied.

When Prior Authorization is required, Paramount will make a decision within two (2) working days from obtaining all the necessary information about the admission, or procedure that requires Prior Authorization. Paramount will advise the provider of the decision within three (3) working days after making the decision. If Paramount makes an adverse determination (i.e., denies approval or coverage), Paramount will notify the requesting provider in writing or electronically within three (3) working days after making the decision.

Please reference our comprehensive formulary to find out which drugs are subject to prior authorization or other coverage review requirements.

If you are told at the pharmacy that your drug isn’t covered because of a prior authorization requirement, you, your designee or your provider may request a coverage review for prior authorization, step therapy or quantity limits. The medical necessity review will determine if your plan will cover your medication. To begin the process for a coverage review ask your prescriber to submit an electronic prior authorization (ePA) request through to Paramount/CVS using the CoverMyMeds application or website.   Alternatively, you may ask your doctor to call Paramount at 419-887-2520 option 2. Your doctor will receive a form to fill out and return via fax. Within 72 hours of receiving a standard request and information sufficient to complete the review, we will notify your provider of our determination of whether coverage is approved.  Within 24 hours of receiving all necessary information for an expedited review for exigent circumstances a response will be received. (Exigent circumstances mean you have a condition that may seriously jeopardize your life, health or ability to regain maximum function if treatment is delayed.) 

While waiting for approval, you may have to pay the full cost of the medication out of pocket, and there is no guarantee you will be reimbursed or that the coverage review will be approved. If you do not follow the coverage review process outlined above, you will continue to pay the full cost of the medication out of pocket. Therefore, we recommend you reach out to your doctor to discuss switching to a plan-preferred drug or complete the coverage review process.

How to obtain non-formulary drugs

Paramount’s formulary includes a variety of effective high-value drugs that meet our strict clinical standards. If you choose to take a drug that is not included on the formulary, that drug will generally not be covered by your health plan. You will have to pay 100 percent of the cost. This will be true unless your doctor or health provider requests a formulary coverage review and an exception is made based on medical necessity.

To begin the process for a formulary coverage review, ask your prescriber to submit an electronic prior authorization (ePA) request to Paramount/CVS using the CoverMyMeds application or website. Alternatively, you may ask your doctor to call Paramount at 419-887-2520 option 2. Your doctor will receive a form to fill out and return via fax. Within 72 hours of receiving the request and information sufficient to complete the review, we will notify your provider of our determination of whether coverage is approved. An expedited review is available for exigent circumstances, meaning you have a condition that may seriously jeopardize your life, health or ability to regain maximum function, or are undergoing a current course of treatment using a non-formulary medication. We will respond to expedited reviews within 24 hours of receiving the request and information sufficient to complete the review.

• If your request is denied, your drug will not be covered by your plan, and you will be told in writing of your external review rights as part of our initial decision. You may request an external review by an independent review organization (IRO) within 180 days from your receipt of the notice of Final Adverse Benefit Determination. All requests must be in writing, including electronically, except for expedited external reviews, which can be made orally. IROs will complete standard reviews within 30 days of receiving the request and information sufficient to complete the review, and expedited reviews within 72 hours of receiving the request and information sufficient to complete the review. An expedited review can be requested if your treating provider believes the Adverse Benefit Determination involves a medical condition that could seriously jeopardize your life or health or your ability to regain maximum function if treatment is delayed. You will be told in writing of the IRO’s decision.

• How do I file a request for an expedited external review?

  • Telephone: (419) 887-2525
  • Toll Free: 1-800-462-3589
  • Facsimile: (419) 887-2037
  • E-mail: PHCMbrSvcAppeals@medmutual.com
  • Or via a mailed written request to:

  Paramount Insurance Company
Member Service Department-Appeals
P.O. Box 928
Toledo, Ohio 43697-0928

There is no cost to you associated with requesting any applicable appeals or external reviews.

A Member or physician can request and gain access to clinically appropriate drugs, and Preventive Health Services items or services that are not otherwise covered. However, if Your physician recommends a particular contraceptive service or FDA-approved contraceptive item based on medical necessity, Paramount will defer to the determination of the physician and cover that particular service or item without cost sharing.

A Member or physician can submit a standard exception request of a clinically appropriate non-formulary drug in non-exigent circumstances and receive a decision within 72 hours of a request. For expedited exception requests based on Exigent Circumstances determination and notification will be provided no later than 24 hours following receipt of the request. If request is approved, coverage continues for the duration of the prescription, including refills. If the request is denied, members may appeal to an accredited Independent Review Organization (IRO). The member and physician will be notified of the IRO’s decision no later than 24 hours following receipt of request for expedited exception request and 72 hours following receipt of a standard request. For more information, to request coverage of a non-formulary drug or appeal a denial, contact the Member Services Department.

Member Services Department

 419-887-2525

Toll-Free 800-462-3589

TTY 419-887-2526

TTY Toll-Free 888-740-5670

The Explanation Of Benefit (EOB) provides details about a medical insurance claim that has been processed and explains what portion Paramount paid to the health care provider and what portion of the payment, if any, is the patient's responsibility. The EOB is not a bill. Pay special attention to the Claims Detail portion of the EOB which states, You are responsible for this amount. This is the portion of the medical expense not covered by Paramount, and includes deductible, co-pay or coinsurance. The provider will bill the patient and the patient’s payment should be paid directly to the provider. The EOB will also include deductible and out-of-pocket year-to-date totals as well as pertinent messages regarding network providers and a patient’s right for review of denied claims.

The EOB will include the following information:

• The member receiving the service
• The provider who billed the service
• The date of service
• A description of the service
• The amount Paramount Dental paid for the service
• The amount you may owe or may have already paid for the service
• If you have questions about your EOB, contact Member Services.

Member Services Department

419-887-2525

Toll-Free 800-462-3589

TTY 419-887-2526

TTY Toll-Free 888-740-5670 

If you have more than one health insurance plan, those plans need to work together to make sure you’re getting the most out of your coverage. That process is referred to as Coordination of Benefits. Coordinating your benefits helps us process your claims faster and maximizes your benefits, which can lower your out-of-pocket costs. One plan becomes your primary plan and pays your claims first. Then the second plan pays toward the remaining cost.

Please refer to your Member Handbook and Summary of Benefits for more detailed information.