2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 7. Filing a Claim for Covered Services
Section 7. Filing a Claim for Covered Services
Section 7. Filing a Claim for Covered Services
This Section primarily deals with post-service claims (claims for services, drugs, or supplies you have already received).
See Section 3 for information on pre-service claims procedures (services, drugs, or supplies requiring precertification or prior approval), including urgent care claims procedures.
How to claim benefits
To obtain claim forms or other claims filing advice, or answers to your questions about our benefits, contact us at the customer service phone number on the back of your Service Benefit Plan ID card, or at our website at www.fepblue.org.
In most cases, physicians and facilities file claims for you. Just present your Service Benefit Plan ID card when you receive services. Your provider must file on the CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form.
When you must file a claim – such as when another group health Plan is primary – submit it on the CMS-1500 or a claim form that includes the information shown below. Use a separate claim form for each family member. For long or continuing inpatient stays, or other long-term care, you should submit claims at least every 30 days. Bills and receipts should be itemized and show:
Note: Canceled checks, cash register receipts, balance due statements, or bills you prepare yourself are not acceptable substitutes for itemized bills.
In addition:
Post-service claims procedures
We will notify you of our decision within 30 days after we receive your post-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.
If we need an extension because we have not received necessary information (e.g., medical records) from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.
If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.
Prescription drug claims
Preferred Retail Pharmacies – When you use Preferred retail pharmacies, show your Service Benefit Plan ID card. To find a Preferred retail pharmacy, visit www.fepblue.org/provider. If you use a Preferred retail pharmacy that offers online ordering, have your ID card ready to complete your purchase. Preferred retail pharmacies file your claims for you. We reimburse them for your covered drugs and supplies. You pay the applicable coinsurance or copayment.
Note: Even if you use Preferred retail pharmacies, you will have to file a paper claim form to obtain reimbursement if:
See the following paragraphs for claim filing instructions.
Non-preferred Retail Pharmacies
Standard Option: You must file a paper claim for any covered drugs or supplies you purchase at Non-preferred retail pharmacies. Contact your Local Plan or call 800-624-5060 to request a retail prescription drug claim form to claim benefits. Hearing-impaired members with TTY equipment may call 711. Follow the instructions on the prescription drug claim form and submit the completed form to: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057.
Basic Option: There are no benefits for drugs or supplies purchased at Non-preferred retail pharmacies.
Mail Service Prescription Drug Program
Eligible members: We will send you information on our Mail Service Prescription Drug Program, including an initial mail order form. To use this program:
Alternatively, your physician may call in your initial prescription at 800-262-7890, TTY: 711. You are responsible for the copayment. You are also responsible for the copayments for refills ordered by your physician.
After that, to order refills either call the same phone number or access our website at www.fepblue.org and either charge your copayment to your credit card or have it billed to you later. Allow up to ten days for delivery on refills.
Note: Specialty drugs will not be dispensed through the Mail Service Prescription Drug Program. See Section 5(f) for information about the Specialty Drug Pharmacy Program.
Basic Option: The Mail Service Prescription Drug Program is available only to members with primary Medicare Part B coverage under Basic Option.
Specialty Drug Pharmacy Program
Standard and Basic Options: If your physician prescribes a specialty drug that appears on our Service Benefit Plan Specialty Drug List, your physician may order the initial prescription by calling our Specialty Drug Pharmacy Program at 888-346-3731, TTY: 711, or you may send your prescription to: BCBS FEP Specialty Drug Pharmacy Program, CVS Specialty, 9310 Southpark Center Loop, Orlando, FL 32819. You will be billed later for the copayment. The Specialty Drug Pharmacy Program will work with you to arrange a delivery time and location that are most convenient for you. To order refills, call the same phone number to arrange your delivery. You may either charge your copayment to your credit card or have it billed to you later.
Note: For the most up-to-date listing of covered specialty drugs, call the Specialty Drug Pharmacy Program at 888-346-3731, TTY: 711, or visit our website, www.fepblue.org.
Records
Keep a separate record of the medical expenses of each covered family member, because deductibles (under Standard Option) and benefit maximums (such as those for outpatient physical therapy or preventive dental care) apply separately to each person. Save copies of all medical bills, including those you accumulate to satisfy a deductible under Standard Option. In most instances they will serve as evidence of your claim. We will not provide duplicate or year-end statements.
Deadline for filing your claim
Send us your claim and appropriate documentation as soon as possible. You must submit the claim by December 31 of the following year after you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided you submitted the claim as soon as reasonably possible. If we return a claim or part of a claim for additional information (e.g., diagnosis codes, dates of service, etc.), you must resubmit it within 90 days, or before the timely filing period expires, whichever is later.
Note: Timely filing for overseas pharmacy claims is limited to one year from the prescription fill date.
Note: Once we pay benefits, there is a five-year limitation on the re-issuance of uncashed checks.
Overseas claims
Please refer to the claims filing information in Section 5(i).
When we need more information
Please reply promptly when we ask for additional information. We may delay processing or deny benefits for your claim if you do not respond. Our deadline for responding to your claim is stayed while we await all of the additional information needed to process your claim.
Authorized representative
You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, a healthcare professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent. For the purposes of this Section, we are also referring to your authorized representative when we refer to you.
Notice requirements
The Secretary of Health and Human Services has identified counties where at least 10% of the population is literate only in certain non-English languages. The non-English languages meeting this threshold in certain counties are Spanish, Chinese, Navajo, and Tagalog. If you live in one of these counties, we will provide language assistance in the applicable non-English language. You can request a copy of your explanation of benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.
Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the procedure or treatment code and its corresponding meaning.
See Section 3 for information on pre-service claims procedures (services, drugs, or supplies requiring precertification or prior approval), including urgent care claims procedures.
How to claim benefits
To obtain claim forms or other claims filing advice, or answers to your questions about our benefits, contact us at the customer service phone number on the back of your Service Benefit Plan ID card, or at our website at www.fepblue.org.
In most cases, physicians and facilities file claims for you. Just present your Service Benefit Plan ID card when you receive services. Your provider must file on the CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form.
When you must file a claim – such as when another group health Plan is primary – submit it on the CMS-1500 or a claim form that includes the information shown below. Use a separate claim form for each family member. For long or continuing inpatient stays, or other long-term care, you should submit claims at least every 30 days. Bills and receipts should be itemized and show:
- Patient’s name, date of birth, address, phone number, and relationship to enrollee
- Patient’s Plan identification number
- Name and address of person or company providing the service or supply
- Dates that services or supplies were furnished
- Diagnosis
- Type of each service or supply
- Charge for each service or supply
Note: Canceled checks, cash register receipts, balance due statements, or bills you prepare yourself are not acceptable substitutes for itemized bills.
In addition:
- If another health plan is your primary payor, you must send a copy of the explanation of benefits (EOB) form you received from your primary payor (such as the Medicare Summary Notice (MSN)) with your claim.
- Bills for home nursing care must show that the nurse is a registered or licensed practical nurse.
- If your claim is for the rental or purchase of durable medical equipment, home nursing care, or physical, occupational, speech, or cognitive rehabilitation therapy, you must provide a written statement from the provider specifying the medical necessity for the service or supply and the length of time needed.
- Claims for dental care to repair accidental injury to sound natural teeth should include documentation of the condition of your teeth before the accidental injury, documentation of the injury from your provider(s), and a treatment plan for your dental care. We may request updated treatment plans as your treatment progresses.
- Claims for prescription drugs and supplies that are not received from the Retail Pharmacy Program, through the Mail Service Prescription Drug Program, or through the Specialty Drug Pharmacy Program must include receipts that show the prescription number, name of drug or supply, prescribing provider’s name, date, and charge. (See Section 7 for information on how to obtain benefits from the Retail Pharmacy Program, the Mail Service Prescription Drug Program, and the Specialty Drug Pharmacy Program.)
Post-service claims procedures
We will notify you of our decision within 30 days after we receive your post-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.
If we need an extension because we have not received necessary information (e.g., medical records) from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.
If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.
Prescription drug claims
Preferred Retail Pharmacies – When you use Preferred retail pharmacies, show your Service Benefit Plan ID card. To find a Preferred retail pharmacy, visit www.fepblue.org/provider. If you use a Preferred retail pharmacy that offers online ordering, have your ID card ready to complete your purchase. Preferred retail pharmacies file your claims for you. We reimburse them for your covered drugs and supplies. You pay the applicable coinsurance or copayment.
Note: Even if you use Preferred retail pharmacies, you will have to file a paper claim form to obtain reimbursement if:
- You do not have a valid Service Benefit Plan ID card;
- You do not use your valid Service Benefit Plan ID card at the time of purchase; or
- You did not obtain prior approval when required (see Section 3).
See the following paragraphs for claim filing instructions.
Non-preferred Retail Pharmacies
Standard Option: You must file a paper claim for any covered drugs or supplies you purchase at Non-preferred retail pharmacies. Contact your Local Plan or call 800-624-5060 to request a retail prescription drug claim form to claim benefits. Hearing-impaired members with TTY equipment may call 711. Follow the instructions on the prescription drug claim form and submit the completed form to: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057.
Basic Option: There are no benefits for drugs or supplies purchased at Non-preferred retail pharmacies.
Mail Service Prescription Drug Program
Eligible members: We will send you information on our Mail Service Prescription Drug Program, including an initial mail order form. To use this program:
- Complete the initial mail order form;
- Enclose your prescription and copayment;
- Mail your order to CVS Caremark, P.O. Box 1590, Pittsburgh, PA 15230-1590; and
- Allow up to two weeks for delivery.
Alternatively, your physician may call in your initial prescription at 800-262-7890, TTY: 711. You are responsible for the copayment. You are also responsible for the copayments for refills ordered by your physician.
After that, to order refills either call the same phone number or access our website at www.fepblue.org and either charge your copayment to your credit card or have it billed to you later. Allow up to ten days for delivery on refills.
Note: Specialty drugs will not be dispensed through the Mail Service Prescription Drug Program. See Section 5(f) for information about the Specialty Drug Pharmacy Program.
Basic Option: The Mail Service Prescription Drug Program is available only to members with primary Medicare Part B coverage under Basic Option.
Specialty Drug Pharmacy Program
Standard and Basic Options: If your physician prescribes a specialty drug that appears on our Service Benefit Plan Specialty Drug List, your physician may order the initial prescription by calling our Specialty Drug Pharmacy Program at 888-346-3731, TTY: 711, or you may send your prescription to: BCBS FEP Specialty Drug Pharmacy Program, CVS Specialty, 9310 Southpark Center Loop, Orlando, FL 32819. You will be billed later for the copayment. The Specialty Drug Pharmacy Program will work with you to arrange a delivery time and location that are most convenient for you. To order refills, call the same phone number to arrange your delivery. You may either charge your copayment to your credit card or have it billed to you later.
Note: For the most up-to-date listing of covered specialty drugs, call the Specialty Drug Pharmacy Program at 888-346-3731, TTY: 711, or visit our website, www.fepblue.org.
Records
Keep a separate record of the medical expenses of each covered family member, because deductibles (under Standard Option) and benefit maximums (such as those for outpatient physical therapy or preventive dental care) apply separately to each person. Save copies of all medical bills, including those you accumulate to satisfy a deductible under Standard Option. In most instances they will serve as evidence of your claim. We will not provide duplicate or year-end statements.
Deadline for filing your claim
Send us your claim and appropriate documentation as soon as possible. You must submit the claim by December 31 of the following year after you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided you submitted the claim as soon as reasonably possible. If we return a claim or part of a claim for additional information (e.g., diagnosis codes, dates of service, etc.), you must resubmit it within 90 days, or before the timely filing period expires, whichever is later.
Note: Timely filing for overseas pharmacy claims is limited to one year from the prescription fill date.
Note: Once we pay benefits, there is a five-year limitation on the re-issuance of uncashed checks.
Overseas claims
Please refer to the claims filing information in Section 5(i).
When we need more information
Please reply promptly when we ask for additional information. We may delay processing or deny benefits for your claim if you do not respond. Our deadline for responding to your claim is stayed while we await all of the additional information needed to process your claim.
Authorized representative
You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, a healthcare professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent. For the purposes of this Section, we are also referring to your authorized representative when we refer to you.
Notice requirements
The Secretary of Health and Human Services has identified counties where at least 10% of the population is literate only in certain non-English languages. The non-English languages meeting this threshold in certain counties are Spanish, Chinese, Navajo, and Tagalog. If you live in one of these counties, we will provide language assistance in the applicable non-English language. You can request a copy of your explanation of benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.
Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the procedure or treatment code and its corresponding meaning.