Claims Payment Policy & Other Information
Listed below are claims payment policies and other information for Qualified Health Plans offered by Blue Cross and Blue Shield of Alabama. A Qualified Health Plan is an insurance plan that has been certified by the Health Insurance Marketplace and provides essential health benefits, follows established limits on cost sharing and meets other requirements under the Affordable Care Act.
Out-of-network liability and balance billing
If you receive services from an out-of-network provider, these services may not be covered at all under the plan. In that case, you will be responsible for all charges billed to you by the out-of-network provider. If the out-of-network services are covered, in most cases, you will have to pay significantly more than what you would pay an in-network provider because of lower benefit levels and higher cost sharing. Additionally, out-of-network providers have not contracted with us or any Blue Cross and/or Blue Shield plan for negotiated discounts and can bill you for amounts in excess of the allowed amounts under the plan.
If you receive out-of-network services for a medical emergency in the emergency room of a hospital, those services will be paid at the applicable in-network coinsurance amounts for benefits described in your benefit booklet, but subject to the out-of-network calendar year deductible.For emergency services for medical emergencies provided within the emergency room department of an out-of-network hospital, the allowed amount will be determined in accordance with the Affordable Care Act. Emergency services are not covered out-of-network under our dental plans.
Enrollee claims submission
When you receive services from an in-network provider, your provider will generally file claims for you. If your provider does not file your claim for you, you can call our Customer Service Department at the number on the back of your ID card and ask for a claim form. Tell us the type of service or supply for which you wish to file a claim (for example, hospital, physician, dentist or pharmacy), and we will send you the proper type of form. You can also find our claim forms on our website at:
Claims must be submitted and received by us within 24 months after the service takes place to be eligible for benefits.
Claim forms must be submitted to:
Blue Cross and Blue Shield of Alabama
450 Riverchase Parkway East
Birmingham, Alabama 35244-2858
Grace periods and claims pending policies during the grace period
If you purchased an individual plan through the health insurance marketplace and you are receiving advance payments of tax credits and/or cost sharing reductions in accordance with the Affordable Care Act, each of your monthly periodic payments is due on the first day of the month for that coverage period. There is a grace period of three months for all monthly premium payments after the initial premium payment.
If you pay a monthly payment later than the first day of the coverage period to which it applies, but before the end of the grace period for the coverage period, any claim you submit for benefits will be placed in a pending status (suspended) on the first day of the second month of the grace period and then processed by the plan only when all periodic monthly payments due during the grace period are received. If you fail to pay in full all periodic monthly payments due and payable before the end of the grace period for those coverage periods, your coverage under the plan will be retroactively canceled back to the last day of the first month of the grace period. Failure to timely pay premium payments is not a special open enrollment event for later coverage under the plan.
In certain situations, a claim may be reprocessed and denied retroactively, even after it has been paid. In these cases, you are responsible for payment to the provider. A retroactive denial is the reversal of a previously paid claim. In most cases, you can prevent a retroactive denial by paying your premiums on time and/or by promptly notifying the plan or, if applicable, the marketplace of changes in your eligibility status for the plan.
Enrollee recoupment of overpayments
If you believe you believe you have overpaid your premium due to our overbilling, please contact us by calling the Customer Service Department number on the back of your ID card.
Medical necessity and prior authorization timeframes and enrollee responsibilities
The plan will only pay for care that is medically necessary and not investigational, as determined by us. In some cases, the plan requires that you or your treating provider precertify the medical necessity of your care. Please note that precertification relates only to the medical necessity of care; it does not mean that your care will be covered under the plan. Precertification also does not mean that we have been paid all monies necessary for coverage to be in force on the date that services or supplies are rendered. In some cases, your provider will initiate the precertification process for you. You should be sure to check with your provider to confirm whether precertification has been obtained. It is your responsibility to ensure that you or your provider obtains precertification. Generally, if precertification is required and not obtained, no benefits will be payable under the plan.
- Preservice non-urgent review: The request is received prior to the services being rendered, We have 15 days to make our decision.
- Preservice urgent review: Care service are needed as soon as possible, but it isn't an emergency. We have 72 hours to make our decision.
- Urgent concurrent review:Care and services are being provided currently to the member. We have 24 hours to make our decision if we receive the request no later than 24 hours before the end of your preapproved stay or course of treatment. If the request is not received before the 24 hour time frame, we have 72 hours to make our decision.
- Emergency admissions: The provider or the member has up to 48 hours to notify us of the admission.
- Non-urgent concurrent review: Care and services are currently being received, but it is non-urgent. We have 72 hours to make our decision for the continued stay.
- Post service review: Care and services have been provided and the member has discharged from the service, we have 30 days to make a decision.
Drug exceptions timeframes and enrollee responsibilities
If your drug is not covered and you think it should be, you may ask us to make an exception to the drug coverage rules by calling the Customer Service Department number on the back of your ID card. Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception. We will give you a response within 72 hours (24 hours for expedited exception requests) of receiving all information we need to make a decision. If we deny your request, you may request an internal appeal and an external, independent review of our decision as described in the Claims and Appeals section of your benefit booklet.
Information on Explanations of Benefits (EOBs)
Each time Blue Cross processes a claim submitted by you or your healthcare provider, we send you an Explanation of Benefits (EOB). An EOB is not a bill. An EOB is a statement that describes what medical treatments and/or services we paid on your behalf, what our payment was and your financial responsibility under the terms of the plan. 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. It also tells you how much has been credited toward any required deductible and out-of-pocket maximums.
Coordination of Benefits (COB)
Coordination of Benefits (COB) is a provision designed to help manage the cost of healthcare by avoiding duplication of benefits when a person is covered by two or more benefit plans. COB provisions determine which plan is primary and which is secondary. A primary plan is one whose benefits for a person's healthcare coverage must be determined first without taking the existence of any other plan into consideration. A secondary plan is one which takes into consideration the benefits of the primary plan before determining benefits available under its plan.