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.
If you get care at facility outside of your plan’s network, you may get a bill for more money. This is called balance billing. Your health plan pays a set amount for covered services, called the allowed amount. If the care provider charges more than this amount, you may have to pay the remaining costs. For example, if a hospital that is not in your plan’s network charges $1,500 for a stay, but your plan only allows $1,000, you might have to have to pay the $500 difference.
Emergency services are treated differently. If you go to an out-of-network hospital from the emergency room and are admitted, your care will be covered like it would be at an in-network hospital. This means your plan will pay for your care as usual. However, the out-of-network hospital or doctor might still send you a bill for costs not covered by your plan, such as extra charges after you pay your deductible, copay or coinsurance. If you have questions or need help, please call Customer Service.
For medical, vision and pharmacy claims:
If you go to a doctor or provider who works with Blue Cross Blue Shield, they will send the claim for you. If your provider does not work with Blue Cross Blue Shield, you need to fill out a claim form yourself. You can use the following forms in your Member Resources:
For dental claims:
If your dental service is not covered, your dentist does not have to send in a claim. You can send in a claim yourself by filling out an American Dental Association (ADA) claim form. You can get this form from your dentist.
Steps to file a claim for reimbursement:
1. Fill out and sign the form.
2. Include an itemized bill from your provider or pharmacy that shows what service or medicine you received.
3. Mail or fax your claim to the following:
Important: You must send your claim form within 12 months of the date you received care.
If you have questions, please contact Customer service by calling 844-363-8457.
You must file a claim within one year from the date you received the service. If you do not file your claim on time, we will deny it. However, if you can show that it was not possible to file your claim within one year, we will review your claim as long as you file it as soon as you can. If your claim is denied because it was late, you have the right to appeal. With your appeal, you must show why you could not file your claim on time.
If you do not agree with a decision about your claim, you can ask us to look at it again. This is called an appeal. You or an authorized representative can file one using the appeal forms in your Member Resources. Your provider can also submit an appeal on our Eligibility and Claims page.
After we get your appeal:
A grace period is extra time that BCBSND gives members to pay their health insurance premium. This helps members keep their health insurance active, even if they are late with a payment. All payments are due before the coverage starts, but if a member enters a new month without paying, the grace period begins.
The length of the grace period depends on whether the member gets help paying for their insurance through the Advanced Premium Tax Credit (APTC) from the federal government. If a member gets APTC through the Federally Facilitated Marketplace (FFM), they have up to three months in a row to pay their bill in full, as long as they paid for the first month to start their plan.
What is a Pending Claim?
A pending claim is a request for payment that has been sent in, but it has not been approved, denied, finalized or completed.
What is my Grace Period?
If you get help paying for your health insurance from the FFM, you have three consecutive months to pay your bill if you miss a payment. If you do not get any help from the FFM, you have 31 days to pay your bill if you miss a payment.
How can I avoid my coverage getting cancelled?
Always pay your premium on time. Your premium is due on the first day of the month that your coverage starts. For example, your payment for January is due on January 1. Also, make sure to answer all questions on your application honestly and report your income correctly to the FFM.
A retroactive denial happens when a health insurance company takes back money they already paid for a claim.
This can happen if your eligibility for coverage changes after the claim was paid. For example, this might occur if someone gives false or incorrect information on their application, keeps getting services after their coverage ends, does not report changes that affect their coverage, or does not pay their monthly premium. If this happens, the insurance company may decide you were not covered for those services and will not pay for them. To avoid retroactive denials, make sure to report any changes right away, pay your monthly premium on time and follow all the rules for keeping your coverage.
Some things you can do to help prevent a retroactive denial:
If this health plan is secondary to another insurer, request your primary insurer to send us an Explanation of Benefits
If you pay more than you owe for your premium, you may get money back. What happens depends on when we get your payment. If you pay too much while your coverage is still active, the extra money will be used to pay for next month’s premium. If you pay too much after your coverage has ended, you will get a refund by check. If you think you have overpaid your premium, please contact Customer Service.
Refund requests can be submitted using any of the following:
Medically necessary services, supplies or treatments are those that a health care provider gives to treat an illness or injury. These services must be reasonable, necessary and/or based on proven medical guidelines. The standards for these services are:
Certain services need approval, called prior authorization, before they are done. You can find a list of these services in your Benefit Plan book under the Authorizations section. The services that need prior authorization may be different for each plan. So make sure you check your own plan.
You should get prior authorization before getting the service. If you have an emergency and cannot get prior authorization, you or someone helping you should tell the Claims Administrator about your hospital admission on the next business day or as soon as possible. Your provider can also ask for approval as long as the claim has not been sent in yet. If you do not get prior authorization, you may have to pay the full cost of the service.
Utilization Management tries to review requests within these timeframes:
Sometimes you may need a medicine that is not listed on your health plan’s drug list (formulary). If this happens, you can ask us to cover the medicine by requesting a formulary exception. We will cover one of these drugs as part of our exception process if it is found to be medically necessary. A drug may be considered medically necessary if:
Your doctor can request this by faxing the Coverage Exception Prescriber Fax Form found online. You can also ask for a formulary exception by filling out the Request for Prescription Drug Exception form in your Member Resources or by calling Customer Service.
If a drug is denied, you have the right to ask for another review by people outside of BCBSND. This is called an external review.
If you think we made a mistake by denying your request, you can ask us to send your case to an independent review organization (IRO). This is a group of experts who do not work for us, and we must follow their decision.
You, your doctor or your representative can ask for an external review. You can do this by mail, phone or fax by using the following form in your Member Resources:
Member Pharmacy Coverage Exception Form - External Review
Mail: BCBSND
PO Box 1570
Fargo, ND 58107-1570
Phone: 844-363-8457
Fax: 701-277-2209
How long does it take to get a decision?
If you need a faster review because of a serious health problem, check the “Expedited/Urgent” box on the form mentioned above.
We will let you know our decision about your claim within 30 days of getting it. Sometimes, we may need more time. In those cases, we can take up to 45 days to decide. This can happen for two reasons:
If we ask you for more information, you will have at least 45 days to send it to us. If we do not get the information within that time, we will have to deny your claim.
After you visit a doctor or health care provider, you may get a letter called an Explanation of Benefits (EOB). This letter shows what services you received, how much they cost and how much your plan paid. An EOB is not a bill. If you owe any money, your health care provider will send you a separate bill.
BCBSND sends EOBs after we finish processing your claim. This means we have received your claim and made a decision about it.
Learn more about how to read EOBs.
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.
