Claims Payment Policy and Practices for Qualified Health Plans (QHP)

Information provided here on our policies:

• Out-of-network liability and balance billing
• Enrollee claim submission
• Grace periods and claims pending
• Retroactive denials
• Recoupment of premium overpayments
• Medical necessity and prior authorization: enrollee responsibilities
• Drug exception time frames and enrollee responsibilities
• Explanation of benefits (EOB)
• Coordination of benefits (COB)

Out-of-network liability and balance billing

PPO:
On the Blue Shield PPO plan, you can choose to seek services from a non-participating provider for most covered services.

Participating providers have a contract with Blue Shield and agree to accept Blue Shield’s Allowable Amount as payment in full for covered services. As a result, your cost share is less when you receive covered services from a participating provider.

Except for emergency services, and services received at a participating hospital under certain conditions, you will pay more for covered services from a non-participating provider. Non-participating providers do not have a contract with Blue Shield to accept Blue Shield’s Allowable Amount as payment in full for covered services, and can balance-bill for the difference between the allowable amount and the billed charges. You will be responsible for any plan deductibles, copayment and coinsurance amounts, non-covered items, and the difference between the billed change and the allowed amount.

HMO:
Participating providers have a contract with a medical group in this plan’s network. With an HMO plan, there is generally no coverage for services from providers outside of your medical group without a referral.

Non-participating providers do not have a contract with Blue Shield to accept Blue Shield’s allowed charges as payment in full for covered services. Except for emergency services, urgent services, and services received at a participating hospital under certain conditions, this plan does not cover services from non-participating providers. You will be responsible for any plan deductibles, copayment and coinsurance amounts, non-covered items and the difference between the billed change and the allowed amount.

Enrollee claim submission

When you receive healthcare services, a claim must be submitted to request payment for covered services. A claim must be submitted even if you have not yet met your deductible. Blue Shield uses claims information to track dollar amounts that count towards your deductible.

When you see a participating provider, your provider submits the claim to Blue Shield.  When you see a non-participating provider, you may have to submit the claim to Blue Shield or the applicable benefit administrator. Claim forms are available by logging into the member website at blueshieldca.com or by contacting the benefit administrator. Please submit your claim form and medical records within one year of the service date.

How to submit a claim

Grace periods and claims pending

Premium grace period: if you do not receive advance payments of premium tax credits

The Notice of Grace Period is sent to Subscribers or Contract holder whose bill is still not paid at the end of the due date. The Subscriber or Contract holder has a 30-day grace period from the date of the notice of the grace period to pay all outstanding Premiums before coverage is canceled due to nonpayment of Premiums. Coverage will continue during the grace period. If the Subscriber or Contract holder does not pay all outstanding Premiums within the grace period, coverage will end 30 days after the last day of paid coverage. The Subscriber or Contract holder will be liable for all Premiums owed, even if coverage is canceled. This includes Premiums owed for coverage during the 30-day grace period.

Premium grace period: if you receive advance payments of premium tax credits, and/or state advanced premium assistance subsidy

If the subscriber previously paid Blue Shield at least one full month’s premium during the benefit year, and is late on a premium payment, Blue Shield will notify the subscriber of their grace period as follows: the subscriber will have a subsidized grace period of three consecutive months from the due date to pay all outstanding premiums. Blue Shield will pay claims for covered services during the first month of the subsidized grace period. Coverage will be suspended for the second and third months of the subsidized grace period until the subscriber pays all premiums owed.

If the three-month subsidized grace period expires before the subscriber pays all outstanding premiums, Blue Shield will terminate coverage. The last day of coverage will be the last day of the first month of the three-month subsidized grace period. The subsidized coverage will only end on the last day of the month and never mid-month.

Retroactive denials

Whenever payment on a claim is made in error, Blue Shield has the right to recover such payment from the subscriber or, if applicable, the provider or another health benefit plan, in accordance with applicable laws and regulations. With notice, Blue Shield reserves the right to deduct or offset any amounts paid in error from any pending or future claim to the extent permitted by law. Circumstances that might result in payment of a claim in error include, but are not limited to, payment of benefits in excess of the benefits provided by the health plan, payment of amounts that are the responsibility of the subscriber (cost share or similar charges), payment of amounts that are the responsibility of another payor, payments made after termination of the subscriber’s coverage, or payments made on fraudulent claims.

To prevent retroactive denials:

• Make sure your providers have your current ID card;
  
• Know how you can access care;
• Know which services are covered under your plan;
• Know which services are not covered under your plan;
• Know how you must get prior authorization for certain services; and
• Pay your premiums on time.

Recoupment of premium overpayments

If the subscriber pays premiums beyond the date coverage ends, those premiums are unearned. Blue Shield will refund unearned premiums to the subscriber, minus any amount Blue Shield pays for benefits received after the date coverage ends. Blue Shield will only issue a refund to the subscriber if the amount the subscriber paid in unearned premiums is more than the amount Blue Shield pays for benefits after coverage ends.

To obtain a refund of a premium overpayment, call the Shield Concierge (HMO) or Customer Service (PPO) phone number on the back of your ID card.

Medical necessity and prior authorization: enrollee responsibilities

PPO:
Benefits are only available for services and supplies that are medically necessary. Blue Shield reserves the right to review all claims to determine if a service or supply is medically necessary. A physician or other health care provider’s decision to prescribe, order, recommend, or approve a service or supply does not, in itself, make it medically necessary.

Coverage for some benefits requires pre-approval from Blue Shield. This process is called prior authorization. Prior authorization requests are reviewed for medical necessity, available plan benefits, and clinically appropriate setting. The prior authorization process also identifies benefits that are only covered from participating providers or in a specific clinical setting.

If you see a participating provider, your provider must obtain prior authorization when required. When prior authorization is required but not obtained, Blue Shield may deny payment to your provider. You are not responsible for Blue Shield’s portion of the allowable amount if this occurs, only for your cost share.

If you see a non-participating provider, you or your provider must obtain prior authorization when required. When prior authorization is required, but not obtained, Blue Shield may deny payment and you will be responsible for all billed charges.

You do not need prior authorization for emergency services or emergency hospital admissions at participating or non-participating facilities. For non-emergency inpatient services, your provider should request prior authorization at least five business days before admission.

When a decision will be made about your prior authorization request:

Expedited requests include urgent medical and exigent pharmacy requests. Once the decision is made, your provider will be notified within 24 hours. Written notice will be sent to you and your provider within two business days.

HMO:
Members with HMO plans are enrolled with a Blue Shield delegated entity. These entities are known as either Independent Physician Association (IPA) or Medical Group (MG). These delegated entities are responsible for utilization management and claim payment of services deemed their responsibility, per the contractual Division of Financial Responsibility (DOFR).

Delegation is the process by which Blue Shield allows the IPA/medical group to perform certain functions, which are considered the responsibility of Blue Shield, on Blue Shield’s behalf for the purposes of providing appropriate and timely care for our members.

Benefits are only available for services and supplies that are medically necessary. Blue Shield and its delegates reserve the right to review all claims, to determine if a service or supply is medically necessary. A physician or other health care provider’s decision to prescribe, order, recommend, or approve a service or supply does not, in itself, make it medically necessary.

Coverage for some benefits requires pre-approval from the delegated entity. This process is called prior authorization. Prior authorization requests are reviewed for medical necessity, available plan benefits, and clinically appropriate setting. The prior authorization process also identifies benefits that are only covered from participating providers, or in a specific clinical setting.

Out of Network benefits are not available to HMO members, unless the services are urgent or emergent. IMPORTANT: Urgent and Emergent services do not require prior authorization.

Delegated entities are required to review, authorize and approve out of network specialty referrals if they do not have an In network provider available for a medically necessary service. They are also required to pay any claims resulting from an out of network referral per the contractual DOFR. When properly authorized, members are only responsible for their plan co-payment and cannot be balance billed.

Please note, the regulatory turn around times for delegated entities to make determinations on all prior authorization requests is the same for BSC managed plans.

When a decision will be made about your prior authorization request:

Drug exception time frames and enrollee responsibilities

Blue Shield’s Drug Formulary is a list of FDA-approved generic and brand drugs. This list helps physicians or health care providers prescribe medically necessary and cost effective drugs. Drugs not listed on the formulary may be covered when approved by Blue Shield, through the exception request process.

To request coverage for a non-formulary drug, you, your representative, your physician, or your health care provider may submit an exception request to Blue Shield. Once all required supporting information is received, Blue Shield will approve or deny the exception request, based on medical necessity, within 72 hours in routine circumstances, or 24 hours in exigent circumstances.

To start the exception request process, call the Shield Concierge (HMO) or Customer Service (PPO) phone number on the back of your ID card.

If Blue Shield denies your exception request to cover a non-formulary drug, step therapy, or prior authorization request, a grievance can be filed by you, your authorized representative, or a doctor. If you decide to file a grievance, you are entitled to a process called External Exception Request Review. Reviews will be resolved by Blue Shield within 24 hours for exigent (urgent) requests or 72 hours for a standard review. Members who file a grievance with Blue Shield also have the right to file a complaint with the Department of Managed Health Care and request an Independent Medical Review.

Please contact us to file a grievance at (844) 831-4133 or email AGDExternalReview@blueshieldca.com.
 

Explanation of benefits (EOB)

Blue Shield or the Benefit Administrator will process your claim within 30 business days of receipt if it is not missing any required information. If your claim is missing any required information, you or your provider will be notified, and asked to submit the missing information. Blue Shield cannot process your claim until we receive the missing information.

Once the claim is processed, you may receive an Explanation of Benefits (EOB). The Explanation of Benefits will include valuable information including the provider and date of each service, a description of each service, patient responsibility, deductible status (if applicable) and the amount paid.

Coordination of benefits (COB)

Individual and Family Plans:
Individual and Family Plans do not coordinate benefits with other Individual and Family Plans or Group Health Plans. However, if you are also covered with Medicare, or have more than one employer sponsored group health plan, after we receive information from you, we will determine which plan provides benefits first. Further information about coordination of benefits and limitation for duplicate coverage can be found in your Evidence of Coverage.

Group Health Plans:
When you are covered by more than one group health plan, payments for allowable expenses will be coordinated between the two plans. Coordination of benefits rules determine which plan will pay first when both plans have responsibility for paying the medical claim. Further information about Coordination of Benefits and Limitation for Duplicate Coverage can be found in your Evidence of Coverage.