Frequently Asked Questions


General Product Information

Benefits and Coverage

Providers

Claims

Out-of-Pocket Expense

Prior Review & Precertification



General Product Information    top

Q: What if I have a medical question in the middle of the night?

You can call your primary care physician or you can call Health Line BlueSM at 1-877-477-2424. This 24-hour, health information line 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 currently cover your dependent(s) under a Blue Options plan, your dependent(s) moving out-of-state will continue to be covered until age 26. Please review your Member Guide or consult your employer regarding dependent eligibility requirements.

Q: What do I do if I need care while traveling?

Blue Cross and Blue Shield of North Carolina's BlueCard® program offers cost-effective, quality health care for covered members traveling outside of North Carolina. You may call 1-800-810-BLUE (2583) to find participating providers anywhere in the United States. You may also visit www.bcbs.com to obtain detailed information about the program as well as check for BlueCard participating providers by specialty and geographic location. Make sure to show your ID card to identify yourself as a Blue Cross and Blue Shield of North Carolina member. The participating provider will file the claim for you.

In addition, BlueCard Worldwide offers Blue Options members the ability to receive in-network benefits for inpatient health care at participating hospitals in major travel destinations and business centers throughout the world. You can find out which providers participate by calling 1-800-810-BLUE (2583). You may also visit www.bcbs.com to access the BlueCard Doctor and Hospital Finder. You are responsible for contacting BCBSNC for any care requiring precertification.

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. For nonparticipating pharmacies you will receive out-of-network benefits. (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.)


Benefits and Coverage    top

Q: Does Blue Options cover routine physical exams and immunizations?

Yes. Check out the About My Plan section for additional information on your Blue Options coverage.

Q: If my doctor does not participate in the Blue Options plan, can I still have my routine physical with him or her and just pay the out-of-network costs?

No. There are no routine benefits for out-of-network services.

Q: What services are covered when I receive a routine exam?

Routine exams include services recommended by the American Medical Association guidelines.

Q: What if I take my child for his/her immunizations, but he/she can't receive them because he/she is sick?

Make another appointment for the immunizations. You don't have to pay a copayment for the next visit if your child only receives immunizations.

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 an in-network or out-of-network 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, outpatient 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 in-network benefits.

Q: What happens to my coverage if I move out of the area?

Blue Cross and Blue Shield of North Carolina's BlueCard® program offers cost-effective, quality health care for covered members living outside of North Carolina. BlueCard is a valuable program that provides you network access and provider discounts across the United States.

Under the BlueCard program, members who live outside of North Carolina can visit a network provider in the state where services are rendered and show their ID card to identify himself or herself as a Blue Cross and Blue Shield of North Carolina member.

After services are rendered, the network provider files the claim for you and routes it to the local Blue Cross and Blue Shield Plan. After applying network discounts, the local Blue Cross and Blue Shield Plan sends the claim to BCBSNC where the applicable fees are paid.

You will be responsible for all applicable deductibles and coinsurance as well as meeting any precertification requirements.

BlueCard is ideal for members who have children attending out-of-state schools. You can find preferred providers anywhere in the United States by calling 1-800-810-BLUE (2583). You may also visit www.bcbs.com to obtain detailed information about the program as well as check for Blue Cross and Blue Shield participating providers by specialty and geographic location. With BlueCard, the provider files the claim for you and it is processed as described above.

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. For nonparticipating pharmacies you will receive out-of-network benefits. (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?

Blue Cross and Blue Shield of North Carolina's BlueCard program offers cost-effective, quality health care for covered members traveling outside of North Carolina. BlueCard is a valuable benefit that provides you network access and provider discounts across the United States. The discounts received through Blue Cross and Blue Shield participating providers in other states reduce the amount of billed charges, which reduces the amount that you owe.

Under the BlueCard program, you can travel outside of North Carolina and visit a network provider in the state where services are rendered. Make sure to show your ID card to identify yourself as a Blue Cross and Blue Shield member.

After services are rendered, the network provider files the claim for the member and routes it to the local Blue Cross and Blue Shield Plan. After applying network discounts, the local Plan sends the claim to BCBSNC where we make applicable payments.

You will be responsible for all applicable deductibles and coinsurance as well as meeting any precertification requirements.

BlueCard is ideal for members who have children attending out-of-state schools or for anyone who travels. You may call 1-800-810-BLUE (2583) to find preferred providers anywhere in the United States. You may also visit www.bcbs.com to obtain detailed information about the program as well as check for BlueCard participating providers by specialty and geographic location. The provider files the claim for you and it is processed as described above.

In addition, BlueCard Worldwide offers Blue Options members the ability to receive in-network benefits for inpatient health care at participating hospitals in major travel destinations and business centers throughout the world. You can find out which providers participate by calling 1-800-810-BLUE (2583). You can also visit www.bcbs.com to access the BlueCard Doctor and Hospital Finder. You are responsible for contacting BCBSNC for any care requiring precertification.

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. For nonparticipating pharmacies you will receive out-of-network benefits. (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?

Blue Cross and Blue Shield of North Carolina's BlueCard program offers cost-effective, quality health care for covered members traveling outside of North Carolina. BlueCard is a valuable benefit that provides network access and provider discounts to BCBSNC members across the United States. The discounts received through Blue Cross and Blue Shield participating providers in other states reduce the amount of billed charges, which also reduces the amount that you owe.

Under the BlueCard program, you can travel outside of North Carolina and visit a network provider in the state where services are rendered. Make sure to show your ID card to identify yourself as a BlueCard member.

After services are rendered, the network provider files the claim for the member and routes it to the local Blue Cross and Blue Shield Plan. After applying network discounts, the local Blue Cross and Blue Shield Plan sends the claim to BCBSNC and we make applicable payments.

You will be responsible for all applicable deductibles and coinsurance as well as meeting any precertification requirements.

BlueCard is ideal for members who have children attending out-of-state schools or for anyone who travels. You can call 1-800-810-BLUE (2583) to find preferred providers anywhere in the United States. You can also visit www.bcbs.com to obtain detailed information about the program as well as check for participating providers by specialty and geographic location. The provider files the claim for you and it is processed as described above.

In addition, BlueCard Worldwide offers Blue Options members the ability to receive in-network benefits for inpatient health care at participating hospitals in major travel destinations and business centers throughout the world. You can find out which providers participate by calling 1-800-810-BLUE (2583). You may also visit www.bcbs.com and use the online BlueCard Doctor and Hospital Finder. You are responsible for contacting BCBSNC for any care requiring precertification.


Providers    top

Q: How can I find a preferred 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 listing 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 Options member, you may visit any in-network physician. You can locate in-network 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, please call BCBSNC Customer Service to assist you. If one is not reasonably available, work with your provider to contact BCBSNC for authorization. You can also submit your claim to be reimbursed based on out-of-network benefits.

Q: Can I go to a non-network provider?

In most cases you may visit a non-network provider, but covered services would be paid at the out-of-network benefit level. Please note that BCBSNC will only pay benefits up to the allowed amount. Out-of-network providers may bill you the difference between what BCBSNC pays and the actual charge. Routine care will not be covered out of the network. NOTE: Some PPO plans do not cover out-of-network services. Please refer to your Member Guide and Summary of Benefits to see if this applies to you.

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.)

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.


Claims    top

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
P. O. Box 90320
Richmond, VA 23230

You may view a listing of participating hospitals or obtain an international claim form at http://www.bcbs.com/already-a-member/coverage-home-and-away.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.

Q: Can I get reimbursed for drugs I got from a pharmacy outside of the network?

Yes. You may be reimbursed for prescription drugs that you received from an out-of-network pharmacy, but you may have to pay full charges at the pharmacy and file the claim. You will receive out-of-network benefits and be responsible for paying the copayment amount (or other member liability such as coinsurance or deductible) plus any charges exceeding the in-network allowed amount.

However, chances are good that your pharmacy will be participating. Ninety-four percent of North Carolina pharmacies contract with us, providing 99.5 percent of all members access to at least one pharmacy within 20 miles. If you cannot locate a participating pharmacy within 20 miles of your home, please call Customer Service at 1-877-258-3334. Also, at least 96 percent of U.S. pharmacies outside of North Carolina participate in our national network. (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.)


Out-of-Pocket Expense    top

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    top

Q: What services require Prior Review or a referral?

Referrals
You do not need to get a referral from your primary care provider to receive covered services from a participating specialist. However, some participating specialists may require a new patient introduction from your treating doctor. BCBSNC recommends that you take advantage of your primary care provider's expertise in coordinating your care.

Prior Review
Most inpatient admissions, skilled nursing facility admissions, and all private duty nursing services require Prior Review from Blue Cross and Blue Shield of North Carolina (BCBSNC). In addition, BCBSNC requires Prior Review for certain other outpatient services.

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.

Except for office visits, Magellan Behavioral Health must approve services for mental health and substance abuse in advance. Please call the behavioral health and substance abuse number listed on your BCBSNC ID card.

The list of services, which must be approved in advance, may change from time to time. For the current list of services requiring Prior Review, please refer to our prior plan review list or call the Customer Service number on your BCBSNC ID card.

Additionally, some prescription drugs require Prior Review to be covered. Some prescription drugs are also 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.

If your services are out-of-network or you receive services outside of North Carolina, you are responsible for requesting or having your provider request Prior Review for those services that require preauthorization from BCBSNC.

Q: How do I get Prior Review or a referral?

Prior Review
Participating providers or specialists will coordinate Prior Reviews or Precertification for you. You may want to check with your participating provider to make sure Prior Review has been obtained. For services at a nonparticipating provider or out-of-state, you are responsible for having your provider request preauthorization when the services you receive require Prior Review from BCBSNC.

Referrals
You do not need to get a referral from your primary care provider to receive covered services from a participating specialist. However, some participating specialists may require a new patient introduction from your treating doctor.