How Our Health Insurance Works
To help you find that information quickly and easily, we put together this summary1 explaining how our health insurance works, with additional information about BCBSNC Quality Improvement programs.
As a BCBSNC member, you have certain rights and responsibilities. These guidelines are included in your BCBSNC benefit booklet, or you can view them online at bcbsnc.com.
To access Member Rights and Responsibilities, visit bcbsnc.com/memberservices/public/forms. On that page, you'll find the "Rights & Responsibilities" link on the left, where you can view a page detailing what you can expect from BCBSNC and what we expect from you.
If you'd like us to mail you a printed copy of your benefit booklet, just call the toll-free number on your BCBSNC ID card to request a copy.
Member's Rights and Responsibilities
As a Blue Cross and Blue Shield of North Carolina (BCBSNC) member, you have the right to:
- Receive information about your coverage and your rights and responsibilities as a member.
- Receive, upon request, facts about your plan, including a list of doctors and health care services covered.
- Receive polite service and respect from BCBSNC.
- Receive polite service and respect from the doctors who are part of the BCBSNC networks.
- Receive the reasons why BCBSNC denied a request for treatment or health care service, and the rules used to reach those results.
- Receive, upon request, details on the rules used by BCBSNC to decide whether a procedure, treatment, site, equipment, drug or device needs prior approval.
- Receive, upon request, a copy of BCBSNC's list of covered prescription drugs. You can also request updates about when a drug may become covered.
- Receive clear and correct facts to help you make your own health care choices.
- Play an active part in your health care and discuss treatment options with your doctor without regard to cost or benefit coverage.
- Participate with practitioners in making decisions about your health care.
- Expect that BCBSNC will take measures to keep your health information private and protect your health care records.
- Voice complaints and expect a fair and quick appeals process for addressing any concerns you may have with BCBSNC.
- Make recommendations regarding BCBSNC's member rights and responsibilities policies.
- Receive information about BCBSNC, its services, its practitioners and providers and members' rights and responsibilities.
- Be treated with respect and recognition of your dignity and right to privacy.
As a BCBSNC member, you should:
- Present your BCBSNC ID card each time you receive a service.
- Read your BCBSNC benefit booklet and all other BCBSNC member materials.
- Call BCBSNC when you have a question or if the material given to you by BCBSNC is not clear.
- Follow the course of treatment prescribed by your doctor. If you choose not to comply, advise your doctor.
- Provide BCBSNC and your doctors with complete information about your illness, accident or health care issues, which may be needed in order to provide care.
- Understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible.
- Make appointments for non-emergency medical care and keep your appointments. If it is necessary to cancel an appointment, give the doctor's office at least 24-hours notice.
- Play an active part in your health care.
- Be polite to network doctors, their staff and BCBSNC staff.
- Tell your place of work and BCBSNC if you have any other group coverage.
- Tell your place of work about new children under your care or other family changes as soon as you can.
- Protect your BCBSNC ID card from improper use.
- Comply with the rules outlined in your member benefit guide.
As required by the Women's Health and Cancer Rights Act of 1998, your health insurance policy provides benefits for mastectomyrelated services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses and complications resulting from a mastectomy, including lymphedema. This coverage is subject to the same deductibles, copayments, coinsurance or limitations as applied to other medical and surgical benefits provided under your policy. If you have questions, please check your benefit booklet or call the Customer Service number on your ID card for more information.
At BCBSNC, when you change health plans or your doctor* is no longer part of the BCBSNC network, you may be eligible to get continued care from your doctor for a short time. During that time, you and your doctor should look for a new, in-network doctor for your care. BCBSNC will help its members who need continued care during a change in coverage. This process is called “continuity of care."
To be eligible for continuity of care, one of these four conditions must apply:
- You have a short-term health problem that is life-threatening and needs continued care from your doctor to prevent a chance of death or permanent harm.
- You have a long-term health problem that is life-threatening, degenerative or disabling and need continued care over a longer time.
- You are in the second or third trimester of pregnancy or completing post-partum care.
- You have a terminal illness, which means a medical prognosis that puts your life expectancy at six months or less.
You must send a request to BCBSNC for continuity of care. A BCBSNC nurse will review your request. You can call Customer Service at the phone number on the back of your ID card and ask for a continuity of care request form. Your doctor also has to agree to BCBSNC's rules for continued care.
If you are new to BCBSNC, you must send the form in within 45 days of your effective date.
If you are not a new member and have learned that your doctor is not in the BCBSNC network, you must send the form in within 45 days from when you found out your doctor was out of BCBSNC's network.
For teenagers and young adults, it can be tough to know when to switch from their childhood doctor to one who specializes adult care. Most choose to make this transition around 18 to 21 years of age. BCBSNC can help members find an in-network doctor near them who is qualified to care for adults. If you are a pediatrician, you can also help your teenage and young adult patients transition to a primary care provider for adults.
Through its Physician Advisory Group and Quality Improvement Committee, BCBSNC has established Access to Care Standards so that you'll know you can get the care you need, when you need it. BCBSNC and BCBSNC contracting physicians are committed to meeting these standards in order to provide the best service possible.
Search for prescription drugs and pharmacy services, or obtain a list of pharmaceuticals.
Some medications require more than a provider's prescription in order to be covered by BCBSNC. These medications require that you meet certain criteria. Your provider must also answer specific questions prior to coverage. This allows all of us to work together to provide you with the safest, most effective and cost-efficient medications.
The BCBSNC Care Management & Operations (CM&O) Department works with physicians and members to facilitate the most medically appropriate, cost-effective, quality care for our members. In Care Management & Operations find out about:
- Access to utilization management staff
- How medical necessity decisions are made
- Peer-to-peer review
- Protecting your patients' health care needs
BCBSNC offers a suite of health management programs for select health conditions for our commercial members called Healthy Outcomes. This confidential program is available to eligible members at no cost. Members can visit Blue ConnectSM for more information and to take advantage of our helpful online tools, trackers, modules and articles to help them manage their health.
Practitioners have the right to review information submitted to support their credentialing application, as well as correct any erroneous information included in their file. Practitioners also have the right to receive status updates for their application upon request. Learn more about your rights according to BCBSNC and the National Committee for Quality Assurance (NCQA) guidelines.
All BCBSNC guidelines are based on the most current scientific evidence, and are adapted from standards published by nationally recognized authorities. In addition, each guideline is reviewed and approved at least bienially by BCBSNC's Physician Advisory Group.
At BCBSNC, we want to help improve the health and well-being of our members, as well as encourage simplicity and affordability in health care. To meet these goals we continually review our quality processes, assess member programs and offerings, and ensure care is based on strong clinical evidence. Learn more about what we're doing to improve health care quality.
- Medical Policies
- Prior Review
- Medical Policy and Pre-certification/Pre-authorization Information for Out-of-Area Members
1 In the event of any inconsistency between information contained in this summary and the member's Benefit Booklet, the Benefit Booklet shall govern.
2 The Benefit Booklet defines an adverse benefit determination as follows: A denial, reduction or termination of, or failure to provide full or partial payment for, a benefit, including one that results from the application of any utilization review, or a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate. Rescission of coverage is also included as an adverse benefit determination.
The National Committee for Quality Assurance (NCQA) is an independent, not-for-profit organization that evaluates and reports on the quality of the nation's managed care plans. NCQA maintains and regularly updates quality standards utilized by the health insurance industry to gauge levels of ongoing quality and improvement. The NCQA accreditation program helps employers and consumers compare health plans based on various quality measures.