Transparency in Coverage

CHRISTUS Health is committed to help our patients make informed choices about their health care needs from start to finish. We understand the cost of health care can be stressful, and we are here to alleviate some of the challenges you may face. CHRISTUS offers reliable resources to ensure you receive the highest quality of care and experience. We provide an online estimator customized for your care.  To receive an estimate, please be sure to click the link below and follow the instructions.

Price Estimator

DISCLAIMER

You acknowledge that you are accessing this information for the purposes of estimating your out-of-pocket costs for healthcare services for your selected provider and selected CHRISTUS Health Plan. The services available in this website do not represent a comprehensive list but rather a list of the most common inpatient and outpatient procedures. Should you have a question regarding your procedure, you can contact your provider directly. If you have a question regarding your CHRISTUS Health Plan coverage and benefits, please visit www.christushealthplan.org, or call Member Services at 844-282-3025.

• Out-of-pocket amounts provided by this website are ESTIMATES and valid only for today.
• The amount shown does not include additional procedures that may be performed with your scheduled procedure, nor does it include complications that may result during your procedure.
• Estimates can vary based on the procedure and health insurance benefits (deductible, out of pocket maximum, co-insurance, and copays) selected.
• Estimates are based on actual claims and provider contracted fee schedules.
• This site does not guarantee insurance coverage or payment for a procedure.
• Your actual costs may be different given the actual procedure performed, the benefits at the time of the procedure, and the eligibility and coverage determined by your health insurance provider.
• You will be responsible for the costs for items and services not covered by health insurance.
• Depending on your selected procedure, the out-of-pocket estimate may or may not include professional fees of your physician, anesthesiologist, radiologist, or other specialist.

By accepting these terms and conditions, you acknowledge that your provider and CHRISTUS Health Plan shall not be liable for any differences between the estimate and your final bill. You also understand that you may be eligible for financial assistance and payment plans. You can contact your provider for more information.

Machine Readable Files

CHRISTUS Health Exchange HMO plans require that you select an in-network Primary Care Provider (PCP) to coordinate all of your care. We will pay for covered services that our members receive from our in-network providers. However, members who receive care from an in-network provider without receiving the appropriate prior authorization, when prior authorization is required, will incur higher out-of-pocket expenses.

Services from an out-of-network provider are not covered, and providers may bill you for their services. Out-of-Network services are from doctors, hospitals, and other health care professionals that have not contracted with CHRISTUS Health Plan. A healthcare 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.

Except for emergency services, members who go to an out-of-network provider will have to pay all charges out of pocket for the health services they receive. Emergency services are covered whether or not members use an in-network or out-of-network provider or emergency room. Members will pay in-network cost sharing (copayment, coinsurance and deductible) for covered emergency services. 

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. 

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay 
the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. 

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not 
count toward your annual out-of-pocket limit. 

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. 

You are protected from balance billing for:

Emergency services 
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable 
condition, unless you give written consent and give up your protections not to be balanced 
billed for these post-stabilization services.

[Insert plain language summary of any applicable state balance billing laws or requirements OR state-developed model language as appropriate] 

 

Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. 

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. 

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network. 

When balance billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network).
• Your health plan will pay out-of-network providers and facilities directly.

• Your health plan generally must:

o Cover emergency services without requiring you to get approval for services in advance (prior authorization).
o Cover emergency services by out-of-network providers.
o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
o Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact CHRISTUS Health Plan at 1-844-282-3025. 

Visit https://www.cms.gov/newsroom/fact-sheets/requirements-related-surprise-billing-part-ii-interim-final-rule-comment-period for more information about your rights under federal law. 

Visit https://www.tdi.texas.gov/tips/texas-protects-consumers-from-surprise-medicalbills.html for more information about your rights under Texas state laws

Members must pay all monthly premiums to CHRISTUS Health Plan when they are due. If payments are late, CHRISTUS Health Plan will provide a notice to members with information on how to keep coverage by paying all premiums owed by the end of the grace period defined below.

For members not receiving  advanced premium tax credits (APTC), CHRISTUS Health Plan provides a grace period of 30 days for payment of monthly premiums except for the first binder premium payment. During the 30 day grace period coverage will continue. If CHRISTUS Health Plan doesn’t receive the entire premium amount that is due by the end of the grace period, coverage will be cancelled back to the last day of the grace period. Members may be responsible to CHRISTUS Health Plan for the payment of the portion of the premium for the time coverage was in effect during the grace period.

For members receiving an APTC, CHRISTUS Health Plan provides a grace period of 90 days if member has previously paid at least one full month’s premium during the benefit year.

During the grace period CHRISTUS Health Plan will:

• Pay all appropriate claims for services rendered to the member during the first month of the grace period and may pend (hold) claim payment for services rendered to the member in the second and third months of the grace period;
• Notify Health and Human Services (HHS) of such non-payment; and
• Notify providers of the possibility of denied claims when a member is in the second and third months of the grace period.

If a member receiving APTC reaches the end of their 90 days' grace period without paying all outstanding premiums we will notify the member that coverage will be cancelled. The last day of coverage will be the last day of the first month of the 90 days' grace period. Members will be responsible for payment of all charges for claims that were pended or paid during the second and third month of the grace period.

CHRISTUS Health Exchange in-network plan providers file claims for members after they receive services.  Claim forms can only be submitted to CHRISTUS Health Plan by providers for CHRISTUS Health Exchange members.  

Member Services can be contacted at the following phone number: 1-844-282-3025

Grace Period

Members must pay all monthly premiums to CHRISTUS Health Plan when they are due. If payments are late, CHRISTUS Health Plan will provide a notice to members with information on how to keep coverage by paying all premiums owed by the end of the grace period.

A grace period is a time period when your plan will not terminate even though you did not pay your premium.  Any claims submitted for you during that grace period may be pended. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full.

For members not receiving an Advanced Premium Tax Credit (APTC), CHRISTUS Health Plan provides a grace period of 30 days for payment of monthly premiums except for the first binder premium payment. During the 30 days' grace period coverage will continue. If CHRISTUS Health Plan doesn’t receive the entire premium amount that is due by the end of the grace period, coverage will be cancelled back to the last day of the grace period. Members may be responsible to CHRISTUS Health Plan for the payment of the portion of the premium for the time coverage was in effect during the grace period. 

For members receiving APTC, CHRISTUS Health Plan provides a grace period of 90 days if member has previously paid at least one full month’s premium during the benefit year.

During the grace period CHRISTUS Health Plan will:

• Pay all appropriate claims for services rendered to the member during the first month of the grace period and may pend (hold) claim payment for services rendered to the member in the second and third months of the grace period
• Notify Health and Human Services (HHS) of such non-payment; and 
• Notify providers of the possibility of denied claims when a member is in the second and third months of the grace period. 

If a member receiving APTC reaches the end of their 90 days' grace period without paying all outstanding premiums we will notify the member that coverage will be cancelled. The last day of coverage will be the last day of the first month of the 90 days' grace period. Members will be responsible for payment of all charges for claims that were pended or paid during the second and third month of the grace period.

In some situations, a claim may be denied after a member has already received services from a provider. This may happen when coverage is cancelled for non-payment or loss of eligibility under our plan due to a change in circumstance. This may also happen if our Medical Management team does a retrospective review of a member’s medical records after services have been provided to determine if the services were medically necessary.

Emergency care services may be reviewed retrospectively to determine if a true medical emergency did exist. These types of retrospective reviews are designed to protect members from the high costs associated with unnecessary use of emergency departments and urgent care centers. A member’s treatment of non-emergencies as if they are emergencies at an emergency department or urgent care center when a visit to a doctor’s office would have been appropriate could result in the member’s responsibility to pay a greater portion or all of the charges.

Prompt premium payment can also help members prevent retroactive denials. Members must always notify Healthcare.gov of a change in circumstance that might affect coverage. Members should also review all of our requirements to have health care services pre-authorized before receiving them.

If a member disputes a premium charge or payment, they may call Member Services by calling the number on the back of the ID card.

Some health care services require prior authorization before members receive the services. If members do not follow our requirements for prior authorization, CHRISTUS Health Plan may not pay for the services. In most cases, physicians and other providers will be responsible for getting the prior authorization from the health plan. We have instructions and procedures in place for providers to request prior authorization. 

The clinical department will evaluate the request to assess the medical necessity and coverage of proposed treatment. CHRISTUS Health Plan will also check that the treatment is being provided at the appropriate level of care. Prior authorizations are approved or denied based on current evidence-based clinical standards of care, guidelines, policies and not on incentives or bonus structures. The member and provider will receive notification of CHRISTUS Health Plan’s decision, whether approved or denied. 

Generally, the following types of services require prior authorization: 

• Cardiology Procedures 
• Certain drug and medications 
• Clinical Trial Services 
• Durable Medical Equipment (DME) 
• Home Health Care 
• Hospice Services 
• Non-emergency ambulance transport 
• Nuclear medicine 
• Pain management 
• Physical, occupational, and speech therapy 
• Prosthetic appliances and orthotics 
• Skilled Nursing Facility Care 
• Sleep studies 
• Surgery 
• Transplant Services 

Note: This list may not include all services requiring Prior Authorization. If you need help determining if a service requires Prior Authorization, please contact Member Services at 1-844-282-3100.

Standard/Non-Emergency Care Services

We will evaluate Standard Preauthorization requests and notify your provider of our decision no later than 72 hours following receipt of the request.

Expedited/Review of Ongoing Services

We will evaluate Expedited Preauthorization requests based on urgent circumstances. Urgent circumstances exist when you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function or when you are undergoing a current course of treatment. We will make an expedited preauthorization decision and notify your Provider of the decision no later than 24 hours following the receipt of the request.

You, someone acting on your behalf or your provider of record can ask CHRISTUS Health Plan to make an exception to our coverage rules.

There are several types of exceptions that you, someone acting on your behalf or your provider of record can ask us to make. 

• Cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. 
• Ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, CHRISTUS Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. 

You, someone acting on your behalf or your provider of record call:

CHRISTUS Health Member Services at 1-844-282-3025
Express Script at 1-800-935-6103

Generally, CHRISTUS Health Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects. 

The Plan will provide notice of its decision within 24 hours after receiving an expedited request or 72 hours after receiving a standard request. The adjudication timeframes do not begin until your prescriber submits his or her supporting statement to the Plan for review. 

If CHRISTUS Health Plan’s coverage determination is unfavorable, the decision will contain the information needed to file a request for appeal/redetermination with the Plan.

Appeals
You, someone acting on your behalf or your provider of record has the right to appeal an unfavorable determination (denial) orally or in writing. A physician who has not previously reviewed the case will make the appeal decision. The appealing party must send the appeal, whether orally or in writing, no later than 180 days after the date of receiving written notification of the unfavorable determination.   

To submit an oral appeal, call the following toll-free number: 1-844-282-0380
To submit a written appeal, mail or fax the written appeal to the following address or fax number: 

Appeals and Grievances Department
CHRISTUS Health
PO BOX 169009
IRVING, TX  75016

Fax: 1-866-416-2840

Our deadlines to resolve the appeal and send a written decision to the enrollee or someone acting on the enrollee’s behalf and the provider of record are: 

Expedited Appeal: One working day from the date we receive all information necessary to complete the appeal. 
Standard Appeal: 30 calendar days of receipt of the appeal. 

 

We may provide the determination by telephone or electronic transmission, but will provide a written determination within three working days of the initial telephonic or electronic notification. 
If an appeal is requested and we continue to deny the request, we will send you a written decision and automatically send your case to an independent reviewer.

Independent Review Organization (External Review)

MAXIMUS Federal Services will perform an expedited review for life-threatening (urgent care) services and issue a decision within 72 hours of the request that the determination be made. 
An expedited external review happens faster if a person asks for it by calling toll-free telephone number: 1-888-866-6205

The 72-hour timeframe for an expedited request begins when the phone call ends. 

A person may also ask for an expedited external review by mail or fax to: 

MAXIMUS Federal Service
3750 Monroe Avenue, Suite 705
Pittsford, NY 1453

Fax: 1-888-866-6190

You may submit a standard external review request via mail, fax, or submit an online request for an external review within four months after the date you received the final denial notice from CHRISTUS Health Plan.  

MAXIMUS Federal Services will perform a standard review and issue a written notice of the final external review decision as soon as possible, but no later than 45 days after receipt of the request. 

Mail or fax your request directly to CHRISTUS Health Plan or send your request to:

MAXIMUS Federal Service 3750
Monroe Avenue, Suite 705
Pittsford, NY 1453 

Fax: 1-888-866-6190

For payment requests, including payment requests that involve exceptions, CHRISTUS Health Plan will provide written notice of its decision (and make payment when appropriate) within 14 calendar days after receiving a request.

 

After a member receives a health care service, CHRISTUS Health Plan will send an Explanation of Benefits (EOB) notice to the member.  Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.

An EOB is a statement to explain what medical treatments and/or services a plan paid for on a member’s behalf, the plan’s payment and the member’s financial responsibility (out of pocket costs) pursuant to the terms of the policy. If you have questions about your EOB, please contact Member Services at the number on the back of your ID card.

Coordination of benefits exists when a member is also covered by more than one health plan. Benefits can be coordinated to establish proper payment of services. CHRISTUS Health Plan can assist with COB, but we will need you to complete the Other Health Insurance (OHI) Form. CHRISTUS Health Plan sends this form out annually; however you may contact Member Services at the number on the back of the ID card to request the form sooner if needed. One plan becomes your primary plan and pays your claim first. Then the second plan pays toward the remaining cost according to your policy.