Frequently Asked Questions
Prior Review & Precertification
Q: What if I have a medical question in the middle of the night? You can call your primary care physician or Health Line Blue®. This 24-hour, health information line (1-877-477-2424) allows you to have a confidential conversation about your health questions with a registered nurse anytime of the day or night. Q: Can I cover a dependent who lives out-of-state or is away at school? If you or your covered dependent(s) move outside of the Blue Care service area, please contact your group administrator to find out your options. Dependent(s) may only receive Blue Care benefits for emergency or urgent care. If your dependent needs to fill a prescription, BCBSNC offers a comprehensive pharmacy network within the 50 United States, and you will receive the in-network level of prescription drug benefits at any participating pharmacy. Call BCBSNC Customer Service to identify participating pharmacies in the 50 United States. (In some cases, employer groups carve out the prescription drug benefit and contract with a vendor separately from BCBSNC. Please refer to your Member Guide to confirm that your pharmacy benefits are offered through BCBSNC.) In addition, guest membership is available to certain members such as students or workers on temporary assignment. If your dependent(s) will be out of the service area for at least 90 days, you or your dependent(s) will be eligible for this program. Under guest membership, your dependent(s) would enroll in the Health Maintenance Organization (HMO) offered by the Blue Cross and Blue Shield Plan in the state where your dependent(s) temporarily resides. In addition, he/she would receive an ID card and benefit booklet from that plan. While participating in the guest membership program, your dependent receives all services covered by the product offered through the Blue Cross and Blue Shield Plan in the state where he or she would receive care. Your dependent is responsible for following that plan's guidelines for accessing care. Q: What do I do if I need care while traveling? If you travel outside of Blue Care's service area, you may receive Blue Care benefits for emergency care, in-network urgent care, and approved follow-up care only. Non-emergency or non-urgent care outside of the Blue Care service area is not a covered benefit. In an emergency, visit the nearest hospital. In an urgent care situation, contact the BlueCard® Information Line at 1-800-810-BLUE (2583). A patient care coordinator will provide you with names and contact information for providers in the area. If you need to fill a prescription, BCBSNC offers a comprehensive pharmacy network within the 50 United States, and you will receive the in-network level of prescription drug benefits at any participating pharmacy. Call BCBSNC Customer Service to identify participating pharmacies in the 50 United States. (In some cases, employer groups carve out the prescription drug benefit and contract with a vendor separately from BCBSNC. Please refer to your Member Guide to confirm that your pharmacy benefits are offered through BCBSNC.) Q: Does Blue Care cover routine physicals and immunizations? Yes. Check out the Blue Care Available Benefits section for additional information about your coverage. Q: What services are covered when I receive a routine exam? Routine exams include services recommended by the American Medical Association guidelines. Q: Do you cover emergency care? Yes, your health plan provides benefits for the treatment of an emergency. If you go to an emergency room for treatment of an emergency, your benefits will be the same, regardless of whether you use a participating or nonparticipating provider. If you are admitted to the hospital from the emergency room or held for observation, your initial hospital admission is eligible for in-network benefits and the emergency room copayment will be waived. If you are held for observation, out-patient benefits will apply and your emergency room copayment will be waived. Once you are admitted as a hospital inpatient, your benefits will be paid like any other inpatient facility or professional charges. However, you may need to transfer to a participating hospital once your condition has been stabilized in order to continue receiving benefits. Q: What happens to my coverage if I move out of the area? Permanent Move Temporary Move In addition, guest membership is available to certain members such as students or workers on temporary assignment. If you will be out of the service area for at least three months but less than six months or your dependent(s) will be out of the service area for at least 90 days, you or your dependent(s) will be eligible for this program. Under guest membership, you or your dependent(s) would enroll in the HMO offered by the Blue Cross and Blue Shield Plan in the state where the member temporarily resides. You or your dependent(s) would also receive an ID card and benefit booklet from that Plan. While participating in the guest membership program, the member receives all services covered by the product offered through that Blue Cross and Blue Shield Plan in the state where the member would receive care. The member is responsible for following that Plan's guidelines for accessing care. If you need to fill a prescription, BCBSNC offers a comprehensive pharmacy network within the 50 United States, and you will receive the in-network level of prescription drug benefits at any participating pharmacy. Call BCBSNC Customer Service to identify participating pharmacies in the 50 United States. If you use a nonparticipating pharmacy, you will not receive benefits, except in case of emergency. (In some cases, employer groups carve out the prescription drug benefit and contract with a vendor separately from BCBSNC. Please refer to your Member Guide to confirm that your pharmacy benefits are offered through BCBSNC.) Q: What routine coverage do I have while I am traveling? Non-emergency or non-urgent care outside of the Blue Care service area is not a covered benefit. If you travel outside of Blue Care's service area, you may receive Blue Care benefits for emergency care, in-network urgent care, and approved follow-up care only. If you need to fill a prescription, BCBSNC offers a comprehensive pharmacy network within the 50 United States, and you will receive the in-network level of prescription drug benefits at any participating pharmacy. Call BCBSNC Customer Service to identify participating pharmacies in the 50 United States. (In some cases, employer groups carve out the prescription drug benefit and contract with a vendor separately from BCBSNC. Please refer to your Member Guide to confirm that your pharmacy benefits are offered through BCBSNC.) Q: What emergency coverage do I have while I am traveling? If you travel outside of Blue Care's service area, you may receive Blue Care benefits for emergency care, in-network urgent care, and approved follow-up care. Non-emergency or non-urgent care outside of the Blue Care service area is not a covered benefit. In an emergency, please visit the nearest hospital. In an urgent care situation, contact the BlueCard Information Line at 800-810-BLUE (2583). A patient care coordinator will provide you with names and contact information for providers in the area. Q: What is a primary care physician? Primary care physicians handle the majority of your health care and can be general practitioners, family doctors, general internists or pediatricians and some internal medicine doctors. Q: Can I change my primary care physician? Yes. Please visit Find a Doctor to locate a new participating Primary care physician at anytime. This is an open access policy that does not require an assigned primary Care Provider. Q: Does everyone in my family have to use the same Primary care physician? No. Each family member can have the same or a different primary care physician. Q: What if my current doctor is not in the network? You would not receive benefits and you would need to obtain a new primary care physician in order to take advantage of your coverage. Q: What happens if I need to see a specialist? Just make sure they are participating and a referral is not necessary— except if you are seeking mental health services. (Mental health services must be authorized by Magellan Behavioral Health.) Q: How can I find a participating doctor? Use our online Provider Search. New providers will continue to be added to the network and some providers may elect to discontinue their participation. We update our online provider listings weekly. Please check again if your provider is not included in this week's listing. Q: What if a primary care physician cannot see me right away? As a Blue Care member, you may visit any participating physician. You can locate participating providers by visiting our online Provider Search or by calling Customer Service at 1-877-258-3334. Q: What if a network provider isn't available to treat my condition? If you have not found a network provider to be reasonably available, call BCBSNC Customer Service to assist you. If one is not reasonably available, work with your provider to contact BCBSNC at 1-800-672-7897 for authorization. Q: Can I go to a non-network provider? No, Blue Care is an HMO product; therefore, only care from participating providers is covered—except for emergency care or if a North Carolina provider was not accessible for the type of care required. Q: What do I do with a foreign medical bill for care I received outside of the U.S.? If you receive a bill for inpatient, outpatient or professional medical care received outside the United States, please send the bill with an international claim form to our foreign claims center at: BlueCard Worldwide Service Center You may view a listing of participating hospitals or obtain an international claim form at http://www.bcbs.com/bluecardworldwide/index.html. The BlueCard Worldwide Service Center translates foreign claims and calculates the foreign exchange rate. The Service Center then forwards the claim to BCBSNC to be processed. If you receive a foreign medical bill for prescription drugs, outpatient hospital services or other medical services that you received outside of the United States, please file those claims directly to BCBSNC. Q: If I take all of my children to their primary care physician at the same time, how much do I pay? You pay one copayment for each child. Q: What is a copayment? A copayment is a fixed-dollar amount that you pay for some services (usually paid at the time the service is provided). Q: Do I have to pay a copayment for my weekly allergy shot? Not necessarily. You only pay a copayment when there is a medical service provided by your primary care physician or specialist. If your provider elects to file an office visit combined with the service, the office visit is subject to copayment.
Prior Review & Precertification Q: Do I have to get a referral from my primary care physician in order to see my OB/GYN? No. This is an open-access policy and no referrals are needed. Check out our Provider Search for a participating OB/GYN. Q: What services require Prior Review or a referral? Referrals Prior Review For maternity admissions, your doctor is not required to obtain Prior Review from BCBSNC for prescribing a length of stay up to 48 hours for a normal vaginal delivery or up to 96 hours for delivery by Cesarean section. You or your doctor must request Prior Review for coverage for additional days. Although no Prior Review is required for emergency situations, please notify BCBSNC of your inpatient admission as soon as reasonably possible. Mental health and substance abuse services must be approved in advance by Magellan Behavioral Health. Please call the mental health and substance abuse number on your ID card for preauthorization. The list of services, which must be approved in advance, may change from time to time. For a current list of services that require Prior Review, please refer to our Prior plan review list or call the Customer Service number on the back of your BCBSNC ID card. Some prescription drugs require Prior Review in order to be covered. Additionally, some prescription drugs are subject to quantity limits based on criteria developed by BCBSNC. For these drugs, Prior Review is required before excess quantities will be covered. Some drugs have absolute quantity limits which cannot be exceeded. To get a list of these types of prescription drugs, visit our Prior Review and quantity limitations page or call the Customer Service number on your BCBSNC ID card. Please note that BCBSNC may occasionally change the list of these prescription drugs. Prior Review will be waived for restricted access drugs and devices if the member's provider certifies that a nonrestricted formulary drug or device has been harmful or ineffective in treating the member's condition. |
