Blue Cross Blue Shield Individual Health Plans – The information below applies to individual On-Exchange plans unless otherwise noted. For specific definitions, please refer to the specific policy/plan materials (e.g. benefits booklet, application, summary of benefits and coverage). Also, this information does not change the terms of your health insurance policy/plan. Additionally, this information is pending regulatory approval.
Balance billing occurs when an out-of-network provider charges a subscriber, other than co-payments, coinsurance, or any amount that may remain in the allowance. Out-of-network services are provided by doctors, hospitals, and other health care providers who are not covered by your plan. A healthcare provider who is not in your plan’s network may charge a higher price for a service than specialists who are in your plan’s network. Depending on your health care provider, the service may cost more or may not be covered by the plan. The collection of this additional amount is called a balance. In these cases, you will be responsible for paying for what your plan doesn’t cover.
Blue Cross Blue Shield Individual Health Plans
If the amount billed for covered services exceeds the allowable amount, you are not responsible for the difference. Pay only any applicable co-payments, deductibles, coinsurance and out-of-pocket expenses.
Health Insurance, Medicare & Dental Insurance
You may be responsible for paying any fees that exceed the allowable amount, as well as any applicable co-payments, deductibles, coinsurance and out-of-pocket expenses.
All providers outside your product range are not covered unless emergency services and urgent care are needed. These services will be billed at the in-network benefit level.
All out-of-network providers are covered at the out-of-network benefit level, unless emergency services are needed. These services will be billed at the in-network benefit level.
Your ID card gives you access to participating suppliers in North Carolina and beyond through the Blue Card® program, and benefits are provided at the network level benefits level.
Health Insurance Update
Note: In the event of an emergency, you are only responsible for your share of the cost of the network, regardless of your plan. See “Offline benefit exclusions” for more information.
You will only be responsible for your share of the cost of the network and providers cannot charge you more than your share of the cost of the network in the following situations:
*These situations may not qualify for the out-of-network benefit exclusion if the member agrees. See www.cms.gov/nosurprises for a surprise bill notice explaining your rights and how consent can affect these situations.
The subscriber, instead of the provider, submits a request to the broadcaster for payment for the services received. A claim is a request to an insurance company to pay for medical services.
Blue Cross And Blue Shield Of Louisiana
Network providers in North Carolina are responsible for submitting requests directly to Blue Cross NC. However, you’ll need to file a grievance if you don’t show your ID when you fill a prescription at a network pharmacy, or if the network pharmacy records don’t show you’re eligible for coverage, or you’re within the three month grace period if you receive a federal grant. To be reimbursed for the full cost of the prescription, less any co-pays or co-insurance, return it to the network pharmacy within 14 days of receipt of the prescription so it can be re-processed with the correct eligibility information and the pharmacy will reimburse you . If you cannot return to the pharmacy within 14 days, send requests in time to be received within 18 months from the date of service to receive online services. Claims not received within 18 months of the date of service are not covered, unless the member is incapacitated.
You may need to pay the out-of-network provider in full and submit your claim to Blue Cross NC. Claims must be received by Blue Cross NC within 18 months of the date of service. Claims not received within 18 months of the date of service are not covered, unless the member is incapacitated.
A QHP Issuer must provide a grace period of three consecutive months if an Enrollee receiving prepayment of premium taxation has previously paid at least one full month of premiums during the benefit year. During the grace period, the QHP Issuer must provide an explanation of the 90-day grace period for award tax credit enrollees in accordance with 45 CFR 156.270(d).
You are required to pay the premium by the due date. Failure to do so could result in your coverage being terminated. If you’re enrolled in an individual health insurance plan offered on the health insurance marketplace and you don’t receive an upfront tax credit or don’t pay your premium on time, you’ll have a 25-day grace period. A grace period is a period of time in which your plan is not terminated even if you have not paid your premium. Any complaints submitted during this grace period will be considered. If a claim is pending, it means that payment to the supplier will not be made until the overdue premium has been paid in full. If you don’t pay your overdue premium by the end of the 25-day grace period, your coverage will end. If you pay the total premium due before the end of the grace period, we will pay all service requests you received during the grace period and successfully filed.
Blue Cross Blue Shield Medicare Review
If you are enrolled in an individual health insurance plan offered on the health insurance marketplace and receive the premium tax credit upfront, you will have a three month grace period and we will pay all applications for covered services that are submitted correctly within the first month. grace period. During the second and third months of this grace period, any claims you make will be processed. If your doctors, hospitals or pharmacies complain to you while you are in the second and third month of the grace period, Blue Cross NC is required to notify them that your bill is overdue. They will be told they won’t get paid if you don’t pay your bill by the end of the third month. These providers will also be able to check and verify that you have paid your bill before submitting further service requests.
If you pay the total premium due before the end of the three month grace period, we will pay all covered service requests successfully submitted in the second and third month of the grace period. To get out of the grace period without your policy being cancelled, you must pay your bill in full.
If you do not pay the full premium due by the end of the three-month grace period, your coverage will expire on the last day of the first month of the three-month grace period, and you will be liable for any charges for services rendered during the second. and the third month of the quarterly grace period. Your ISP may charge you for these services. We will retain all premium payments made in the first month of coverage and refund any other premiums claimed in the second or third month. Also, if you order another Marketplace policy in the future, you may be required to pay any amount owed on your old plan and the first month’s premium on your new plan before coverage begins.
A retroactive waiver is the cancellation of a previously paid claim, making the subscriber liable for payment.
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Applications may also be rejected retroactively after the Registrant has received the Services from the Provider based on retroactive eligibility changes, including but not limited to non-payment of rewards and Marketplace instructions.
An enrollee overpayment recovery is a refund of an enrollee’s overpayment of a premium due to overbilling by an issuer.
Any overpaid rewards are usually credited to your account and applied to future rewards. If you would like a refund of the overpayment, you can contact the customer service number on the back of your ID and request a refund.
Medical necessity is used to describe care that is reasonable, necessary, and/or appropriate based on evidence-based clinical standards of care. Pre-authorization (pre-verification) is the process by which an issuer approves a request for access to a covered benefit before the member has access to the benefit. Some services may require prior authorization and may be subject to a medical necessity review.
Transparency In Coverage
Network providers in North Carolina are responsible for requesting prior review if needed. Network providers outside of North Carolina, with the exception of Veterans Affairs (VA) and military providers, are responsible for requesting a preliminary review for hospital services. It is your responsibility to make sure that you or your provider requests a background check with Blue Cross NC for all other covered services received outside of North Carolina, even if you see a provider on the network.
For inpatient and outpatient mental health and substance abuse services in or outside of North Carolina,
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