PPACA - Transparency in coverage
Understanding your coverage.
Out-of-network liability and balance billing
Out-of-network medical services (PPO)
If a PPO member gets medical services from an out-of-network provider, they may be required to pay at the time of service. Although out-of-network providers may file claims on your behalf, they are not required to do so. Therefore, you must be prepared to pay for the service and submit your claim to us for reimbursement. Unless otherwise required by law, all payments come directly to you. It is your responsibility to pay the out-of-network provider, if payment has not already been made.
Out-of-network emergency services
When emergency services are from out-of-network providers, benefits are at the in-network benefit level. You are responsible for any applicable cost-sharing amounts such as deductibles, coinsurance, and copayments. Out-of-network providers administering emergency services are prohibited from balance billing you, with certain exceptions.
Balance billing (PPO)
Out-of-network providers do not have to accept our payment as payment in full. You may be responsible for the difference between the provider’s charge for that service and the amount we paid. This difference is the balance billing charge. Out-of-network providers administering emergency services are prohibited from balance billing you, with certain exceptions.
Enrollee claim submission
An in-network provider will submit a claim for benefits directly to us.
For PPO members, out-of-network providers may file claims on your behalf, but they are not required to do so. You must be prepared to pay for the service and submit your claim to us for reimbursement.
If you need to submit a medical claim to us, you should request an itemized bill from your health care provider. Submit the itemized bill to us with a completed claim form.
Contact Member Services or visit our forms page for a copy of a claim form. Claims are processed more quickly when this claim form is used. You must complete a separate claim form for each family member who received medical services. Submit claims, which include a completed claim form and an itemized bill to:
PO Box 211457
Eagan, MN 55121
Contact Member Services at 800.730.7219 (TTY: 711) if you need help submitting a medical claim. 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
If you are eligible for premium subsidies
If Premiums are delinquent for an Exchange Member who receives a Subsidy, and at least one month’s Premium has been paid in full during the calendar year, coverage for the Member shall remain in effect during a 90-day grace period. During the grace period, we will pay for claims incurred during the first month of the grace period and pend claims in the second and third months of the grace period. If Premiums have not been paid in full by the end of the grace period, we shall terminate coverage effective as of the last day of the first month of the grace period, and we will have no liability for pended claims.
If you are not eligible for premium subsidies
Those who purchased plans on the exchange and are not eligible for premium subsidies are entitled to a 30-day grace period when they miss a premium payment. If a premium payment is not paid when due, it may be paid during the grace period. This grace period is a 30-day period during which we cannot cancel coverage due to missed or late premium payments. During this 30-day window, the contract stays in force. However, we pend all claims for services received during this grace period. This means claims are in a temporary hold status until the premium owed is paid. If you have not paid the premium in full by the end of the grace period, your coverage is canceled on the last day of the month when premium was last paid in full.
Retroactive denials
A retroactive denial is the reversal of a previously paid claim. If we deny the claim, you are responsible for payment. You can avoid retroactive claim denials by paying premiums on time, using participating providers for services, and getting preauthorization for services.
Recoupment of overpayments
If a premium bill is overpaid and you do not want to put the overpaid amount towards the next bill, call Member Services to ask for a refund. If you paid by credit card, the overpayment is refunded to your credit card. All other refunds are 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 you for the diagnosis and/or direct care and treatment of your medical condition, disease, illness, or injury. We provide benefits only for services we, or our designee, determine to be medically necessary. The fact that a provider may prescribe, recommend, order, or approve a service or supply does not determine medical necessity or make 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, in-network providers are responsible for getting the required prior authorizations. Out-of-area facility providers in the BlueCard network must handle prior authorization on your behalf for an inpatient stay. You are responsible for getting prior authorization when you see any other BlueCard provider or an out-of-network provider. You must submit nonurgent prior authorization requests at least 15 days before the service. You 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.
You or your provider should call our Clinical Management department at 800.471.2242.
Learn more about prior authorization.
Drug exception timeframes and enrollee responsibilities
Internal exception process - You, your representative or your prescribing physician (or other prescriber) may ask us to make an exception to cover a drug that is not on the formulary. This is a non-formulary exception request.
- Standard review - We will make an initial standard exception request decision no later than 72 hours from receipt of the request as long as there is enough information to process the request.
- Expedited review - An expedited non-formulary exception may be requested if your life, health or ability to regain maximum function could be seriously harmed by waiting up to 72 hours for a decision or if you are undergoing a current course of treatment using a non-formulary drug. We will make an initial expedited coverage decision no later than 24 hours after receiving the expedited exception request as long as there is enough information to process the request.
To request a standard or expedited exception determination, call or write our Pharmacy Benefit Manager at:
Clinical Review Department
2900 Ames Crossing Road
Eagan, MN 55121
You can also call the Member Services number on your ID card.
If authorization is approved, the prescription will be filed and the appropriate cost share will be applied.
External exception process - If Capital Blue Cross 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).
If we deny the standard or expedited nonformulary exception request, you, your representative, or your 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). You, your representative, or your 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, we forward the request to an IRO which will review and respond with their decision as quickly as possible, but no later than 72 hours from our receipt of the external exception request, as long as there is enough information to process the review. If additional information is necessary to process the request, the decision is made no later than 72 hours from when enough information is received.
- Expedited request - If the original internal non-formulary exception request was an expedited exception request, the IRO reviews the external exception request and makes a determination no later than 24 hours from when we received the external exception request, as long as there is enough information to process the request. If additional information is necessary to process the external exception request, the decision is made no later than 24 hours from when enough 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, you 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 you have 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.
Coordination of benefits
Coordination of benefits applies when you or a family member have 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 an out-of-network provider, the member may be required to pay for the service at the time the service is rendered. Although out-of-network providers may file claims on behalf of the member, they are not required to do so. Members who obtain dental services from out-of-network providers must be prepared to pay for the service and submit their claim to Capital Blue Cross 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 out-of-network 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 in-network HMO providers. Services by out-of-network providers are covered only in emergency situations.
Out-of-network emergency services
When emergency services are provided by out-of-network providers, members may be responsible for the difference between the provider’s charge for that service and the amount Capital Blue Cross Dental paid for that service.
Balance billing (PPO)
Out-of-network providers are not obligated to accept the Capital Blue Cross Dental payment as payment in full. Members may be responsible for the difference between the provider’s charge for that service and the amount Capital Blue Cross 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
An in-network provider will submit a claim for benefits directly to Capital Blue Cross Dental. Out-of-network providers may submit claims on behalf of the member, but they are not required to do so. Members who obtain dental services from out-of-network providers must be prepared to pay for the service and submit their claim to Capital Blue Cross Dental for reimbursement.
If it is necessary for members to submit a dental claim to Capital Blue Cross Dental, they should be sure to request an itemized bill from their provider. The itemized bill should be submitted to Capital Blue Cross Dental with a completed claim form.
Members can obtain a copy of the claim form by contacting Member Services 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:
Dental Claims Processing Center
PO Box 211424
Eagan, MN 55121
Members who need help submitting a dental claim can contact Member Services 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
If Premiums are delinquent for an Exchange Member who receives a Subsidy, and at least one month’s Premium has been paid in full during the calendar year, coverage for the Member shall remain in effect during a 90-day grace period. During the grace period, we will pay for claims incurred during the first month of the grace period and pend claims in the second and third months of the grace period. If Premiums have not been paid in full by the end of the grace period, we shall terminate coverage effective as of the last day of the first month of the grace period, and we will have no liability for pended claims.
Members who are not eligible for premium subsidies
Members who purchased plans on the federally facilitated marketplace and are not eligible for premium subsidies are entitled to a 31-day grace period when a premium payment is missed. If a premium payment is not paid when due, it may be paid during the grace period. This grace period is a 31-day period during which coverage is not cancelled due to missed or late premium payments. During this 31-day window the Contract stays in force. However, all claims for services received during this grace period are to be pended. This means claims are put into a temporary hold status until the premium owed is paid. If the premium has not been paid in full by the end of the grace period, coverage is canceled on the last day of the month when premium was last paid in full. Any pended claims will be denied and it will be your responsibility to pay the claims.
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 Member Services 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 in-network 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.
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.
