Transparency in Coverage

The Affordable Care Act (ACA) requires that all health plans provide information that will help consumers understand how reliably the plan reimburses for covered services and other practical information. Health care transparency provides consumers with the information necessary to choose their health care plan.

  • Out of network liability and balance billing
  • Enrollee claim submission
  • Grace periods and claims pending
  • Retroactive denials
  • Recoupments of overpayments
  • Medical necessity and prior authorization timeframes and enrollee responsibilities
  • Drug Exception timeframes and enrollee responsibilities
  • Explanation of benefits
  • Coordination of benefits

Out of network liability and balance billing

If you receive services at an out-of-network facility, you may be balance billed. The amount the plan pays for covered services is based on the allowed amount. You may be responsible for any excess charges of the allowance for covered services, with the exception of emergency services. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing). For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference.

Enrollee claim submission

Medical, Vision and Pharmacy Claims:
If you received care from a health care provider that participates with Blue Cross Blue Shield, the provider will submit the claim on your behalf. If the provider does not participate with Blue Cross Blue Shield, you will need to complete a member submitted claim form for medical, vision or pharmacy claims found below:

Dental Claims:
If the services are non-covered, a participating provider is not required to submit a claim. The member may submit a claim for these charges by completing an American Dental Assocation (ADA) claim form supplied by the Member's dental provider.

Once the medical, vision, pharmacy or dental claim form has been completed you can mail or fax the form to:

Mail: 4510 13th Ave S, Fargo, ND 58121
Fax: 701-282-1888

The claims form must be submitted within 12 months of the occurrence. If you have further questions, please contact Member Services by visiting our Contact Us page or by calling 1-844-363-8457.

Grace periods and claims pending

A grace period is the amount of time BCBSND will allow members to pay owed premium to keep their health insurance active. Because all premiums are due prior to the effective date of the coverage, the grace period begins at any point a member enters a coverage month for which the member has not paid.

Grace periods for members will vary, depending on whether they are receiving an Advanced Premium Tax Credit (APTC) from the federal government through the Federally Facilitated Marketplace (FFM). For members receiving APTC through the FFM, insurers are required to allow up to three months to pay premium in full, as long as the first month of coverage is paid to effectuate the plan.

  • Once a member enters the second month of the three month grace period, claims will pend until premium is paid in full.
  • Once a member enters the second month of the three month grace period, BCBSND will no longer pay for prescription drugs upfront.
  • Once members have entered the three month grace period, they are required to pay the total premium amount owed by the end of the three months of grace for coverage to continue.
  • Once all outstanding premium is paid by the end of the third month of grace, claims will process per the benefit plan, and BCBSND will again begin paying for pharmacy drugs at the Point of Service (POS)
  • If all outstanding premiums are not paid, all claims pending and any claims previous paid in the second and third months of the grace period will deny, and the member will be responsible for full payment to the provider.

What is my Grace Period?
If you receive an APTC from the FFM, your grace period is three months. If you do not receive any assistance from the FFM, your grace period is 31 days.

How can I avoid my coverage getting cancelled?
Always pay premium timely. Premium is due the 1st of the month for which coverage is active. So, coverage for January is due January 1st. Answer all questions on your application honestly and report all income correctly with the FFM.

Retroactive denials

A retroactive denial is the reversal of a previously paid claim. BCBSND may reverse a previously paid claim when eligibility has changed retroactively. Eligibility can change retroactively in cases of fraud (when a member fills out an application with incorrect or fraudulent information), when members or dependents continue receiving services after losing eligibility, when members fail to meet the reporting requirements for loss of eligibility, or in situations where premium is not paid, leaving the member uncovered for services. Members can avoid retroactive denials by reporting all changes timely, paying monthly premium, and ensuring eligibility requirements are met.

Recoupment of overpayments

If a member overpays their premium amount, they may receive reimbursement, dependent on the when BCBSND receives the payment. Members who over pay while coverage is still active will see the remaining premium amount credited to their next month's premium. Members who overpay - beyond their coverage cancel date will receive a refund in the form of a check. If you believe you have overpaid your premium, please call the number on the back of your ID card.

Medical necessity and prior authorization timeframes and enrollee responsibilities

Medically necessary services, supplies or treatments are provided by a health care provider to treat an illness or injury that are reasonable, necessary and/or appropriate based on evidence based clinical standards of care. These standards of care must be:

  • Medically required and appropriate for the diagnosis and treatment of the member's illness or injury
  • Consistent with professionally recognized standards of care
  • Will not involve costs that are excessive in comparison with alternative services that would be effective for diagnosis and treatment of the member's illness or injury.

Certain services are subject to prior authorization before being performed. These are found in the member's Benefit Plan book under the Authorizations section. Services that are subject to prior authorization may vary from Plan to Plan, so attention should be given to the individual Plan that is being considered.

Prior authorization should be obtained before the service is provided, however if the Member's medical condition does not allow the Member to obtain prior authorization due to an emergency Admission, the Member or the Member's representative is requested to notify the Claims Administrator of the Admission during the next business day of the Claims Administrator or as soon thereafter as reasonably possible to obtain authorization. There are no penalties applied for the Member if prior authorization is not obtained. The service will be reviewed for medical necessity when the claim is submitted.

Drug Exception timeframes and enrollee responsibilities

A member with a metallic plan may ask BCBSND to make an exception to cover a drug that is not on the Formulary. This is known as a formulary exception request. This occurs after the initial review has been completed and denied as a non-formulary drug by Prime Therapeutics (Prime), BCBSND's Pharmacy Benefit Manager. A member (or member representative) can request a formulary exception review by completing the request form. This form is available on BCBSND's website or via Member Services at the telephone number and address on the back of the member Identification Card. The completed form should be mailed or faxed to the BCBSND location listed on the form.

Upon receipt of this form, BCBSND reviews the information from Prime Therapeutics and submits the request to be reviewed internally at BCBSND or to the Independent Review Organization (IRO) the same day.

If the request is a standard request being reviewed internally by BCBSND, BCBSND will respond with their determination within 72 hours after receiving the exception request. If request is expedited or exigent, BCBSND will complete the case within 24 hours. BCBSND will notify the requestor of the determination within a 24-hour time frame.

If the request is a standard request being requested through external review, an IRO will respond with their determination within 72 hours after receiving the exception request. If request is expedited or exigent, the IRO will complete the case within 24 hours. The IRO will notify BCBSND with their determination and BCBSND will in turn notify the requestor.

A letter is sent to the requestor and member with notification of the determination. If the decision is overturned, Prime will be notified and allow the drug to be paid. If the decision is denied, the member may follow the standard appeals process by contacting Member Services by visiting our Contact Us page or by calling 1-844-363-8457.

Explanation of Benefits

After a visit to a health care provider, a member may receive an Explanation of Benefits (EOB) detailing the services received, how much they cost and how much your plan paid. An EOB is not a bill. Your health care provider will provide a bill for any amount you may owe.

BCBSND sends EOBs after claims have been processed, which means the claim has been received and adjudicated.

Learn more about how to read EOBs.

Coordination of Benefits

Coordination of Benefits applies when a person has health coverage from more than one health insurance provider. Coordination of Benefit rules provide the order in which each plan pays a claim for benefits.

The plan that pays first is the "Primary Plan." The Primary Plan must pay benefits in accordance with its policy terms without regard to the possibility that another plan may cover some expenses.

The plan that pays after the Primary Plan is the "Secondary Plan." The Secondary Plan may reduce the benefits it pays so that payments from all plans do not exceed 100 percent of the total allowable expense.