How Your Health Insurance Works
As a member of Blue Cross and Blue Shield of North Carolina (BCBSNC), you should know your rights, how to track claims, how to appeal a decision and other information essential to being an active partner in maintaining your good health. To help you find that information quickly and easily, we put together this summary1 explaining how your 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 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.
To learn more about your benefits and access to medical services, please visit mybcbsnc.com and log in to Blue ConnectSM for details within your benefit booklet.
Your benefit booklet provides information regarding:
- Benefits and services included in, and excluded from, coverage
- Pharmaceutical management procedures, if they exist
- Copayments and other charges for which members are responsible
- Benefit restrictions that apply to services obtained outside the organization's system or service area
- How to submit a claim for covered services, if applicable
- How to obtain information about practitioners who participate in the provider network
- How to obtain primary care services, including points of access
- How to obtain specialty care and behavioral health care services and hospital services
- How to obtain care after normal office hours
- How to obtain emergency care, including the organization's policy on when to directly access emergency care or use 911 services
- How to obtain care and coverage when subscribers are out of the organization's service area
- How to voice a complaint
- How to appeal a decision that adversely affects coverage, benefits or a member's relationship with the organization
- How the organization evaluates new technology for inclusion as a covered benefit
There are two common reasons that an adverse benefit determination2 may be made:
- The service may not be medically necessary
- The service is not covered under your health plan
Your First Step
To find out whether something is covered by your health plan, first carefully review the benefits in your benefit booklet or visit bcbsnc.com/content/services/medical-policy to see our medical policies. If you need more help, a BCBSNC Customer Service professional can help you review your benefits. If you disagree with an adverse benefit determination, you have the right to appeal by following the process below. For more information about the appeals process, please refer to your benefit booklet.
Level One — only level required for individual/direct-pay members for noncertifications
At this level, you can appeal an adverse benefit determination, or submit a grievance, by submitting a written request that includes a description of the situation and, if applicable, a full explanation of why you disagree with the initial BCBSNC decision. Be sure to supply any documentation that supports your position and BCBSNC will review this information. If you disagree with the outcome, in most instances you can proceed to the next level of the appeals process.
Level Two — applicable to employer group health plan members and individual/direct-pay members for grievances
Please refer to your benefit booklet for specific details regarding the Level Two appeals process.
Level Three — external review
For members of fully-insured employer group health plans and individual/direct-pay plans, this level is handled through the North Carolina Department of Insurance (NCDOI). You may request a review through the NCDOI for all medical necessity denials. Generally, you must complete Level One and Level Two appeals before you can appeal to the NCDOI. If your request is accepted by the NCDOI for review, it will be sent to an Independent Review Organization (IRO). BCBSNC must follow the decision of the IRO. For members of non-grandfathered self-funded employer group health plans, the external review by an IRO is facilitated by either BCBSNC or the employer group. You should contact your Plan Administrator for details.
As required by the Women's Health and Cancer Rights Act of 1998, your health insurance policy provides benefits for mastectomy related 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.
* Doctor may also mean a nurse practitioner, physician assistant or other health care expert that you have seen for health care.
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. To find an in-network doctor near you who is qualified to care for adults, visit www.bcbsnc.com and click Find a Doctor or call the customer service number on the back of your member ID card.
- Online: Blue ConnectSM
Access to utilization management review staff:
1-800-672-7897 (toll free)
BCBSNC Customer Service:
1-800-446-8053 8 a.m. – 9 p.m., Monday – Friday
- To receive a printed version of any content, please call the Customer Service number listed on your ID card.
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
- Protecting your 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.
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.
Notice of Privacy Practices
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.