Claims Payment Policies

The information provided below applies to 2017 Individual On-Exchange plans and Small Group On-Exchange plans unless otherwise noted. For specific definitions, please review your specific policy/plan materials (ex. benefit booklet, application, Summary of Benefits and Coverage). Additionally, this information does not modify any of the terms of your health insurance policy/plan. Further, all of this information is pending regulatory approval.

Contents

Out-of-Network Liability and Balance Billing


Balance billing occurs when an out-of-network provider bills an enrollee for charges – other than copayments, coinsurance, or any amounts that may remain on a deductible.

In-Network Out-of-Network
Allowed amount
vs.
Billed Amount
If the billed amount for covered services is greater than the allowed amount, you are not responsible for the difference. You only pay any applicable copayment, deductible, coinsurance, and non-covered expenses. (See Filing Claims below for additional information.) You may be responsible for paying any charges over the allowed amount in addition to any applicable copayment, deductible, coinsurance, and non-covered expenses.
Care Outside of North Carolina Your id card gives you access to participating providers outside the state of North Carolina through the Blue Card® Program, and benefits are provided at the in-network benefit level. If you are in an area that has participating providers and you choose a provider outside the network, you will receive the lower out-of-network benefit. Also see "Out-Of-Network Benefit Exceptions."

Out-of-Network Benefit Exceptions

In an emergency, in situations where in-network providers are not reasonably available as determined by BCBSNC's access to care standards, or in continuity of care situations, out-of-network benefits will be paid at the in-network benefit level. However, you may be responsible for charges billed separately by the provider which are not eligible for additional reimbursement. If you are billed by the provider, you will be responsible for paying the bill and filing a claim with BCBSNC.

Enrollee Claims Submission


An enrollee, instead of the provider, submits a claim to the issuer, requesting payment for services that have been received.

Filing Claims: In-Network

In-network providers in North Carolina are responsible for filing claims directly with BCBSNC. However, you will have to file a claim if you do not show your ID card when you obtain a prescription from an in-network pharmacy, or the in-network pharmacy's records do not show you as eligible for coverage, or (for individual only) you are in your three month grace period if you receive a federal subsidy. In order to recover the full cost of the prescription minus any applicable copayment or coinsurance you owe, return to the in-network pharmacy within 14 days of receiving your prescription so that it can be reprocessed with your correct eligibility information and the pharmacy will make a refund to you, if necessary. If you are unable to return to the pharmacy within 14 days, mail claims in time to be received within 18 months of the date of the service in order to receive in-network benefits. Claims not received within 18 months from the service date will not be covered, except in the absence of legal capacity of the member.

Filing Claims: Out-of-Network

You may have to pay the out-of-network provider in full and submit your own claim to BCBSNC. Claims must be received by BCBSNC within 18 months of the date the service was provided. Claims not received within 18 months from the service date will not be covered, except in the absence of legal capacity of the member.

Claims Forms Link with Submission Instructions and Contacts: https://www.bcbsnc.com/members/public/forms/index.htm

Grace Periods and Claims Pending Policies During the Grace Period (Individual On-Exchange Only)


A QHP issuer must provide a grace period of three consecutive months if an enrollee receiving advance payments of the premium tax credit has previously paid at least one full month's premium during the benefit year. During the grace period, the QHP issuer must provide an explanation of the 90 day grace period for enrollees with premium tax credits pursuant to 45 CFR 156.270(d).

The grace period gives members who receive subsidies from the federal government more time to pay their bill. Your payment is due on the first of the month. If we didn't receive your premium payment by that date, you started your three-month grace period. During the second and third month of your grace period, any claims you submit will be put on hold. These claims won't be paid until your bill is paid in full. If your doctors, hospital, or pharmacy send in claims for you while you're in the second and third months of your grace period, BCBSNC is required to tell them your bill is past due. They will be told they won't be paid unless you pay your bill before the end of the third month. These providers will also be able to check and see if you've paid your bill before they submit more claims for services. To come out of the grace period and not have your policy terminated, you must pay your account in full.

Retroactive Denials


A retroactive denial is the reversal of a previously paid claim, through which the enrollee then becomes responsible for payment.

Claims may be denied retroactively, even after the enrollee has obtained services from the provider based on retroactive changes to eligibility, which include, but are not limited to failure to pay premiums and instructions from the Marketplace.

Best Practices to reduce the chance of retroactive denials:

  • Make premium payments on time
  • Remain eligible for coverage in accordance with the Marketplace rules

Enrollee Recoupment of Overpayments


Enrollee recoupment of overpayments is the refund of a premium overpayment by the enrollee due to the over-billing by the issuer.

Individual On-Exchange:

Any premium overpayments will normally be credited to your account and applied to future premiums due. Should you wish to obtain a refund, the policy owner can contact customer service (on the back of the ID card) and request a refund.

Small Group On-Exchange:

Contact your employer for questions regarding premium overpayments.

Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities


Medical necessity is used to describe care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. Prior authorization (prior review) is a process through which an issuer approves a request to access a covered benefit before the insured accesses the benefit.

Prior Review – In-network:

In-network providers in North Carolina are responsible for requesting prior review when necessary.

In-network providers outside of North Carolina, except for Veterans' Affairs (VA) and military providers, are responsible for requesting prior review for inpatient facility services. For all other covered services received outside of North Carolina, you are responsible for ensuring that you or your provider requests prior review by BCBSNC or its designee even if you see an in-network provider.

For inpatient or certain outpatient mental health and substance abuse services, either in or outside of North Carolina, use the information on the back of your ID card to request prior review and receive certification.

Prior review is not required for an emergency or for an inpatient hospital stay for 48 hours after a vaginal delivery or 96 hours after a Cesarean section.

Prior Review – Out-of-Network:

You are responsible for ensuring that you or your out-of-network provider, in or outside of North Carolina, requests prior review by BCBSNC or its designee when necessary.

See "Who to Contact?" for information on who to call for prior review and to obtain certification for mental health and substance abuse services and all other medical services.

Failure to request prior review and obtain certification will result in a full denial of benefits. However, prior review is not required for an emergency or for an inpatient hospital stay for 48 hours after a vaginal delivery or 96 hours after a Cesarean section.

General Information:

BCBSNC will make a decision on your request for certification within a reasonable amount of time taking into account the medical circumstances. The decision will be made and communicated to you and your provider within three business days after BCBSNC receives all necessary information but no later than 15 days from the date BCBSNC received the request. BCBSNC may extend this period one time for up to 15 days if additional information is required and will notify you and your provider before the end of the initial 15-day period of the information needed and the date by which BCBSNC expects to make a decision. You will have 45 days to provide the requested information. As soon as BCBSNC receives all the requested information, or at the end of the 45 days, whichever is earlier, BCBSNC will make a decision within three business days. BCBSNC will notify you and the provider of an adverse benefit determination electronically or in writing.

You have a right to an urgent review when the regular time frames for a decision: (i) could seriously jeopardize your life, health, or safety or the life, health or safety of others, due to your psychological state; or (ii) in the opinion of a practitioner with knowledge of your medical or behavioral condition, would subject you to adverse health consequences without the care or treatment that is the subject of the request. BCBSNC will let you and your provider know of its decision within [72] hours after receiving the request. Your provider will be notified of the decision, and if the decision results in an adverse benefit determination, written notification will be given to you and your provider.

If BCBSNC needs more information to process your urgent review, BCBSNC will let you and your provider know of the information needed as soon as possible but no later than 24 hours after we receive your request. You will then be given a reasonable amount of time, but not less than 48 hours, to provide the requested information. BCBSNC will make a decision on your request within a reasonable time but no later than 48 hours after receipt of requested information or the end of the time period given to the provider to submit necessary clinical information, whichever comes first.

Drug Exceptions Timeframes and Enrollee Responsibilities


Issuers' exceptions processes allow enrollees to request and gain access to drugs not listed on the plan's formulary, pursuant to 45 CFR 156.122(c).

BCBSNC has a process for an enrollee, the enrollee's designee, or the enrollee's prescribing physician (or other prescriber) to request a standard review of a decision that a drug is not covered by the plan. BCBSNC will make its determination on a standard exception and notify the enrollee or the enrollee's designee and the prescribing physician (or other prescriber, as appropriate) of its coverage determination no later than 72 hours following receipt of the request. BCBSNC has a process for an enrollee, the enrollee's designee, or the enrollee's prescribing physician (or other prescriber) to request an expedited review based on exigent circumstances. Exigent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug. BCBSNC will make its coverage determination on an expedited review request based on exigent circumstances and notify the enrollee or the enrollee's designee and the prescribing physician (or other prescriber, as appropriate) of its coverage determination no later than 24 hours following receipt of the request.

If BCBSNC denies a request for a standard exception or for an expedited exception, BCBSNC has a process for the enrollee, the enrollee's designee, or the enrollee's prescribing physician (or other prescriber) to request that the original exception request and subsequent denial of such request be reviewed by an independent review organization. BCBSNC will make its determination on the external exception request and notify the enrollee or the enrollee's designee and the prescribing physician (or other prescriber, as appropriate) of its coverage determination no later than 72 hours following its receipt of the request, if the original request was a standard exception request and no later than 24 hours following its receipt of the request, if the original request was an expedited exception request.

Starting January 1, 2017, Members (or their authorized representatives) may visit http://www.bcbsnc.com/content/services/formulary/rxnotes.htm for information about the ways to submit a request. Generally, members may submit requests:

  • By fax (visit the website above for fax form and numbers)
  • By mail to BlueCross BlueShield of North Carolina, Healthcare Management and Operations, Pharmacy Exception, P. O. Box 2291, Durham, NC 27702
  • By telephone at 1-800-672-7897

Once BCBSNC has all necessary information to make a decision, BCBSNC will provide a response to the member and their provider approving or denying their request (if approved, notice will provide duration of approval) within applicable timeframes.

Information on Explanation of Benefits (EOBs)


An EOB is a statement an issuer sends the enrollee to explain what medical treatments and/or services it paid for on an enrollee's behalf, the issuer's payment, and the enrollee's financial responsibility pursuant to the terms of the policy.

EOB Information Link: https://www.bcbsnc.com/members/public/forms/eob/

Coordination of benefits (COBs)


Coordination of benefits exists when an enrollee is also covered by another plan and determines which plan pays first.

Coordination of Benefits applies when an enrollee is covered by two health plans at the same time. The provision is designed so that the payments of both plans do not exceed 100% of the covered charges. The provision also designates the order in which the multiple health plans are to pay benefits. Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim first. The unpaid balance is usually paid by the secondary plan to the limit of its responsibility. Benefits are thus "coordinated" between the two health plans.