PPACA - Transparency in Coverage

Understanding your coverage.

Medical


Out of network liability and balance billing

Out of Network Medical Services (PPO)

If a PPO member obtains medical services from a nonparticipating provider, the member may be required to pay for the service at the time the service is rendered. Although nonparticipating providers may file claims on behalf of the member, they are not required to do so. Therefore, members who obtain medical services from nonparticipating providers must be prepared to pay for the service and submit their claim to Capital BlueCross for reimbursement. Unless otherwise required by law, all payments are made directly to the member. It is the member’s responsibility to pay the nonparticipating provider, if payment has not already been made.

Out-of-Network Emergency Services

When emergency services are provided by nonparticipating providers, benefits will be provided at the in-network benefit level. Members will be responsible for any applicable cost-sharing amounts such as deductibles, coinsurance, and copayments.

Balance Billing (PPO)

Nonparticipating providers are not obligated to accept Capital BlueCross’ payment as payment in full. Members may be responsible for the difference between the provider’s charge for that service and the amount Capital BlueCross paid for that service. This difference between the provider’s charge for a service and the plan allowance is called the balance billing charge.

Enrollee claim submission

A participating provider will submit a claim for benefits directly to Capital BlueCross.

For PPO members, nonparticipating providers may file claims on behalf of the member, but they are not required to do so. Members who obtain medical care services from nonparticipating providers must be prepared to pay for the service and submit their claim to Capital BlueCross for reimbursement.

If it is necessary for members to submit a medical claim to Capital BlueCross, they should be sure to request an itemized bill from their health care provider. The itemized bill should be submitted to Capital BlueCross with a completed claim form.

Members can obtain a copy of the claim form by contacting Customer Service or visiting the forms page. The member’s claim will be processed more quickly when this claim form is used. A separate claim form must be completed for each member who received medical services. Members can submit their claims, which include a completed claim form and an itemized bill to:

PO Box 211457
Eagan, MN 5512

Members who need help submitting a medical claim can contact Customer Service at 800.730.7219 (TTY: 711). All claims must be submitted within 12 months from the date of service with the exception of claims from certain state and federal agencies.

Grace periods and claims pending

Members eligible for premium subsidies

Members eligible for premium subsidies on plans purchased on the federally facilitated marketplace are entitled to a three-month grace period when a premium payment is missed. During the first month of the grace period, Capital BlueCross must continue to provide coverage (pay claims). In addition, Capital BlueCross notifies the affected providers on the possibility that claims may be denied during the second and third months of the grace period if the premium is not paid.

If the premium is paid in full by the end of the three month grace period, any pended claims will be processed in accordance with the terms of your contract. If the premium is not paid in full by the end of the grace period, any claims incurred in the second and third months may be denied.

Members who are not eligible for premium subsidies

Members have a 30-day grace period when a premium payment is missed. If the member does not make payment during the grace period, the contract will be cancelled effective on the last day of the grace period and Capital BlueCross will have no liability for services which are incurred after the grace period.

Retroactive denials

A retroactive denial is the reversal of a previously paid claim. If the claim is denied, the member becomes responsible for payment. Retroactive denial of claims can be avoided by paying premiums on time, using participating providers for services, and obtaining prior authorization for services.

Recoupment of overpayments

If a member overpays his premium bill and does not want to hold the overpaid amount to use toward the next bill, the member should call Customer Service to request a refund. If a member paid by credit card the overpayment will be refunded onto the member’s credit card. All other refunds will be issued by check.

Medical necessity and prior authorization timeframes and enrollee responsibilities

Medical necessity generally means services or supplies that a physician exercising prudent clinical judgment would provide to a member for the diagnosis and/or direct care and treatment of the member's medical condition, disease, illness, or injury. Capital BlueCross provides benefits only for services Capital BlueCross or its designee determines to be medically necessary. The fact that a provider may prescribe, recommend, order, or approve a service or supply does not of itself determine medical necessity or make such a service or supply a covered benefit.

Prior authorization is required for certain medical and therapy service and all non-emergency hospital stays require advance approval (called prior authorization) to ensure that you receive medically appropriate treatment.

  • For PPO Members, participating providers are responsible for obtaining required prior authorizations. Out of area facility providers that participate in the BlueCard network must handle prior authorization on a member’s behalf for an inpatient stay. The member is responsible for obtaining prior authorization when they see any other BlueCard participating provider or nonparticipating provider and may be subject to a monetary penalty for failure to comply with prior authorization requirements. Members must submit nonurgent prior authorization requests at least 15 days before the service. He or she must include all required information. A prior authorization decision is generally issued within 15 business days of receiving all necessary information for non-urgent requests.

Providers and members should call our Clinical Management department at 800.471.2242.

Learn more about prior authorization.

Drug exception timeframes and enrollee responsibilities

Internal Exception Process - The member, the member’s representative or the member’s prescribing physician (or other prescriber) may ask Capital BlueCross to make an exception to cover a drug that is not on the formulary. This is known as a non-formulary exception request.

  • Standard Review - Capital BlueCross will make an initial standard exception request decision no later than 72 hours from receipt of the request as long as there is sufficient information to process the request.
  • Expedited Review - An expedited non-formulary exception may be requested if the member’s life, health or ability to regain maximum function could be seriously harmed by waiting up to 72 hours for a decision or if the member is undergoing a current course of treatment using a non-formulary drug. Capital BlueCross will make an initial expedited coverage decision no later than 24 hours after receiving the expedited exception request as long as there is sufficient information to process the request.

A request for either a standard or an expedited exception determination should be made by calling or writing our Pharmacy Benefit Manager at:

CVS/caremark

877.432.0116
1300 E Campbell Road
Richardson, TX 75081
Attn: PA Department

If authorization is approved, the prescription will be filled and the appropriate cost share will be applied.

External Exception Process - If Capital BlueCross denies the standard or expedited non-formulary exception request, the member, the member’s representative, or the member’s prescribing physician (or other prescriber) may ask for a second review of the decision and request that it be reviewed by an independent review organization (IRO).

The member, the member’s representative, or the member’s prescribing physician (or other prescriber) may make an external exception request by calling 855.500.CARE (2273).

  • Standard Request - If the original internal non-formulary exception request was a standard exception request, Capital BlueCross will forward the request to an IRO which will review and respond with their decision as expeditiously as possible, but no later than 72 hours from Capital BlueCross’ receipt of the external exception request, as long as there is sufficient information to process the review. If additional information is necessary to process the request, the decision will be made no later than 72 hours from when sufficient information is received.
  • Expedited Request - If the original internal non-formulary exception request was processed as an expedited exception request, the IRO will review the external exception request and make a determination no later than 24 hours from when Capital BlueCross received the external exception request, as long as there is sufficient information to process the request. If additional information is necessary to process the external exception request, the decision will be made no later than 24 hours from when sufficient information is received.

If authorization is approved, your prescription will be filled and the appropriate cost share will be applied.

Explanation of benefits

After a visit to a doctor or other health care provider, a member may receive an Explanation of Benefits (EOB) detailing the services received, how much they cost and how much your plan paid. An EOB is issued only if a member has a cost-sharing responsibility for the services provided. Cost-sharing includes copayment, deductible and coinsurance. An EOB is not an invoice. Your health care provider will provide a bill for any amount you may owe.

Understanding your EOB

Coordination of benefits

Coordination of Benefits applies when a member has health care coverage under more than one benefit plan. Coordination of Benefit rules set the order in which each benefit plan pays a claim for benefits

  • The plan that pays first is the Primary Plan. The Primary Plan must pay benefits in accordance with its policy terms without regard to the possibility that another plan may cover some expenses.
  • The plan that pays after the Primary Plan is the Secondary Plan. The Secondary Plan may reduce the benefits it pays so that payments from all plans do not exceed 100% of the total allowable expense.

Dental


Out of network liability and balance billing

Out of Network Dental Services (PPO)

If a PPO member obtains dental services from a nonparticipating provider, the member may be required to pay for the service at the time the service is rendered. Although nonparticipating providers may file claims on behalf of the member, they are not required to do so. Members who obtain dental services from nonparticipating providers must be prepared to pay for the service and submit their claim to BlueCross Dental for reimbursement. Unless otherwise required by law, all payments are made directly to the member. It is the member’s responsibility to pay the nonparticipating provider, if payment has not already been made.

Out of Network Dental Services (HMO)

HMO members may obtain the full range of covered services only from HMO-participating Providers. Services by nonparticipating providers are covered only in emergency situations

Out-of-Network Emergency Services

When Emergency Services are provided by nonparticipating providers, members may be responsible for the difference between the provider’s charge for that service and the amount BlueCross Dental paid for that service.

Balance Billing (PPO)

Nonparticipating providers are not obligated to accept the BlueCross Dental payment as payment in full. Members may be responsible for the difference between the provider’s charge for that service and the amount BlueCross Dental paid for that service. This difference between the provider’s charge for a service and the plan allowance is called the balance billing charge.

Enrollee claim submission

A participating provider will submit a claim for benefits directly to BlueCross Dental.

Nonparticipating providers may file claims on behalf of the member, but they are not required to do so. Members who obtain dental services from nonparticipating providers must be prepared to pay for the service and submit their claim to BlueCross Dental for reimbursement.

If it is necessary for members to submit a dental claim to BlueCross Dental, they should be sure to request an itemized bill from their provider. The itemized bill should be submitted to BlueCross Dental with a completed claim form.

Members can obtain a copy of the claim form by contacting Customer Service or visiting the forms page. The member’s claim will be processed more quickly when this claim form is used. A separate claim form must be completed for each member who received dental services. Members can submit their claims, which include a completed claim form and an itemized bill to:

BlueCross Dental

PO Box 1126
Elk Grove Village, IL 60009

Members who need help submitting a dental claim can contact Customer Service at 800.613.2624 (TTY: 711). All claims must be submitted within 12 months from the date of service with the exception of claims from certain state and federal agencies.

Grace periods and claims pending

Members eligible for premium subsidies

Members eligible for premium subsidies on plans purchased on the federally facilitated marketplace are entitled to a three-month grace period when a premium payment is missed. During the first month of the grace period, BlueCross Dental must continue to provide coverage (pay claims). In addition, BlueCross Dental notifies the affected providers on the possibility that claims may be denied during the second and third months of the grace period if the premium is not paid.

If the premium is paid in full by the end of the three month grace period, any pended claims will be processed in accordance with the terms of your contract. If the premium is not paid in full by the end of the grace period, any claims incurred in the second and third months may be denied.

Members who are not eligible for premium subsidies

Members have a 30-day grace period when a premium payment is missed. If the member does not make payment during the grace period, the contract will be cancelled effective on the last day of the grace period and BlueCross Dental will have no liability for services which are incurred after the grace period.

Retroactive denials

A retroactive denial is the reversal of a previously paid claim. If the claim is denied, the member becomes responsible for payment. Retroactive denial of claims can be avoided by paying premiums on time, using participating providers for services, and obtaining prior authorization for services.

Recoupments of overpayments

If a member overpays his premium bill and does not want to hold the overpaid amount to use toward the next bill, the member should call Customer Service to request a refund to be issued.

If a member paid by credit card the overpayment will be refunded onto the member’s credit card. All other refunds will be issued by check.

Medical necessity and prior authorization timeframes and enrollee responsibilities

Medical/Dental necessity means care and services that are provided by a properly licensed dentist within the standards of generally accepted dental practice.

Prior authorization is required for medically necessary orthodontia. The participating dentist (or orthodontist as applicable) is required to submit a treatment plan prior to initiating services. The proposed services will be reviewed and a prior authorization will be issued to the subscriber or treating dentists (or orthodontist), specifying coverage. The prior authorization is not a guarantee of coverage and is considered valid for 180 days.

Explanation of benefits

After a visit to your dental provider, a member may receive an Explanation of Benefits (EOB) detailing the services received, how much they cost and how much your plan paid. Cost-sharing includes copayment, deductible and coinsurance.

An EOB is not an invoice. Your dental provider will provide a bill for any amount you may owe.

Understanding Your EOB

Coordination of Benefits

CMS Requirements

Coordination of Benefits applies when a person has dental coverage under more than one plan.

Coordination of Benefit rules set the order in which each plan pays a claim for benefits.

  • The plan that pays first is the Primary Plan. The Primary Plan must pay benefits in accordance with its policy terms without regard to the possibility that another plan may cover some expenses.
  • The plan that pays after the Primary Plan is the Secondary Plan. The Secondary Plan may reduce the benefits it pays so that payments from all plans do not exceed 100% of the total allowable expense.

Claims/Appeals Data


On Market Only

Capital Advantage Assurance Company®

Number of Claims Received in Calendar Year 2017

2,337,663

Number of Claims Denied in Calendar Year 2017

402,910

Number of Internal Appeals Filed in Calendar Year 2017

228

Number of Internal Appeals Overturned from Calendar Year 2017 Appeals

93

Number of External Appeals Filed in Calendar Year 2017

4

Number of External Appeals Overturned from Calendar Year 2017 Appeals

0