Annual Member Notices

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

Your Health

Easy Ways to Manage Your Health

As a valued member, 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.

Register for Your Secure Account

Log in or register to access your secure account. You will find your responsibilities and rights, including advanced care planning and information on communicating care goals.

Access Your Benefit Plan Documents

Simply log in to your secure account to view your documents. If you are unable to access your coverage documents, you can get a copy by calling the Customer Service (Member Services) number on the back of your member ID card. Your coverage documents include information about:
  • Benefit restrictions that apply to services obtained outside our system or service area
  • Language assistance
  • Submitting a claim for covered services, if applicable
  • Using our online tool to find providers and compare treatment costs
  • Providers with whom we contract to offer you member rates on healthcare services
  • Primary care services, including points of access and specialty care, behavioral healthcare services, and hospital services
  • How to obtain care after normal business hours
  • How to obtain emergency care, including our policy on when to directly access emergency care or use 911 services
  • How to obtain care and coverage when you are out of our service area
  • Submitting a complaint or appealing a decision that adversely affects coverage, benefits, or your relationship with us
  • How we evaluate new technology to include as a covered benefit for you
In addition, other important plan information includes:
  • Pharmacy management procedures, including online management of your prescription benefits
  • Copayments and your financial responsibilities
  • How to find information about doctors or other network providers
  • How to obtain a new member ID card
  • Information about our quality improvement program
  • How to transition from pediatric to adult primary care
  • Care management programs and eligibility
  • An affirmative statement about financial incentives
  • The availability of an independent, external review of a final, internal, medical necessity determination

Manage Your Prescription Drug Benefits

If your plan includes prescription drug benefits, your secure account is your one-stop shop to:

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

For the most up-to-date prescription drug information and updates to the list of covered drugs, view the drug lists and forms.

If you would like paper copies of the materials available, call the Customer Service (Member Services) number on your member ID card.

Note: The organization may limit communication of updates to “negative” formulary changes, such as changes that result in restrictions or replacements, and may limit such communications to affected members and their providers.

Importance of Obtaining Preauthorization

Preauthorization is the medical necessity review completed before you receive certain healthcare services. Preauthorization ensures the services are medically appropriate. Participating providers for 2020 (including BlueCard® facilities that provide inpatient services outside Capital BlueCross’ 21-county service area) are responsible for obtaining preauthorization. If you receive an outpatient service by a nonparticipating provider or from a BlueCard facility outside our service area, you are responsible for obtaining authorization, if required. If you do not obtain preauthorization, your claim may be reviewed for medical necessity and you may be responsible for paying the cost of the service. Search for participating providers, hospital, and labs, and learn more about preauthorization requirements. Also, check your benefit plan documents for a complete list of services that require preauthorization.

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 Member Services number on your member ID card if you have questions about these benefits.

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.

Coverage for Newborn children

Act 81 supports the administration of a member cost share for newborn coverage. For the first 31 days following birth, any costs for benefits provided to the newborn child will be applied to the subscriber’s cost-sharing amounts. Separate cost-sharing amounts will not apply to the newborn child unless and until the child is separately enrolled as a dependent in accordance with the terms of the subscriber's Certificate of Coverage.

Transition to Adult Primary Care

As children transition into young adults, it is important they receive the right healthcare services. Usually by the time young adults finish school, they should move their care from a pediatrician to a Primary Care Physician (PCP). To help with the transition to adult care, you or your child can visit our find a doctor tool to view the most up-to-date listing of PCPs in your area. With the find a doctor tool, you can learn more about PCPs accepting new patients, and their specialties, hours, and hospital affiliations.

Need more information? Contact Customer Service (Member Services) by calling the number on the back of your member ID card.

Your pediatrician’s office may be able to recommend a participating PCP for adults. Also remember to speak with them about sending your child’s medical records to the new provider.

New for 2020! Pain Management Alternative: Biofeedback Therapy

Effective January 1, 2020, biofeedback therapy will be added to most plans as a pain management alternative to treat certain chronic pain issues, such as migraines. As a pain management alternative, biofeedback can help members manage chronic migraine and tension headaches, as well as chronic back and neck pain without medications. This program expands the pain management services we offer our members and is an alternative to opioid medications. Find details about this and other services in your benefit plan documents on or after January 1, 2020.

Your Privacy

Your Privacy Is Important to Us

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 the following sources:

  • Applications and other forms provided to us
  • 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 this information to provide our products and services to you, and as permitted by law. We maintain physical, electronic, and procedural safeguards that comply with legal requirements to protect your nonpublic, personal financial information. We also maintain a Notice of Privacy Practices. If you have any questions about our privacy policy or want to receive a printed copy of the Notice of Privacy Practices, call the Customer Service (Member Services) number on your member ID card.

Help Fight Healthcare Fraud, Waste, and Abuse

You can help fight the rising costs of healthcare fraud by monitoring claims processed under your plan. When you receive an Explanation of Benefits (EOB) or view it from your secure member account, look for discrepancies such as the date(s) of service, the provider’s information, or the procedure performed. Protect yourself against medical identity theft by guarding your member ID card as you do your credit card.

If you suspect fraud, or believe you are a victim of medical identity theft, report it immediately in any of the following ways:

We're Here to Help

Let our Utilization Management and Customer Service (Member Services) staff help you with questions about preauthorization or your health coverage. Call Customer Service (Member Services) at the number on your member ID card or dial our general line at 800.962.2242 (TTY: 711) for Utilization Management. Emailed questions are reviewed Monday through Friday, 8:00 am– 6:00 pm. Our Customer Service (Member Services) representatives will make every effort to respond within 24 hours or one business day of receiving your inquiry.

Member Rights and Responsibilities

  • A right to receive information about providers; and member rights and responsibilities.
  • A right to be treated with respect and recognition of their dignity and their right to privacy.
  • A right to participate with providers in making decisions about their healthcare.
  • A right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
  • A right to voice complaints or appeals about the organization or the care it provides.
  • A right to make recommendations regarding the organization's member rights and responsibilities policy.
  • A responsibility to supply information (to the extent possible) that the organization and its providers need in order to provide care.
  • A responsibility to follow plans and instructions for care that they have agreed to with their providers.
  • A responsibility to understand their health problems and participate in developing mutually agreed upon treatment goals, to the degree possible.

Other Information

Medical Necessity Review

Clinical medical necessity determinations are based only on the appropriateness of care and service, and the existence of coverage. We do 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 healthcare services.

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

If you disagree with our adverse benefit determination, you may seek internal review of that determination by submitting a written appeal. An internal, expedited review may be requested if the situation is considered life-threatening or the member's health is in jeopardy. This expedited review may be requested by contacting Customer Service (Member Services) using the telephone number provided on the determination letter or mailing the request to the address provided on the determination letter. We respond with an internal appeal review determination as soon as possible, but no later than 72 hours of receiving the appeal request. You 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 benefit plan documents for specific guidelines on your right to appeal. For more information on the appeal process, call the Customer Service (Member Services) number on your member ID card.

Claims Filing Reminder

Participating providers handle all claims paperwork for hospital and medical care and automatically send them to us for processing. However, you may be responsible for submitting claims for certain services. For instance, if you visit a nonparticipating provider, you may need to submit a claim for any covered service. Also, you may need to provide information related to your eligibility for coverage from time to time. For example, you may need to respond to queries from us about other insurance coverage to coordinate benefits or resolve other-party liability issues. If you do not return the requested information, we may withhold payment of a claim until we receive the information.

Quality Measures

We have quality initiative procedures in place to help us evaluate how we are doing as a health plan. Our annual quality improvement program is available for you to review. For a paper copy, call the Customer Service (Member Services) number on the back of your member ID card.

Nondiscrimination and Foreign Language Assistance Notice

We comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Review our Nondiscrimination and Foreign Language Assistance Notice.

Help for People with Disabilities & English as a Second Language

We Provide Free Aids and Services to People with Disabilities or Whose Primary Language is Not English, Such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic format)
  • Qualified interpreters for other languages
  • Written information in other languages

If you need these services, call 800.962.2242 (TTY: 711).  If you believe we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our civil rights coordinator. You can file a grievance in person or by mail, fax, or email at:

Capital BlueCross
PO Box 779880, Harrisburg, PA 17177-9880
800.417.7842 (TTY: 711), fax: 855.990.9001
CRC@capbluecross.com

If you need help filing a grievance, our civil rights coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW., Room 509F, HHH Building
Washington, D.C. 20201
Toll-free: 800.368.1019, (TTY: 800.537.7697)
Complaint forms are available.

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 Member Services at the number on the back of your plan member ID card.