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 PPO plans, if you choose an out-of-network healthcare provider, you will have to pay an additional cost for the difference between the amount they charge and BCBSAZ’s allowed amount. For HMO and EPO 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.

Understanding Networks

Enrollee Claim Submission

Filing Claims

In most cases, network providers will file claims for you. Non-contracted providers may file your claims for you, but have no obligation to do so.

Time Limit for Claim Filing

A complete claim, as described below, must be filed within one year from the date of service. Any claim not filed within one year of the date of service may be denied.
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
  • 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.

Claim Forms

Claim forms are available from BCBSAZ. Go to the “Forms” section of the “Member” area of www.azblue.com or call the Supply Line telephone number listed at the front of your benefit book.

Submitting Claims

Mail New Claims to: Blue Cross Blue Shield of Arizona, P.O. Box 2924, Phoenix, AZ 85062-2924
Claims for Transplant Travel and Lodging: Attention: Transplant Travel Claim Processor, Mail
Stop: A223, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ 85002-3466
Claims for Services Received on a Cruise Ship: Blue Cross Blue Shield of Arizona, P.O. Box 13466,
Phoenix, AZ 85002-3466
Claims for Chiropractic Services: Claims Administration, American Specialty Health Networks, Inc., P.O. Box 509001, San Diego, CA 92150-9001

Grace Period and Claims Pending During Grace Period

Members receiving Advance Payment of the Premium Tax Credit will be allowed a three (3) month grace period if the member has previously paid at least one full month’s premium during the benefit year in which the non-payment of premium occurs. Medical claims with dates of service during the second and third months of the grace period will be pended for payment of premium and denied if premium is not received by the end of the grace period. Retail and mail order pharmacy claims with dates of service during the second and third months of the grace period will be denied unless premium is paid by the end of the grace period.

Retroactive Denials

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

Medically Necessary

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:

Post-Service Claims

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.

Pre-Service Claims

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.

Urgent Claims

When you request coverage for an urgent care claim, a determination will be made within 72 hours after receipt of the request.

Drug Exception Timeframes and Enrollee Responsibilities

Non-Formulary medications are not covered unless an exception is made. If a 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 along with appropriate documentation supporting the review.

You can find the non-formulary request form, along with other prior authorization request forms, at azblue.com. Click on the “Resource Center” tab, select “Pharmacy” and select the “View resources for QHP Pharmacy Plans”. A non-formulary exception request does not guarantee approval. Drugs that are not on the formulary and have specific plan benefit exclusions will not be covered, such as weight loss products.

Formulary exception requests are reviewed within 72 hours from the time that the complete request has been received. If a request is marked as having exigent circumstances, the exception request will be reviewed within 24 hours. An exigent request requires a written statement explaining the reason for 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 contact 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.

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.