Transparency in coverage

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. Out-of-network services are from doctors, hospitals, and other health care professionals that have not contracted with your plan. A health care professional who is out of your plan network can set a higher cost for a service than professionals who are in your health plan network. Depending on the health care professional, the service could cost more or not be paid for at all by your plan. Charging this extra amount is called balance billing. In cases like these, you will be responsible for paying for what your plan does not cover.

Note: If you are experiencing an emergency, you will only be responsible for your in-network share of the cost, regardless of your plan. Please see “Out-of-Network Benefit Exceptions” below, for more information.

You will only be responsible for your in-network share of the cost and providers may not bill you more than your in-network share of the cost in the following situations:

• When emergency services are provided by an out-of-network provider or an out-of-network emergency facility*
• When you receive emergency medically necessary ground or air transport ambulance services from an out-of-network provider*
• When you receive medically necessary air transport ambulance services from an out-of-network provider*
• When non-emergency services are provided by an out-of-network provider at an in-network health care facility*
• When non-emergency services are provided by an out-of-network provider in situations where in-network providers are not reasonably available as determined by Blue Cross NC’s access to care standards
• In Continuity of Care situations
• Blue Home / Blue Local (EPO Products) only: When you receive urgent care services.

* These situations may not qualify for an out-of-network benefit exception if the member gives consent. Please visit the Centers for Medicare and Medicaid Services for notice regarding surprise billing describing your rights and how consent may impact these situations.

An enrollee, instead of the provider, submits a claim to the issuer, requesting payment for services that have been received. A claim is a request to an insurance company for payment of health care services.

Filing claims: In-network

In-network providers in North Carolina are responsible for filing claims directly with Blue Cross and Blue Shield of North Carolina (Blue Cross NC). However, you will have to file a claim if you do not show your member 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 you are in your 3 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 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 Blue Cross NC. Claims must be received by Blue Cross NC 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.

Complete the medical or prescription drug claim form and then:

Submit medical claims forms to:

Mail:

Blue Cross and Blue Shield of North Carolina
PO Box 35
Durham, NC 27702

Fax: 866-990-1385 

Submit prescription drug claim forms to:

Prime Therapeutics
Mail Route: Commercial
PO Box 25136
Lehigh Valley, PA 18002

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).

You are required to pay your premium by the scheduled due date. If you do not do so, your coverage could be canceled. If you are enrolled in an individual health care plan offered on the Health Insurance Marketplace and you do not receive an advance premium tax credit and do not pay your premium on time, you will receive a 25-day grace period. A grace period is a time period when your plan will not terminate even though you did not pay your premium. Any claims submitted for you during that grace period will be pended. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full. If you do not pay your delinquent premium by the end of the 25-day grace period, your coverage will be terminated. If you pay your full outstanding premium before the end of the grace period, we will pay all claims for covered services you received during the grace period that are submitted properly.

If you are enrolled in an individual health care plan offered on the Health Insurance Marketplace and you receive an advance premium tax credit, you will get a three-month grace period and we will pay all claims for covered services that are submitted properly during the first month of the grace period. During the second and third months of that grace period, any claims you incur will be pended. If your doctors, hospital, or pharmacy send in claims for you while you are in the second and third months of your grace period, Blue Cross NC is required to tell them your bill is past due. They will be told they will not 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 have paid your bill before they submit more claims for services.

If you pay your full outstanding premium before the end of the three-month grace period, we will pay all claims for covered services that are submitted properly for the second and third months of the grace period. To come out of the grace period and not have your policy terminated, you must pay your account in full.

If you do not pay all of your outstanding premium in full by the end of the three-month grace period, your coverage will terminate the last day of the first month of the three-month grace period and you will be liable for any charges for services rendered during the second and third months of the three-month grace period. Your provider may balance bill you for those services. We will keep any premium payments made toward the first month's premium, during which you had coverage, and return all other premium amounts applied to the second or third months. Also, if you apply for another Marketplace policy in the future, you may have to pay any amount you owed for your old plan and the first month's premium for your new plan before your coverage starts.

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 and in full
• Remain eligible for coverage in accordance with the Marketplace rules

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

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

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 enrollee accesses the benefit. Some services may require prior authorization and may be subject to review for medical necessity.

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 Blue Cross NC 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 member 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 Blue Cross NC or its designee when necessary.

See "Who to Contact?" in your benefit booklet 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

Blue Cross NC 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 Blue Cross NC receives all necessary information. However, it will be no later than 15 calendar days from the date Blue Cross NC received the request. Blue Cross NC may extend this period one time for up to 15 days if additional information is required. Blue Cross NC will let you and your provider know before the end of the initial 15-day period of the information needed and the date by which Blue Cross NC expects to make a decision. You will have 45 days to provide the requested information. As soon as Blue Cross NC receives all the requested information, or at the end of the 45 days, whichever is earlier, Blue Cross NC will make a decision within three business days. Blue Cross NC will let you and the provider know 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. Blue Cross NC will let you and your provider know of its decision as soon as possible, taking into account the medical circumstances. Blue Cross NC will notify you and your provider 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 Blue Cross NC needs more information to process your urgent review, Blue Cross NC 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. Blue Cross NC will make a decision on your request within a reasonable time but no later than 48 hours after receipt of requested information or within 48 hours after the time period given to the provider to submit necessary clinical information, whichever comes first.

More information, visit our page on requesting prior review.

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).

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) 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. Blue Cross NC 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. Blue Cross NC 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. Blue Cross NC 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 Blue Cross NC denies a request for a standard exception or for an expedited exception, Blue Cross NC 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. Blue Cross NC 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.

There are a few ways to request a drug exception review.

• The prescribing provider can submit a formulary request online through MHK Provider Portal (accessed by logging in to Blue e) or SureScripts. 
• The member or the member's designee can contact us by calling the customer service number listed on the back of their member ID card to request a drug exception request over the phone.  
• The member or the member's designee can also submit a written request using one of the following methods:
  • By fax: 800-795-9403
  • By mail: Blue Cross NC, Attn: Corporate Pharmacy, P.O. Box 2291, Durham, NC 27707

Once Blue Cross NC has all necessary information to make a decision, Blue Cross NC 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.

An EOB is a statement an issuer sends an enrollee that lists the medical treatments 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.

An EOB is generated after a claim has been received and processed. An EOB is not a bill; it explains how your benefits were applied to that particular claim. Each time you receive an EOB, review it closely and compare it to the receipt of the statement from the provider.

In-Network: Doctors, hospitals, clinics, and other health care providers who have a contract with your plan to provide services to you at a discount.

Out-of-Network: Services from health care providers who do not have a contract with your plan will usually cost you more than those received from an in-network provider.

Out-of-Pocket: The total amount that you will pay during a policy period before your plan begins to pay at 100% of the allowed amount. This limit may include copayments and deductibles. It does not include your premium, charges over allowed amounts, or services that are non-covered.

Plan's Limit: This is the specific deductible, coinsurance, or out-of-pocket amount for your plan, and what you may owe cannot exceed these amounts. This does not include copayments or non-covered services.

Amount Satisfied: The total amount of the deductible, coinsurance, and/or out-of-pocket expenses you and/or your family has met for the benefit period as of the date of the EOB. Remember, copayments, if applicable, are not applied to the deductible, coinsurance, or out-of-pocket amounts. Note: If you have met the required amount, this field will simply show "Met" on the EOB.

Claim Number: Identifies specific services received during a health care visit through a uniquely assigned number.

Your Provider Billed: The amount your health care provider submitted for the services you received. You may notice this amount is often higher than the allowed amount. The advantage of being a member of your plan is that the provider has agreed to accept a reduced amount (allowed amount) for the services you received, and your liability is based on the allowed amount and not the billed amount.

Allowed Amount: The discounted rate your plan has negotiated with in-network providers and facilities for covered services. These rates save you money when you receive in-network care.

Member Savings: The amount you saved by visiting an in-network provider or facility and being a member of your plan, entitling you to receive these negotiated discounts.

Your Plan Paid: The amount your plan paid for the services you received based on the allowed amount.

Co-Pay: The fixed dollar amount you pay up front to a health care provider for a covered service. Copayments can vary depending on the service, the type of health care provider, and whether the provider is in or out of network. Copayments do not count toward your deductible or out-of-pocket maximum.

Deductible: The amount you pay for eligible services during a benefit period before your plan begins to pay. The deductible may not apply to all services. This means you may be able to pay a copayment rather than the full amount. (Check your policy for details). Copayments, coinsurance, noncovered services, or any charges in excess of any maximum or allowed amount are never applied to your deductible amount. Note: Your plan may have different deductible amounts for services in and out of the Blue Cross NC provider network.

Deductible types include:

• Individual Deductible: If you have dependents on your policy, each person may have an individual deductible that is applied toward a total family deductible.

• Family Deductible: Your family has a deductible for all covered members on your policy, if applicable. When the sum of all family member payments satisfies the family deductible, each member begins to make payments at the coinsurance rate. Please note that some policies require that a specific number of family members must meet their individual deductibles first before the family deductible is met.

Coinsurance: Your share of the costs of a covered health care service, calculated as a percentage of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. Once you reach your coinsurance maximum, your plan will pay 100% for covered services for the rest of the benefit period.

Not Covered: Out-of-network providers do not have contracts with us to agree to lower negotiated rates, thus, they can bill you for more than your plan's allowed amount. Also, if you or the out-of-network provider does not get prior review or prior authorization for services that require such approval in advance, the out-of-network provider can bill you for the entire charge. If you have any excluded services, (services your plan does not cover) they will appear in this column as well.

Total You May Owe: The amount you owe the provider, including any applicable copayment, deductible, coinsurance, or other liability. If you have already paid a copayment or any other upfront payment to the provider, it will not be reflected here. This information will help you confirm that anything you paid to the health care provider at the time of service was the correct amount per your plan. Your plan is not notified by your provider when you have made any payments to them.

Reason Code: Indicates an explanation is available in the "What Our Codes Mean" section at the end of the EOB. These reasons are used to explain how a service was processed and gives additional information to help you understand how the plan determined what it will pay for the services you received.

Service: A summary description of the type of medical service provided. If you need more information about a particular service, contact your health care provider to discuss the details of how they filed the claim with your plan. Alternatively, you may call customer service at the number listed on your EOB or ID card.

Coordination of benefits exists when an enrollee is covered by more than one plan and determines which plan pays first.

Coordination of benefits (COB) means that if a member is covered by more than one insurance plan, benefits under one insurance plan are determined before the benefits are determined under the second insurance plan. The insurance plan that determines benefits first is called the primary insurance plan. The other insurance plan is called the secondary insurance plan.

Benefits paid by the secondary insurance plan may be reduced to avoid paying benefits between the two plans that are greater than the cost of the health care service. Please refer to your benefit booklet for the rules used to determine which plan is primary and secondary.

The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills. “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care – like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.