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
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.
- 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
- Signature of provider who rendered services
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.
You may obtain a claim form online. You may also obtain a claim form by calling the
Supply Line telephone number listed in your benefit book.
prescription medication reimbursement form. Pharmacy
receipts must be sent with the prescription medication reimbursement form. Pharmacy receipts are the receipts given
by the pharmacist and are not the register receipts.
For Questions regarding your Pharmacy Benefits or how to submit for reimbursement, please contact the Pharmacy Member
Service at (866)325-1794.
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.
Enrollee 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.
Prescription Medication Exception
If a covered medication requires precertification, but you must obtain the medication outside of BCBSAZ's
precertification hours, you may have to pay the entire cost of the medication when it is dispensed. In such cases,
you can file a reimbursement claim with BCBSAZ and have your provider request precertification on the next business
day. Your claim for the medication will not be denied for lack of precertification, but all other exclusions and
limitations of your plan will apply.
If BCBSAZ Denies Your Precertification Request
Denial of precertification is an adverse benefit determination. BCBSAZ will send you a notice explaining the reason
for the denial, and your right to appeal the BCBSAZ decision. Information on where to file an appeal is in the
BCBSAZ Customer Service section of your benefit book.
Time Period for Claim Decisions:
Within 30 days of receiving your claim for a service that was already rendered, BCBSAZ will send you an EOB
adjudicating the claim, or a notice that BCBSAZ has requested records needed to make a decision on your claim. If
BCBSAZ cannot make a decision on your claim within 30 days, BCBSAZ may extend the initial processing time by 15 days
by notifying you, within the initial 30-day period, of the need for an extension, the expected decision date, and
any additional information that may be needed for the decision. You or your provider will have at least 45 days to
submit any requested information.
When you request coverage for a service that has not yet been rendered (precertification), BCBSAZ will make a
precertification decision within a reasonable time period considering the medical circumstances, but not later than
10 business days from receipt of the precertification request. If BCBSAZ requires more time to make a
precertification decision, BCBSAZ may extend the time by an additional 15 days by notifying you, within the initial
10-day period of need for an extension, the expected decision date, and any additional information needed for the
decision. You and your provider will have at least 45 days to submit any requested information.
Concurrent Care Decisions
BCBSAZ may require that your provider submit a plan of care. Based on that plan, BCBSAZ may precertify a certain
number of visits or services over a certain period of time.
You may request precertification for additional periods of care as long as your request is made at least 72 hours
prior to the expiration of an existing plan of care. BCBSAZ will make a determination within 72 hours after receipt
of the request.
When you request coverage for an urgent care claim, a determination will be made within 72 hours after receipt of the
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
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
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
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
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.
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