Prior authorization is the process of obtaining approval from your health insurance company for a service or medication. Without a prior authorization, the service or medication is not covered. Your physician is responsible for obtaining a prior authorization when required. In addition to medical services, certain medications are subject to pre-approval to be eligible for coverage under your pharmacy benefit. We review medical information provided by physicians to determine if clinical guidelines have been met and that the medication is being used appropriately. In addition to those drugs noted on the drug list as requiring prior authorization, most injectable products are subject to prior authorization.
Each person covered by a health insurance plan has a unique ID number that allows healthcare providers and their staff to verify coverage and arrange payment for services. It's also the number health insurers use to look up specific members and answer questions about claims and benefits. If you're the policyholder, the last two digits in your number might be 00, while others on the policy might have numbers ending in 01, 02, etc. Many health insurance cards show the amount you will pay (your out-of-pocket costs) for common visits to your primary care physician , specialists, urgent care, and the emergency department.
If you see two numbers, the first is your cost when you see an in-network provider, and the second—usually higher—is your cost when you see an out-of-network provider. For example, when you're referred to a specific specialist or sent to a specific hospital, they may not be in your insurer's network. If you have questions about the services rendered, you should contact the health care provider.
If you have questions, please contact Member Service at the number on the front of your ID card. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary.
The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council . The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services.
In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.
The BlueCard Program processes your claims using the payment agreement the physician has with his or her local plan. The local plan pays the doctor directly for the services you received. If you're an HMO member, you will need to receive services from an in-network HMO provider.
However, you will be able to receive emergency or urgent care services no matter where you are. For details about your coverage, please review your Blue KC certificate, which outlines the benefits and exclusions related to your health insurance plan. You can view your certificate by logging in and accessing the Plan Benefit section. If you were covered by certain Blue Cross Blue Shield health insurance or administrative services plans between February 2008 and October 2020, you may be a Class Member.
The Court certified two Settlement Classes in this case, a Damages Class and an Injunctive Relief Class. The Second Blue Bid provision of the Settlement Agreement was designed to enable 33 million Members of large, geographically dispersed, self-funded national Employers to have the opportunity to receive a Second Blue Bid. This represents approximately half all membership from large self-funded national Employers in the U.S. and approximately one-third of Members of all Self-Funded Accounts.
The Settlement Agreement provides the final list of eligible accounts at this time and for two years following final approval including appeals. Is the process of obtaining coverage approval from Blue Cross Blue Shield for a service or medication before you receive a service or medication. Without prior authorization, the service or medication is not covered under your health plan benefits.
Your doctor or service provider is responsible for obtaining the prior authorization when required. Prior authorization means that certain services or medications have to be pre-approved by Highmark BCBSWNY before you can receive them. We review medical information provided by your doctor, specialist, or provider to determine if these services or medications are deemed to be medically necessary based on certain clinical guidelines. You can find out what services may require pre-authorization by calling the member service number on the back of your member card. Prescription drugs which require prior authorization are noted on our Medication Guide as such, and most injectable products require prior authorization. You will still be able to access your online account to view claims and explanation of benefits information after your coverage has been cancelled.
In time, your account will be archived and claims information will no longer be accessible online. You can contact member services to review past claim and provider information, obtain copies of EOBs, or request a claims history report. Your insurance company may provide out-of-area coverage through a different health care provider network. If so, the name of that network will likely be on your insurance card. This is the network you'll want to seek out if you need access to healthcare while you're away on vacation, or out of town on a business trip.
Once funds are deposited into your HSA, those funds can be used to pay for qualified medical expenses tax-free, even if you no longer have high-deductible health plan coverage. The funds in your account automatically roll over each year and remain in the account indefinitely until used. Once you discontinue coverage under a high-deductible health plan and/or get coverage under another health plan that disqualifies you from an HSA, you can no longer make contributions to your HSA. However, since you own the HSA, you can continue to use it for future qualified medical expenses. To enroll in a high-deductible health plan, complete the Blue KC application process. The Blue-Saver® PPO health insurance plan is a high-deductible health plan that allows you to establish an HSA as part of your health benefits.
When you enroll in the Blue Saver plan, you may be offered the opportunity to establish a HSA with one of our preferred banks. You will be presented with appropriate banking authorizations and disclosures necessary for Blue KC to work with the bank that will establish your HSA. Please note all financial institutions offering HSA products must comply with the USA Patriot Act, requiring your HSA bank to collect and verify information about you when processing your HSA application. Once your HSA has been established, you will be mailed a welcome kit and HSA debit card from the bank. Each payment you make for covered healthcare services you've received from your providers such as a physical exam counts toward your deductible.
Once Blue KC processes the claims we receive from your providers showing the payments that you have made for covered healthcare services, we apply those payments toward your deductible. When you receive a bill from your doctor, it is often for your copayment, co-insurance, or deductible. These are features of health plans, and basically have the member share in some of the cost of their health care.
For example, some health plans require that the member pay $10 for an office visit and the rest is covered by the plan. Your health insurance policy number is typically your member ID number. This number is usually located on your health insurance card so it is easily accessible and your health care provider can use it to verify your coverage and eligibility. This health plan option includes a tiered network feature called Hospital Choice Cost Sharing.
For most preferred general hospitals, you will pay the lowest in-network cost sharing level. However, if you receive certain covered services from any of the preferred general hospitals, you pay the highest in-network cost sharing level. A Health Savings Account allows members enrolled in a qualified high-deductible health plan to contribute funds on a tax-free basis into the member's account.
These funds are used for payment of qualified medical expenses as defined by the IRS. Unused funds in an HSA roll over in the member's account at the end of each calendar year. Allowable charges are the maximum amount payable to you under your health insurance plan for a particular service. Contracted providers have agreed to accept this amount as payment in full. For example, if the provider charges $100 for a service and Blue KC pays $80 as the allowable charge, the provider cannot ask the member to pay the remaining $20.
Keep in mind, however, that some health insurance plans have coinsurance. In those cases, members are required to pay a percentage of the allowable charge. For specific details about your plan, review your Blue KC certificate, which outlines your payment responsibility. To change a PCP, log in and visit you Profile by clicking on the icon by your name in the top right corner of your homepage. In the Coverage Information section you'll see a list of covered members for your Blue KC policy.
From here select "Change PCP" for the appropriate member and you can search for and designate a new PCP. Once we have processed your PCP change request, we will send you a new member ID card that contains the information of your newly selected PCP. You may also call the Customer Service number listed on your member ID card to change your PCP. Please note that if you have health insurance through your employer, you may be required to contact your group benefits administrator to change your PCP. You can continue to use the funds in your account tax-free for out-of-pocket health expenses.
If you enroll in Medicare, you can use your account to pay Medicare premiums, deductibles, copayments and coinsurance under any part of Medicare. If you have retiree health benefits through your former employer, you can also use your account to pay for your share of retiree medical insurance premiums. The one expense you cannot use your account for is to purchase a Medicare supplement insurance or "Medigap" policy. You cannot use HSA funds to pay for qualified medical expenses incurred before you enrolled in a high-deductible health plan. In order to establish an HSA, you must enroll in a high-deductible health plan.
Your eligibility to contribute to an HSA is determined by the effective date of your high-deductible health plan coverage. There are two times you can make a change to your enrollment options. Your employer schedules an open enrollment period once a calendar year when all employees may make changes to their health insurance plan.
You may also make a change during a special enrollment period if you acquire a new dependent or if your coverage is terminated under another health insurance plan. If you have health insurance through an employer, your group benefits administrator, typically someone in your Human Resources department, can help you make changes to your health insurance plan. If you do not have health insurance through an employer and instead pay your monthly premiums directly to Blue KC, call the Customer Service number listed on your member ID card. Sometimes providers send statements to their patients before Blue KC has finished processing and paying the claim.
If the provider you saw is out-of-network you will be responsible for paying the provider directly. We will send you a payment for the amount that is covered by your plan. You can view your EOBs and details about your claims, including how much you owe, by logging in and visiting the Claims and Usage section. You might see a note on the bill that says "Insurance Pending." We will send you an Explanation of Benefits once we have processed your claim. If you are still unsure if you owe the provider, call their billing office. Please note, if your provider was not in the Blue KC HMO network, you will be responsible for paying all services and fees for seeing that provider.
Because your PCP coordinates your care, you should always let our group know whenever you seek treatment of any kind. For further details about the specific cases that don't require a referral, please call Member Service at the number on the front of your ID card. If you lose your health insurance card with your policy and group number on it, it is important to contact your health insurance company right away and let them know. Call your insurance provider's customer service number and a representative should be able to help you.
It is assigned to your employer by the insurance company and can also be beneficial for both you and your health care provider in finding out what your coverage entails and submitting claims. You pay your normal copay, deductible, or coinsurance, and the local Blue plan pays the rest. Fee for service – This is the traditional health care payment method under which doctors and hospitals receive a payment that does not exceed their billed charge for each service they provide.
This method of payment can also be used in conjunction with an established fee schedule for our managed care and indemnity plans of coverage. Cards show important health plan information, including the network the member may access, who is responsible for managing the member's care, where to submit claims, covered riders, and copayments. Diagrams in the "Sample ID Cards" section of this chapter show how to quickly locate key coverage details and contact information. The descriptions below apply to most private health insurance ID cards in the United States.
If you live outside the U.S. or have government-provided insurance, you may see some different fields on your card. After the funds in your PCA have been used, you will be responsible for a certain amount of your healthcare costs until your deductible amount has been met. You do have the benefit of the negotiated prices for healthcare from network providers, but you will pay for all of the healthcare until your individual or family deductible is met. A qualified health-deductible health plan is a health plan with an annual deductible for an individual or a family that meet the minimum deductible amount published annually by the U.S. The annual out-of-pocket expenses required by the high-deductible health plan also does not exceed the out-of-pocket maximums published by the U.S. Out-of-pocket expenses include deductibles, copayments and other amounts the member must pay for, but do not include premiums or amounts incurred for non-covered benefits.
A copayment, or copay, is the dollar amount that you pay to a provider at the time you receive a service. For example, you might pay a $30 copay each time you visit your allergy doctor. The copay amount is defined in your Blue KC certificate, which outlines your responsibilities for health insurance plan payments. Billed charges are the amount charged or billed by your healthcare provider for the services/supplies you received. Not all provider charges will be paid by your health insurance plan.
When you and your primary care provider determine that you need specialized care, your PCP will "refer" you to a specialized provider from our trusted team. A referral is required by your HMO health plan before the plan will cover certain services. Each covered member of your family may choose his or her own primary care provider , and choosing the right one is important. There are many different types of PCPs, including general practitioners, internists, pediatricians, family medicine physicians, and nurse practitioners. To choose the best fit for you or your family member, begin by asking for recommendations from the people you trust.
