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New Member Liability Collection Policy for Blue Options^SM Deductible and Coinsurance-Only Products - Beginning October 1, 2009

Blue Cross and Blue Shield of North Carolina (BCBSNC) offers product choices to our members that include deductible and coinsurance-only health plans such as Blue Options HSA^SM and Blue Options HRA^SM. These are health plans that do not have copayments and present a different collecting environment for you, the provider.

BCBSNC currently maintains a policy that offers participating providers the option to collect from members enrolled in any of our Blue Options^SM deductible and coinsurance only products (products without copayments), an estimated amount of the member's out-of-pocket expense at the time of service. This existing policy sets limitations on the estimated amounts that can be collected; physicians and professional providers may collect up to the lesser of the member's estimated out-of-pocket costs or $50 for services received in the provider's office; hospitals and ancillary providers may collect up to the lesser of the member's estimated out-of-pocket costs or $500 for services received in a hospital or outpatient facility such as an emergency room or ambulatory surgery center.

Effective October 1, 2009, we are making available a new policy for upfront collection of member liability. Under the guidelines of this new policy providers will be able to collect from members enrolled in the Blue Options^SM deductible and coinsurance-only products, estimated liability amounts without the $50-professional/$500-facility limitations.

Providers electing to follow the guidelines of the new policy will have the option to collect from a member enrolled in a non-copayment plan, the estimated patient responsibility for applicable coinsurance and/or deductible amounts. Additionally, included in this new policy is the option for providers to request from members enrolled in plans that include copays, an upfront estimation of member liability. However, this can only be a request for payment. Members having a copayment as part of their benefits make-up are only required to pay the member copay amount at the time of receiving service.

Guidelines for upfront collection of member liability

(Effective for patient care provided on or after October 1, 2009)

Collection of a member's estimated patient responsibility may be collected at the time of service when the member is enrolled in one of the BCBSNC Blue Options^SM deductible and coinsurance only products (products without copayments) and the participating provider follows the below guidelines:

• An established policy is maintained by the provider for collection of estimated patient financial responsibility, and the provider assists the member with payment plan options in the event that a member cannot pay the complete estimated patient responsibility in advance of receiving service. If a member is unable to pay at the time of service, the provider should not refuse to provide necessary treatment to the member.
• The member must be informed by the provider that the amount being collected is an estimated amount.
• The payment amount requested is according to the provider's negotiated BCBSNC network fee schedule that's effective at the time of service, and appropriate to that member's particular coverage plan type.
• The collecting provider's staff must have access to their current fee allowances (BCBSNC allowable reimbursements for billed charges), a listing of specific services to be delivered to a member that includes CPT codes and applicable allowances for those CPT codes, accompanied with the codes/charges to be billed to BCBSNC for the member's incident of care.
• Collecting providers must calculate the member's out-of-pocket costs based on the lesser of the allowable reimbursement amount or billed charges, taking into account the member's benefit year-to-date deductible or coinsurance benefit status (amount met).
• Collection is only of an amount determined to be accurate with reasonable certainty through the provider's validation of the member's estimated liability, using tools such as Blue e^SM and/or RealMed.
• The collecting provider's staff must have access, utilize and take into consideration C-3 bundling logic and BCBSNC policies addressing; medical, payment and evidence based guidelines.
• The collecting provider's staff must have access, utilize and take into consideration C-3 bundling logic and BCBSNC policies addressing; medical, payment and evidence based guidelines.
• The collecting provider agrees that the final determination of what the member owes will be based on the claim that is submitted to BCBSNC, and as reflected on the final EOP (explanation of payment) from BCBSNC.
• The collecting provider agrees that any applicable refund for overpayment owed to a member will be issued as soon as identified, but no later than 45 days after payment is received for the service.
• Some ASO groups may have specific requirements around upfront member collections. This information is typically found on the member ID card. BCBSNC requests participating providers honor these special requests and collect according to these specified amounts.

Blue Cross and Blue Shield of North Carolina (BCBSNC) policy for all other products prohibits participating providers from requiring upfront payment from a member (other than copayments) until the EOP is received from BCBSNC indicating the correct amount to be collected. Providers following the above guidelines may elect to request estimated amounts from members not enrolled in the BCBSNC Blue Options^SM deductible and coinsurance only products, as long as not a prerequisite for receiving service.

Special instructions

Emergency room

Members enrolled in non-copayment plans seeking care at the ER cannot be required to pay any charges until the BCBSNC explanation of payment (EOP) is received. Following the guidelines above, payment of estimated patient responsibility may be requested for ER services but is not required until receipt of the BCBSNC EOP.

Members enrolled in copayment plans can be requested (and are required) to pay applicable copayments at the time of service or following treatment, however treatment cannot be denied prior to payment. Following the guidelines above, payment of estimated patient responsibility may be requested for ER services but is not required (other than applicable copayments) until receipt of the BCBSNC EOP.

Urgent care

Urgent care providers have the option to follow the above guidelines to bill members enrolled in non-copayment plans an estimated patient responsibility at the time of service or following treatment. Urgent treatment should not be denied prior to payment.

Members enrolled in copayment plans can be requested (and are required) to pay applicable copayments at the time of service or following treatment. Urgent care providers following the guidelines above can request payment of estimated patient responsibility; however members are required to pay copays only. Urgent treatment should not be denied prior to payment.

Hospital and freestanding facilities

Hospitals and freestanding facilities cannot require payment from the member beyond any applicable copayment. Members enrolled in both copayment plans and non-copayment plans can be requested to pay an estimated patient responsibility or enter into a payment plan, but are not required to pay until after receipt of the BCBSNC EOP. Additionally, members should not be sent a final bill until after receipt of the BCBSNC EOP.