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Your plan for better health

Frequently Asked Questions


General Product Information

Benefits and Coverage

Claims

Out-of-Pocket Expense

Prior Review and Precertification

Pharmacy



General Product Information

How do I know if I am eligible for Blue Advantage coverage?    top

Eligibility requirements for Blue Advantage include that you are a North Carolina resident, you are under 65 years old and do not qualify for Medicare, and that you are not covered by other health insurance as of the effective date of your Blue Advantage coverage.


What are my premium payment options?    top

As a Blue Advantage member, you can have your health insurance premium payment deducted directly from your bank account. Once logged in into Member Services, go to the My Account tab and click on Billing and Payments. Then click on the Make a Payment link. You can choose to make a one-time bank-draft payment, or set up automatic monthly bank-draft payments. By choosing automatic (recurring) monthly bank-draft payments, you wonít ever have to worry about postage or forgetting to mail in your payment again. Each month, your payment will automatically be deducted from your bank account and you will see the transaction on your monthly bank statement. We donít charge members for this convenient service, but some banks may charge a fee for automatic bank drafts. Check with your bank for terms and details.

You also have the option to make your payment by postal mail. You can pay by personal check, money order, or credit card. At this time, BCBSNC is unable to accept payments by phone.

For additional information, please visit the Billing and Payments FAQ page.


What are benefit period deductibles?    top

This is the amount you pay for some services before Blue Advantage pays its portion. Once three family members meet their individual deductibles, no additional individual deductibles are required for the remainder of the benefit period. The benefit period is listed on your Member Services, View my Benefits screen.

Deductible Options - Choose the deductible that best meets your needs:

Plan A  $250, $500, $1000, $2500
Plan B  $500, $1000, $2500, $3500, $5000
Plan C  $1000, $2500, $3500, $5000


When will my Blue Advantage coverage begin?    top

Your coverage can begin on the 1st or the 15th of the month. If your application is received by the 8th of the month, your coverage can begin as soon as the 15th of that same month. If your application is received by the 22nd of the month, your coverage can begin as soon as the 1st of the following month. Requested effective dates may not be more than 60 days from the date you submit your application.


How do I renew my coverage?    top

Your coverage is automatically renewed when you continue to pay premiums as they are due. BCBSNC must renew your policy unless we discontinue all policies like yours.


How often do premiums change? When will I be notified of the changes?    top

You won't be singled out for a premium change, although your premiums may be adjusted as you age, add or remove eligible dependents, or if you move. In addition, changes in medical cost trends may impact your premium and are adjusted annually. You will be notified at least 31 days in advance of any change. Currently our rates are adjusted on January 1st each year.


Who can help me with any technical difficulty I may have with Member Services?    top

You can contact our Web Support Unit at 1-888-705-7050, 8:00 a.m.-6:00 p.m., Monday-Friday.


Who can help me if I need assistance during my change application process?    top

We have specialized agents to ensure you receive the information you need. Please select the right option for you:

If you are interested in additional information concerning Blue Options HSASM please contact our Direct Sales Department at 1-800-324-4973, 8 a.m.-5 p.m., Monday-Friday.

If you are currently a Blue Advantage member and need assistance completing your application or have questions concerning your current coverage, please contact Customer Service at 1-888-206-4697, 8:00 a.m. - 9:00 p.m. EST, Monday-Friday.


What is the renewal period?    top

The renewal period is the span of timeóNovember 1st -30th ówhen you can make specific changes to your BCBSNC policy (add maternity, change plans, etc.). Any changes you make to your policy during the renewal period become effective January 1. Your policy is automatically renewed unless you choose to cancel your policy or make changes. You can request changes under the My Benefits and Claims tab.


What is a qualified life event?    top

A qualified life event is defined as one of the following: job loss, marriage, birth, divorce, adoption, legal separation, death or court-ordered health care coverage.


What if I donít like the new rate for my renewed policy?    top

Member Services online allows you to easily review options to your current policy. You can compare different plans with your current policy, review plan details and evaluate new rates and amounts for coinsurance and copayments. Then you can either select a different plan or decide to renew your policy as it is today.


How can I make changes to my policy?    top

Member Services online provides you with access to online policy management, where you can request changes to your policy at your own convenience. Some changes are simple and will take effect immediately, although it may be 48 hours before you can view your changes online. Other changes may require you to provide detailed health information that may require review and could take up to 60 days to become effective.


What changes can I request online through Member Services?    top

Member Services online allows you to change your benefits, update your contact information, change your billing preferences, change names on your policy, add or cancel maternity coverage, and add or remove a spouse or child from your policy. Some changes are simple and will take effect immediately, although it may be 48 hours before you can view your changes online. Other changes may require you to provide detailed health information that may require review and could take up to 60 days to become effective.


When can I change my deductible?    top

Member Services online provides you with convenient access to manage your policy, including allowing you to request changes to your deductible. You can request to increase your deductible at any time throughout the year in order to decrease your monthly premiums; however, you can only decrease your deductible during the renewal period or during a qualified life event, which is subject to review and approval.


When can I add or remove maternity from my policy?    top

You can use Member Services online to add or remove maternity coverage. Maternity coverage can be added to your policy during the renewal period, November 1 through 30, if the policy has been active for at least six months, or during a qualified life event, which is subject to review and approval. The individual to be covered cannot be pregnant at the time the addition is requested. If approved, maternity coverage will become effective January 1. You can remove maternity coverage at any time.


When will I be billed for changes I make to my policy?    top

Changes made to your policy during the renewal period will be reflected in your January bill. If your change requests made during the renewal period have not been approved by the time you receive your January bill, you should pay your January bill as sent and you will later receive a prorated bill reflecting any over- or underpayment. Changes requested to your policy outside of the renewal period will be reflected in your next bill, if those changes have been approved.

If you are interested in additional information concerning Blue Options HSASM, please contact our Direct Sales Department at 1-800-324-4973, 8 a.m.-5 p.m., Monday-Friday.

If you are currently a Blue Advantage member and need assistance completing your application or have questions concerning your current coverage, please contact Customer Service at 1-888-206-4697, 8:00 a.m. - 9:00 p.m. EST, Monday through Friday.


How can I pay my bill and when is my bill due?    top

Payment can be accepted online as a one-time payment or recurring monthly draft from your bank account. You can sign in to your Member Services account here.


Benefits and Coverage

How does the maternity option work?    top

The maternity benefit is available for an extra charge when you first purchase your policy, when you renew, when you add a spouse, or if you have a family status change like marriage. If you purchase the maternity option, services are subject to deductible and coinsurance. Remember, even if you purchase the maternity option after your initial enrollment, medical approval will be required (you or your spouse cannot be pregnant at the time of application). Approved changes made at renewal are effective January 1, and premium adjustments for any changes will apply effective January 1.


What does a routine exam include?    top

All services that are recommended by the American Medical Association guidelines and other services that are medically necessary as determined by your doctor.


Am I still covered if I visit a doctor or hospital outside the network?    top

Yes, you can see any doctor you choose. But remember, you save money when you visit a participating, in-network provider. There are more than 18,000 health professionals and over 100 North Carolina hospitals in the Blue Advantage network. Visit our online provider search to see if your physician is in our network.


Claims

What do I do with a foreign medical bill for care I received outside of the U.S.?    top

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/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.


Out-of-Pocket Expense

If I take all of my children to their Primary Care Physician at the same time, how much do I pay?    top

You pay one copayment for each child.


What is a copayment?    top

A copayment is a fixed dollar amount that you pay for some services (usually paid at the time the service is provided).


Do I have to pay a copayment for my weekly allergy shot?    top

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

What services require Prior Review or a referral?    top

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.

The list of services that must be reviewed 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 the back of 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.


How do I get Prior Review or a referral?    top

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 from a nonparticipating provider or out-of-state, you are responsible for having your provider request preauthorization for those services that 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.


If I have been denied Prior Review or if I have concerns about decisions that have been made regarding coverage of my medical procedures, who can I contact?    top

To make sure you have access to quality, cost-effective health care, we manage utilization through a variety of programs including precertification, transplant management, concurrent and retrospective review, and case management. For those services requiring plan authorization, the member is ultimately responsible for ensuring that appropriate authorization has been received by the health care provider.

If you have a concern regarding the final determination of your care, you have the right to appeal the decision. For more information, please write to us at:

Utilization Management Dept.
Blue Cross and Blue Shield of North Carolina
P.O. Box 2291
Durham, NC 27702


Pharmacy

How does prescription drug coverage work?    top

Always present your BCBSNC ID at the pharmacy in order to receive your pharmacy benefit. Our 4-Tier Drug Formulary places prescription drugs into four categories based on clinical effectiveness, usage and cost. Be sure to discuss generic options with your physician, as generic drugs are placed on Tier 1 and have the lowest copayment. While there is no benefit period maximum per member for generic drugs, there is a $2000 maximum per member per benefit period for brand drugs that have an approved amount that is less than $500. With your BCBSNC pharmacy benefit, there are no claims to file. Additionally, with Plan A, there are no deductibles to pay.