Annual Member Notices

Required State and Federal Notices for Members of the Capital BlueCross Family of Companies

Privacy

Your Privacy Is Important

At Capital BlueCross, we are committed to providing you with the highest quality healthcare products and services. An important part of this commitment is our pledge to do everything we can to protect your nonpublic personal financial information.

Our Privacy Pledge

Capital BlueCross does not sell customer information. We do not disclose your nonpublic personal financial information, except as permitted by law. We do not disclose this information, even when our customer relationships end, except as permitted by law.

Information We Collect

We collect nonpublic personal financial information about you from:

  • Applications and other forms
  • Transactions (such as claims submissions and payments) with us, our affiliates, or others
  • Outside sources, such as healthcare providers, other insurance companies, and federal and state agencies

How We Protect Member Information

Our policies restrict access of your information to employees who need it to provide you with our products and services, and as permitted by law. We maintain physical, electronic, and procedural safeguards that comply with legal requirements to protect your nonpublic personal financial information. Capital BlueCross also maintains a Notice of Privacy Practices. If you have any questions about our privacy policy or want to receive a printed copy of our Notice of Privacy Practices, please call the Customer Service number on your member ID card.

Your Health

Importance of Obtaining Preauthorization

Preauthorization is the approval required prior to receiving some healthcare services to ensure they are medically appropriate. In-network providers, including BlueCard® facilities that provide inpatient services outside Capital BlueCross’ 21-county service area, are responsible for obtaining preauthorization.

Preauthorization is the approval required prior to receiving some healthcare services to ensure they are medically appropriate. In-network providers, including BlueCard® facilities that provide inpatient services outside Capital BlueCross’ 21-county service area, are responsible for obtaining preauthorization.

If you visit an out-of-network provider or receive an outpatient service from a BlueCard facility outside our service area, you are responsible for obtaining preauthorization if it is required. If you don’t, your claim may be denied or you may have to pay a preauthorization fee.

Find in-network doctors, hospitals, and labs and learn more about preauthorization requirements. You also can check your Certificate of Coverage for a complete list of services that require preauthorization.

Newborns’ and Mothers’ Health Protection Act

Under federal law, group health plans and health insurers offering group health insurance coverage generally cannot restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the plan or insurer may pay for a shorter stay if the attending provider (e.g., physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier. Also under federal law, plans and insurers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not, under federal law, require that a physician or other healthcare provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification.

Women’s Health

Capital BlueCross and our family of companies provide benefits for mastectomy-related services in accordance with the Women’s Health and Cancer Rights Act of 1998.These benefits include all stages of reconstruction and surgery to achieve symmetry between breasts; prostheses; and complications resulting from a mastectomy, including lymphedema. Please call the Customer Service number on your member ID card if you have questions about these benefits.

Transition to Adult Primary Care

As children transition into young adults, it is important they receive the right health care services for their age. Usually by the time young adults finish school, they should switch their care from a pediatrician to an adult Primary Care Physician (PCP).

To help with the transition to adult care, you or your child can visit our online Provider Finder to view the most up-to-date listing of PCPs in your area. There you can learn more about PCPs accepting new patients and their specialties, hours, and hospital affiliations.

Simply log in to, or register for, a secure member account to Find a Doctor . You also can speak with a Customer Service Representative by calling the number on the back of your member ID card.

Your pediatrician’s office may be able to recommend a participating adult PCP as well. And remember to speak with your pediatrician about sending your child’s medical records to the new doctor.

Manage Your Prescription Drug Benefits

For Capital BlueCross customers with a prescription drug plan, your secure member account is your one-stop shop for your prescription benefit needs:

  • Check drug coverage and cost
  • Determine a drug’s common side effects
  • Find generic substitutes
  • Download mail order and claim forms
  • Find a pharmacy
  • Submit an exception request
  • Order a refill for an unexpired mail-order prescription
  • Review your prescription history
  • View the formulary (drug list)

For the most up-to-date prescription drug information and updates to the list of covered drugs, visit capbluecross.com. If you would like paper copies of the materials available online, call the Customer Service number on your member ID card.

*Note: The organization may limit communication of updates to “negative” formulary changes (i.e., changes that result in restrictions or replacements) and may limit such communications to affected members and their practitioners.

Easy Ways to Manage Your Health

As a valued customer, you have access to a suite of quality programs, services, and educational tools to help you live healthy and be well – all from the convenience of your computer or mobile device.

If you haven’t yet, register for your secure account to find:

  • Customer responsibilities and rights, including advanced care planning and information on communicating goals of care.

Acupuncture/Chiropractic Update

Effective January 1, 2019, acupuncture will be included in most plans as a pain management alternative to treat certain chronic issues, such as migraines, tension headaches, and neck/back pain. Coverage also will include manipulation therapy (chiropractic care) for such chronic conditions, beyond the acute care treatment already covered.

Our expanded pain management services will provide our members with alternatives to opioid medications. You can find details about these services in your benefit plan documents (Certificate of Coverage and Summary of Benefits and Coverage) on or after January 1, 2019, and through your secure, online account.

Opioid Update

Capital BlueCross is taking proactive steps to help address the opioid crisis, including using the lowest possible effective dosage, while providing safer, more effective care. We are updating our formularies (lists of drugs) to reflect state-level recommendations and opioid guidelines from the federal Centers for Disease Control and Prevention (CDC). Effective January 1, 2019, we will update our selectively closed formulary (those with Individual or CHIP plans). Effective February 1, 2019, our open/closed formulary (most commercial accounts) will be updated.

Members currently taking an opioid impacted by these changes should have received a letter from us with more details. If you did not receive a letter, or want to be certain if a drug you are taking is impacted by the new formularies, please contact your doctor.

Other Information

Medical Necessity Review

Clinical medical necessity determinations are based only on the appropriateness of care and service, and the existence of coverage. Capital BlueCross does not reward, reimburse, or provide a bonus to individuals on the basis of utilization, issuance of denials of coverage, or provision of financial incentives of any kind to encourage decisions that may result in underutilization or that could negatively influence the provision of health care services.

Capital BlueCross does not use incentives to encourage barriers to care and service, nor do we make decisions about hiring, promoting, or terminating practitioners or other staff based on the likelihood, or on the perceived likelihood, that the practitioner or staff member supports, or tends to support, denial of benefits.

If a customer disagrees with Capital BlueCross’ adverse benefit determination, the customer may seek internal review of that determination by submitting a written appeal. A customer also may request an external appeal through an Independent Review Organization of a Final Internal Adverse Benefit Determination pertaining to medical necessity. Please refer to your Certificate of Coverage for specific procedures.

For more information, review our Medical Necessity policy or call the Customer Service number on your member ID card.

Quality Measures

Capital BlueCross has quality initiative procedures in place to help us evaluate how we are doing as a health plan. Our annual Quality Improvement (QI) program evaluation is available to members electronically, or you may request a paper copy by contacting the Customer Service number on the back of your Member ID card.

Claims Filing Reminder

Participating providers handle all claims paperwork for hospital and medical care and automatically send them to Capital BlueCross for processing. However, customers may be responsible for submitting claims for certain services. For instance, if customers visit nonparticipating providers, they may need to submit a claim for any covered service. Also, customers may need to provide information related to their eligibility for coverage from time to time. For example, customers may need to respond to queries from Capital BlueCross about other insurance coverage in order to coordinate benefits or resolve other-party liability issues. If a customer does not return the requested information, Capital BlueCross may withhold payment of a claim until the information is received.

Your Certificate of Coverage

You can access your coverage documents after logging into your secure account. If you are unable to access your coverage document online, you can get a copy by calling the Customer Service number on the back of your member ID card. Your coverage documents include information about:

  • Benefits and services included in, and excluded from, coverage.
  • Pharmaceutical management procedures, if they exist.
  • Copayments and other charges for which members are responsible.
  • Benefit restrictions that apply to services obtained outside the organization’s system or service area.
  • How to obtain language assistance.
  • How to submit a claim for covered services, if applicable.
  • Our online tool to find doctors and compare treatment costs.
  • How to obtain information about practitioners who participate in the organization.
  • How to obtain primary care services, including points of access.
  • How to obtain specialty care and behavioral healthcare services and hospital services.
  • How to obtain care after normal business hours.
  • How to obtain emergency care, including the organization’s policy on when to directly access emergency care or use 911 services.
  • How to obtain care and coverage when subscribers are out of the organization’s service area.
  • How to submit a complaint.
  • How to appeal a decision that adversely affects coverage, benefits or a subscriber’s relationship with the organization.
  • How the organization evaluates new technology for inclusion as a covered benefit.

Expanded Lab Network

Starting January 1, 2019, you will have more in-network options for your routine lab work, including LabCorp! Our broader lab network also may mean extra savings for your wallet! To ensure you are getting the best discount, find a lab near you.

The information provided is not intended to replace the advice of your healthcare provider. Please consult your healthcare provider if you have any questions or concerns about the information provided, as your healthcare provider is familiar with your personal medical history.

Benefits vary by type of product and benefit design; therefore, not all programs or issues addressed may be available, covered, or applicable to your specific coverage. Please refer to your Certificate of Coverage or contact Customer Service at the number on the back of your plan member ID card.