The following policies and practices apply to BCBSAZ's ACA plans for individuals and families.
Out-of-Network Liability and Balance Billing
It is always a good idea to check if a doctor, hospital or other facility is part of the BCBSAZ network before you see them.
Ways to find a doctor:
- Visit the online provider directory
- Or call the number on the back of your BCBSAZ ID card for help locating a doctor or hospital or to have a printed Provider Directory mailed to you
To keep your healthcare costs down, it’s important to get care from healthcare professionals in the network for your plan. For HMO plans, generally you only have coverage for services from out-of-network providers in emergency situations. You will have to pay the whole bill for most other services that are outside the plan’s network.
Enrollee Claim Submission
A claim is a request to an insurance company for payment of health care services. As a member, you may need to submit a claim yourself, especially if you see a provider or use a pharmacy outside of the network. In most cases, the time limit for a member to submit a claim is 1 year from the date of service.
You may obtain a claim form. You may also obtain claim forms from the “Forms” section of the “Member” area of www.azblue.com or by calling the Customer Service number on your ID card. BCBSAZ may reject claims that are filed without complete information needed for processing. If BCBSAZ rejects a submitted claim due to lack of information, BCBSAZ will notify you or the Provider who submitted the claim. Lack of complete information may also delay processing. A complete claim includes, at a minimum, the following information:
• Billed Charges
• Date of Service(s)
• Diagnosis code
• Group number
• Member ID number
• Member name
• Name of Provider
• Patient name
• Patient’s birth date
• Procedure code
• Provider ID number
• Area of oral cavity or tooth treated, as applicable (dental claims only)
• Description of Service (dental claims only)
Even when the claim has all information listed above, BCBSAZ may need to request medical or dental records or coordination of benefits information to make a coverage determination. If BCBSAZ has requested Medical Records or other information from a third party, BCBSAZ will suspend claim processing while the request is pending. BCBSAZ may deny a claim for lack of timely receipt of requested records.
You may mail your claim form to:
Blue Cross Blue Shield of Arizona
P.O. Box 2924
Phoenix, AZ 85062-2924
If you have questions, please contact Customer Service at (602) 864-4465.
Grace Periods and Claims Pending
You are required to pay your premium by the scheduled due date. If you do not do so, your coverage could be canceled. For most BCBSAZ individual health care plans, if you do not pay your premium on time, you will receive a 31-day grace period. A grace period is a time period when your plan will not terminate even though you did not pay your premium.
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. BCBSAZ will pay all properly submitted claims for covered services received during the first month of the grace period. During the second and third months of that grace period, BCBSAZ will pend any claims you incur. If you pay your full outstanding premium before the end of the three-month grace period, BCBSAZ will pay properly submitted claims for covered services received in the second and third months of the grace period. If you do not pay all of your outstanding premium by the end of the three-month grace period, your coverage will terminate, and we will not pay for any pended claims submitted for you during the second and third months of the grace period. Your provider may balance bill you for those services.
It is important to pay your premium on time to avoid termination of coverage. In certain circumstances, coverage may be terminated retroactively. This may occur, for example, if you are entitled to a premium grace period but fail to make your premium payment before the end of the grace period. In such event, claims for services rendered during some or all of the grace period will be denied.
Recoupment of Overpayments
If you feel BCBSAZ has made an error on your premium bill, please contact us at (602) 864-4847.
Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities
BCBSAZ, or BCBSAZ’s contracted vendor, in its sole and absolute discretion, decides whether a service is medically necessary. Decisions about medical necessity may differ from your provider’s opinion. A provider may recommend a service that BCBSAZ decides is not medically necessary and therefore is not a covered benefit. You and your provider should decide whether to proceed with a service that is not covered. Also, not all medically necessary services are covered benefits under your plan. All benefit plans have exclusions and limitations on what is covered. A service may be medically necessary and still excluded from coverage. Certain services and medications require precertification. Precertification is the process BCBSAZ uses to determine eligibility for benefits. Precertification is not a pre-approval or a guarantee of payment and precertification made in error by BCBSAZ is not a waiver of BCBSAZ’s right to deny payment for non-covered services.
Each benefit description in your benefit booklet tells you whether precertification is required for that benefit. If it is required, your network provider must obtain it on your behalf before rendering services. BCBSAZ may change the services that require precertification. If the benefit description does not indicate that precertification is required, and you or your provider are unsure, go to www.azblue.com for a listing of medications and services that require precertification or call the Customer Service number listed in the front of your benefit book.
If precertification is required, but not obtained, the consequences vary by benefit. The benefit description section in your benefit book tells you which consequences will apply to specific benefits.
How to Obtain Precertification
Ask your provider to contact BCBSAZ for precertification before you receive services. Your provider must contact BCBSAZ because he or she has the information and medical records we need to make a benefit determination. BCBSAZ will rely on information supplied by your provider. If that information is inaccurate or incomplete, it may affect the decision on your claim.
Drug Exception Timeframes and Enrollee Responsibilities
Sometimes our members need access to drugs that are not listed on the plan's formulary (drug list). These medications are often referred to as non-formulary medications. These medications are initially reviewed by BCBSAZ through the formulary exception review process. If a member or provider feels there are no suitable formulary alternatives available, he or she may request that an exception be made to allow coverage for a non-formulary medication by filling out the Non-Formulary Exception Request Form.
The member or provider can submit the request to us by faxing the Non-Formulary Exception Request Form along with appropriate documentation supporting the review to 602-864-3126. If the drug is denied, you have the right to an external review.
If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case to an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). We must follow the IRO's decision.
An IRO review may be requested by a member, member's representative, or prescribing provider by mailing, calling, or faxing the request:
Pharmacy Management Department A115
Blue Cross Blue Shield of Arizona
P.O. Box 13466
Phoenix, AZ 85002-3466
Fax: (602) 864-3126
Phone: (602) 864-4028
For standard exception review of medical requests where request was denied, the timeframe for review is 72 hours from when we receive the request.
For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we receive the request.
To request an expedited review for exigent circumstance, select the box labeled “exigent” on the review form and provide a written explanation for the exigency.
For Questions regarding your Pharmacy Benefits please contact Pharmacy Member Services at (866)325-1794.
Explanations of Benefits (EOBs)
After your claim is processed, BCBSAZ and/or any contracted vendors that process claims will send you an EOB. Your BCBSAZ EOBs also will be available through the member portal on www.azblue.com. An EOB shows services billed, whether the services are covered or not covered, the allowed amount and the application of cost-sharing amounts. Carefully review your EOB for any discrepancies or inconsistencies with the amounts your provider actually collects from you or bills to you. BCBSAZ and/or any contracted vendors will also send your network provider the information that appears on your EOB. This information is not sent to out-of-network providers. Most EOBs are consolidated and sent to you in a monthly Member Health statement rather than as single EOBs.
The following are some definitions to help you understand the information in the statement:
Amount Billed: A provider’s full billed charge.
Amount Paid: What BCBSAZ pays for a claim. The amount paid is based on the allowed amount, the coverage provided by your benefit plan, and any contract between BCBSAZ and the provider. If you see a non-contracted provider, BCBSAZ sends any payment directly to you, minus your cost share.
Message Code (Msg. code): Additional information about the way a claim was processed and paid, if needed.
Cost Share: The amount you pay for a covered service. Examples of cost share include copays, deductibles, and coinsurance.
Deductible: A flat amount the member must pay before the insurer will make any benefit payments on certain services.
Copay: A specific dollar amount you must pay to the provider for some covered services such as a doctor’s office visit. It is usually paid at the time of services.
Coinsurance: The percentage of the allowed amount that you pay for certain covered services after meeting any applicable deductible.
Example of Acceptable Language:
Each time we process a claim submitted by you or your health care provider, we explain how we processed it in the form of an Explanation of Benefits (EOB).
The EOB is not a bill. It simply explains how your benefits were applied to that particular claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you're responsible for paying the provider. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.
Coordination of Benefits (COB):
Coordination of benefits is how insurers determine who pays first when two or more health insurance plans are responsible for paying the same medical claim. If you have more than one health plan for yourself or a family member it is important to tell BCBSAZ about that coverage so we can make sure your medical claims are paid correctly. Two ways you may do that are online (sign into your member account at azblue.com/Member; Click on Account Profile; under ‘Other Insurance Information’, click on Add/Edit other insurance) or by contacting Customer Service at (602) 864-4465.