• Job Opportunities
Decrease (-) Restore Default Increase (+)
Print    Email

Transparency in Coverage and Cost-Sharing

Paramount recognizes the value in sharing information with you so you can make the best health-related decisions based on your needs. This page will give you a brief overview of some important elements of your Individual Marketplace coverage. While much of this information is available in your member handbook and/or summary of benefits, this page reviews the basics so you can quickly understand commonly used terms and policies.

Out-of-Network Liability and Balance Billing

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.

Enrollee Claim Submission

A claim is an itemized statement of costs for health care services and/or supplies provided by a facility, doctor, or other health care provider.

Certain medical services may require additional information, such as notes from the provider, payment or rejection notices from other insurance carriers (including Workers’ Compensation, other health plans, Medicare, auto insurance, etc.), origin and destination points for ambulance transfers or accident information. Delays in submitting this special information, when required, may delay the claims from processing.

You don’t need to submit claims for services received from in-network providers. If you have received services from an out-of-network provider, it is your responsibility to submit a claim for consideration. You must obtain a standard claim form from the provider or use the form below and send the claim to Paramount at the address below within 120 days from the date of service. Be sure to include your Paramount ID number and a brief explanation of the circumstances related to the service to:

Paramount Insurance Company
PO Box 928
Toledo, OH 43697-0928

Claim Form

Contact Member Services if you need assistance submitting a claim at:

Phone: (419) 887-2525 Toll-free: 1-800-462-3589
TTY: (419) 887-2526 Toll-free: 1-888-740-5670

Grace Periods and Claims Pending

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 1-800-462-3589
TTY (419) 887-2526
TTY Toll-Free 1-888-740-5670

Retroactive Denials

Paramount conducts audits on paid claims and may issue denials retroactively, when appropriate, making you responsible for payment. Examples to reduce the likelihood of retroactive denials include, use of only in-network providers, except in an emergency, and paying premiums timely.

Recoupment of Overpayments

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

Medical Necessity and Prior Authorization Timeframes and Member Responsibilities

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.

Drug Exception Timeframes and Member Responsibilities

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 1-800-462-3589
TTY (419) 887-2526
TTY Toll-Free 1-888-740-5670

Explanation of Benefits

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 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 1-800-462-3589
TTY (419) 887-2526
TTY Toll-Free 1-888-740-5670

Coordination of Benefits

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.