Obtaining Service and Filing Claims

Transcription

1 Chapter 5 Obtaining Service and Filing Claims Your group s health benefits program covers eligible medical and surgical services performed in an office, facility, or at home by a doctor or other health care professional. While Participating Providers file claims on behalf of Members, there are certain situations where the Subscriber (or Member) may need information about the claims process. When assisting your group Members with claims questions, you may run into unusual terminology. Providers of service (and, at times, those of us who process claims) sometimes use terms with which you may not be familiar. The Reference and Glossary chapter of this manual contains the most frequent claims jargon that you may come across and our Group Service Department is available to assist you in getting a clearer understanding of the claim situation in question. You can call Group Service toll-free at or use our employer secure services at /Employer+Secure+Communications, to contact us to receive a clearer understanding of the claim situation in question. This chapter contains a wealth of information about: Filing claims for medical coverage as well as prescription drug, dental, and vision coverage The information needed to file a claim What to do when a Member is out of the area or out of the country Coordination of Benefits Subrogation (e.g., Workers Compensation, auto accidents, slip and fall situations) Claim appeals Examples of the forms listed in this chapter are contained in the Forms and Reports chapter in this manual. Please note that words which are double underlined are defined in the Reference and Glossary chapter.

2 5.2 Group Administrator s Manual Claims and How They Work Participating Providers When a Member receives covered services from a medical, prescription drug, dental, or vision Provider, we say a claim has been incurred. A claim is an itemized statement of charges for health care services and/or supplies provided by a facility Provider, a professional Provider, or other Provider. When Members use Participating Providers, the Participating Provider sends the claim to us. The Member usually has no paperwork to complete. As a general rule, when Participating Providers supply services, payment is made directly to the Participating Provider. The Member does NOT receive payment but an Explanation of Benefits (EOB) is generated describing what was covered under the program. Payment is made directly to the Participating Provider at the discounted reimbursement rate. EOBs contain important information about the claim, services provided, amounts, and dates of service, as well as information related to the amounts the Member is responsible to pay, claim denial, and the denial reason, if applicable. In 2010, Capital BlueCross replaced most of the medical paper EOBs with online EOBs. Members no longer receive a medical EOB when services are covered in full or require only the Member s copayment at the time of service. We made this change as a green initiative. Members will continue to receive medical EOBs by mail when they: Owe a deductible, coinsurance, or have some other Member liability; Submit a claim for out-of-network services; Are owed a refund; or Are notified of a claim adjustment to a previously processed claim. rkd/a2/8400/2.doc (10/2012)

3 Group Administrator s Manual 5.3 All medical EOBs are posted to the secure area of our Web site and are accessible via the Member s personal account. A Member can easily establish a personal account by visiting mycapbluecross.com. Members can continue to receive medical EOBs through the mail by calling Member services using the number on the back of their Capital BlueCross ID cards. HMO Members who receive Capitated Services generally do not receive EOBs, unless the Member received a mixture of Capitated and non-capitated Services. See the Capitation section of Chapter 4. Non-Participating Providers If a non-participating Provider directly delivers the service, the Member MAY need to pay for services when they are received and the Member may need to submit a claim to be reimbursed. If the Member uses a non-participating Provider or a Provider participating in the BlueCard network and located outside the Capital BlueCross 21-county service area, it is the Member s responsibility to obtain Preauthorization. The Member should call the Capital BlueCross Clinical Management Department toll-free at to obtain the necessary Preauthorization. A non-participating Provider may call on the Member s behalf; however, it is ultimately the Member s responsibility to obtain Preauthorization. For SeniorBlue HMO/PPO, non-participating HMO/PPO Providers must receive Preauthorization from the PCP. Please note that although many non-participating Providers do file claims on behalf of Capital BlueCross Members, they are not required to do so. Members may need to complete additional follow-up paperwork if the Provider has not furnished all the needed information. When non-participating Providers supply services, payment is generally made to the SUBSCRIBER, who in turn pays the Provider of service if payment has not already been made. rkd/a2/8400/3.doc (10/2012)

4 5.4 Group Administrator s Manual Providers Outside the Capital BlueCross Network Area There may also be differences in how claims are processed if services are received in area (i.e., within the Capital BlueCross 21-county service area) or out-of-area (i.e., anyplace other than the Capital BlueCross 21-county service area). Please refer to Chapter 4 of this manual for additional information about in-area and out-of-area situations. If the Member uses a non-participating Provider, or a Provider participating in the BlueCard network and located outside the Capital BlueCross 21-county service area, it is the Member s responsibility to obtain Preauthorization. The Member should call the Capital BlueCross Clinical Management Department toll-free at to obtain the necessary Preauthorization. A non-participating Provider may call on the Member s behalf; however, it is ultimately the Member s responsibility to obtain Preauthorization. A special note about privacy and claims information: Individual Member claim information is protected under the Health Insurance Portability and Accountability Act (HIPAA). Only the adult Member can release certain information to other individuals about his or her claim (or his or her dependent if the dependent is under the age of majority we use the age of 18; the age of majority for Magellan Behavioral Health, Inc. is 14). Capital BlueCross personnel MUST abide by HIPAA regulations concerning privacy and the release of Member information. This means there may be instances where we are not able to provide you with some of the information you request. We will ALWAYS do our best to work with you and assist you and the Member. And, frequently we will contact the Member directly at your request to resolve a claim situation. More information is available about HIPAA in the HIPAA Privacy and You chapter in this manual. rkd/a2/8400/4.doc (10/2012)

5 Group Administrator s Manual 5.5 Claim Forms There are different claim forms for different types of claims. (Examples of these claim forms are included in the Forms and Reports chapter.) These include: Program Claim Form Name Comprehensive The Medical Expense Claim Form (Form NF-43A) Dental BlueCross Dental The BlueCross Dental Claim Form HMO The Medical Expense Claim Form (Form NF-43A) POS The Medical Expense Claim Form (Form NF-43A) PPO (includes PPO Plus, PPO 1-2-3, HRA, and HSA arrangements) The Medical Expense Claim Form (Form NF-43A) Rx The Prescription Reimbursement Claim Form Senior The Medical Expense Claim Form (Form NF-43A) SeniorBlue HMO Participating HMO Providers always submit their own claim form; nonparticipating HMO Providers must receive Preauthorization from the PCP. rkd/a2/8400/5.doc (10/2012)

6 5.6 Group Administrator s Manual SeniorBlue PPO Participating HMO Providers always submit their own claim form; nonparticipating HMO Providers must receive preauthorization from the PCP. Traditional The Medical Expense Claim Form (Form NF-43A) Vision BlueCrossVision Claim for Vision Care Expense Form Examples of all claim forms can be found in the Forms and Reports chapter of this manual. Claim forms are always available from our Web site, Helpful information about the content of these forms is listed below. Filing a Medical Claim Participating Providers file claim forms for Members. Non-Participating Providers may or may NOT file claim forms for Members, and Members will likely need to file their own claim form to be reimbursed for eligible services performed by a non-participating Provider when services by non-participating Providers are eligible under the program design. It is VERY IMPORTANT that ALL INFORMATION is completed on the claim form. A separate claim form must be completed for each family member who receives medical services. All itemized bills for the services received by the individual family member must be attached to the claim form. (A separate claim form is NOT needed for each bill.) All EOB forms (e.g., Medicare, other insurance carrier) for bills being submitted must be attached to the claim form. (See the Other Party Liability section of this chapter for more information about individuals having more than one applicable coverage.) rkd/a2/8400/6.doc (10/2012)

7 Group Administrator s Manual 5.7 Most importantly, if a claim (including HMO) has to be filed by the Subscriber/Member: Mail ALL medical program claims to: Capital BlueCross PO Box Harrisburg, PA For assistance in submitting these claims, Members should call Customer Service at the number listed on their identification card. (Please note that although claims can be submitted for up to 12 months from the date of service, it is in the Member s best interest to file claims promptly after services are received.) What is an Itemized Bill? We very often talk about itemized bills for Members who are submitting claims. By our definition, itemized bills include the following: Provider s Official Billing Statement The Provider s bill must include the name, address, phone number, and type of provider (MD, DO, etc.). It must also include the performing Provider National Provider Identifier (NPI) number and billing Provider NPI number, and usually the Provider s license number. General receipts or cash register receipts are NOT official billing statements. Full Name of the Patient Standard Provider bills contain the name of the individual who received services (also the individual s identification number and date of birth). rkd/a2/8400/7.doc (10/2012)

8 5.8 Group Administrator s Manual Procedure Code (Type of Service Received) Standard Provider bills contain procedure codes appropriate for the service received, such as brief office visit, appendectomy, wheel chair, etc. If a Provider cannot locate an appropriate procedure code, he/she may bill with an unclassified code and provide a written description of the procedure. Sometimes medical records or letters on medical necessity for the claim are included to assist our Claims Department in determining eligibility. Date Service was Received The month, day, and year the patient received service(s) are standard pieces of information on a Provider s bill. Amount Charged for Service The amount the Provider CHARGES for the service must be on the bill. (Note: There is a difference between the amount a Participating Provider charges and the amount the Provider may be paid. The amount we actually PAY the Provider is called the Allowable Amount and is not on the itemized bill.) Diagnosis The diagnosis for which the patient received treatment must be on the Provider s bill. The diagnosis may be a code (called an ICD [International Classification of Diseases] 9 code) OR may be in written form (e.g., diabetes). Services Requiring Special Information Certain types of services may require additional information on the Provider s bill. These include the following: rkd/a2/8400/8.doc (10/2012)

9 Group Administrator s Manual 5.9 (Please note: Providers of service, whether participating or non-participating Providers, are generally aware of the types of information needed to process insurance claims and in many instances, the information provided to the Member will contain the appropriate information. However, we want you to know the specific information we must have in certain instances just in case a Member uses a Provider who does not routinely provide the information we need.) Service Received Special Information Needed Surgery The specific type of surgery must be identified on the bill (e.g., appendectomy, cholestectomy, hysterectomy, etc.). Anesthesia The length of time the patient was under anesthesia and the specific type of surgery for which the anesthesia was given must be shown on the Provider s bill. Home Health Care Bills for home health care require the type of service (physical medicine, occupational therapy, speech language pathology, skilled nursing, home health aide, etc.), the date(s) of service, and some benefit designs require preauthorization (POS, HMO). Blood The number of pints received, the charge for each pint received, and the number of pints replaced by donor(s) is needed on the Provider s bill. Chemotherapy The name of the drug, its dosage, the charge for each drug, and the method of administration (e.g., oral, intramuscular injection, intravenous, etc.) must be shown on the Provider s bill. rkd/a2/8400/9.doc (10/2012)

10 5.10 Group Administrator s Manual Home Medical Equipment A certification from the prescribing doctor indicating medical necessity and the expected length of time the equipment will be needed must be submitted with the Provider s bill. If the bill is for RENTAL equipment, the purchase price of the equipment must be on the Provider s billing statement. Ambulance Information The point of origin and destination must be shown on the Provider s statement (e.g., from hospital to skilled nursing facility). If mileage is charged, the number of miles must be included. Special Situations Situation Special Instructions Other Insurance Payment/Rejection Notice Always include copies of other insurance processing information with a medical claim. This permits us to more quickly process coordination of benefit factors for the claim. Accident Information Always indicate if services were received because of an accident. Depending on the type of accident (e.g., automobile accident), other insurance may be responsible for paying first. Workers Compensation Payment or Rejection Notice Always include copies of payment or rejection information if services were received due to injuries or illness eligible for Workers Compensation consideration. rkd/a2/8400/10.doc (10/2012)

11 Group Administrator s Manual 5.11 Medical Records To determine if services are medically necessary or appropriate, we may contact the Member and/or the Provider of service to obtain medical records, physician notes, or treatment plans. If the patient/subscriber has additional medical information from the Provider of service indicating medical necessity and/or treatment plans, we suggest the Member send this information immediately with the initial claim form to speed processing. What s the Difference Between Provider Charge and Allowable Amount? There is sometimes confusion about the difference between what Participating Providers CHARGE for services and what Capital BlueCross programs PAY Providers. Very simply, Capital BlueCross does all it can to keep the costs of health care as low as possible. To do this, we negotiate discounts with our Participating Providers. We call the negotiated amount we have agreed to pay a Provider the Allowable Amount. It is the maximum amount we will consider paying for a service regardless if the service is received from a Participating Provider or a non-participating Provider. Here s a simple example: The charge for a doctor s office visit is set by the individual doctor to be $100. Our Allowable Amount for the doctor s office visit is $60. Doctor 1 participates in the Capital BlueCross network. The doctor submits the claim and Capital BlueCross pays the doctor $60 for the office visit. The Member cannot be billed for the additional $40 because the doctor, as a condition of being in the network, has agreed to accept $60 for this service. rkd/a2/8400/11.doc (10/2012)

12 5.12 Group Administrator s Manual Doctor 2 is not participating in the Capital BlueCross network. The doctor charges $100 and may ask that the patient pay that entire amount when services are received or the doctor may agree to bill the patient directly for $100. After processing the claim, Capital BlueCross will pay the Subscriber $60 (the Allowable Amount). The nonparticipating doctor may bill the patient for the additional $40 (if it was not collected at the time of service) and it will be the Member s responsibility to pay the doctor the balance of the bill. (This is called balance billing.) What Happens if There s a $10 Office Visit Copay With our Product? Continuing from the previous examples, Doctor 1 still charges $100 for the office visit. He collects $10 from the patient at the time of service and submits the claim to us. The Allowable Amount is $60 and that s the maximum amount to be paid for the office visit service. Copayments are a form of cost sharing between the patient and what the program pays. The copayment is a part of the Allowable Amount for the service. Since the doctor has already received $10 from the patient (the Member s cost share), Capital BlueCross pays the Provider $50 for the office visit. The doctor still receives the total Allowable Amount of $60; it s just shared between Capital BlueCross and the Member to match the group s selected product design. What About a Product With Coinsurance? Let s assume your group program pays 100 percent in-network and 80 percent out-ofnetwork for eligible services. (Eligible services are those that are medically necessary and appropriate and covered under the terms of your group contract.) In addition, there is a $10 office visit copayment in the group product design. Doctor 1 charges $100 for an office visit and is a Participating Provider. The patient pays $10 when services are received, the Provider submits the claim, and Capital BlueCross pays the Provider $50. There is no balance billing to the Member because this is a Participating Provider and network services have a 100 percent coinsurance (i.e., 100 percent of the Allowable Amount is paid by Capital BlueCross). rkd/a2/8400/12.doc (10/2012)

13 Group Administrator s Manual 5.13 Doctor 2 is a non-participating Provider who charges $100 for an office visit. The patient may be asked to pay the $100 at the time of service. (The office visit copayment of $10 does NOT apply to the nonparticipating claim in the example product design.) The claim is submitted to Capital BlueCross and we pay the Subscriber 80 percent of the Allowable Amount for the service (i.e., 80 percent x $60 = $48 paid to the Subscriber). The balance of $52 is the Member s cost share responsibility received from the non-participating Provider. What Happens if I Need an HMO or POS Referral? Members enrolled in Capital BlueCross HMO or POS products may need to obtain a referral from their PCP before receiving services from a specialist Provider. Typically, the HMO product requires referrals and self-referrals may result in a denial of coverage. However, Members who have the HMO product with the Direct Access benefit are not required to obtain referrals before receiving services from participating specialists. HMO and POS referrals are completed and submitted by the PCP and, under certain circumstances, the specialist to whom the PCP referred the Member. Typically, PCPs refer to participating specialists who submit claims on behalf of the Member. For HMO programs, the Member may not be covered for the cost of the self-referred services. If a referral is made to a non-participating Provider by a PCP for any reason, a preauthorization is required. Certain services do not require a referral. These services include: medically necessary obstetric and gynecologic services, diagnostic tests, radiology services, outpatient chemotherapy and radiation therapy, and emergency care. Although referrals are not necessary for these services, Providers of the diagnostic testing services may require an order from the physician requesting the test before the test can be performed. Always refer to the group contract and Member Certificate of Coverage for specific information about benefit program design. (For POS services, the Member may have to submit the claim to us for reimbursement using a Claim Form [see the Forms and Reports chapter of this manual for an example and instructions]). rkd/a2/8400/13.doc (10/2012)

14 5.14 Group Administrator s Manual Members submitting these claims should request an itemized bill from the non-participating Provider and send it to: Capital BlueCross PO Box Harrisburg, PA For help in submitting these claims, Members should call our Customer Service Department at: ( for HMO) Teletype (TTY) ( for HMO) What if an Employee Doesn t Live Here? Or, the Employee is on Vacation? We recognize that businesses have employees who may live and work outside the Central Pennsylvania and Lehigh Valley geographic areas. And, vacation plans often take Members outside the Capital BlueCross 21-county service area. While we do have requirements that a company be headquartered in this area and have an employee base here, it s important that Capital BlueCross coverage be available to our Members wherever they are. Your out-of-area employee (i.e., individuals who do not live in the Capital BlueCross 21-county service area or a Member on vacation out of area) has access to the BlueCard national network of Providers. The BlueCard Program has a national network of Participating Providers utilizing all Blue Plans. Within the BlueCard program, claims processing is an integrated system among all the Blue Plans. BlueCard allows Capital BlueCross Members to receive the same benefits regardless of where they receive services. Whether your Member is traveling or residing outside the Capital BlueCross service area, their benefit program goes wherever they go. rkd/a2/8400/14.doc (10/2012)

15 Group Administrator s Manual 5.15 If a Capital BlueCross Member receives covered services from a facility or professional Provider outside our service area and the Provider is a member Provider with the local Blue Plan, your Member only needs to show his or her Capital BlueCross ID Card and pay any applicable out-of-pocket amounts. The Capital BlueCross ID Card information allows the Provider to file the claim correctly. The Provider will file the claim with the local Blue Plan who in turn will electronically route the information to us for processing. We respond to the initiating local Blue Plan after applying your group s applicable benefits and the local Blue Plan pays their member Provider for the covered service. HMO Members must reside within the Capital BlueCross service area. The BlueCard program applies for urgent and emergent care only. Nonemergency (or routine) care must be coordinated by the HMO Member s PCP. Finding BlueCard Participating Providers When Away From Home If a Member is located outside the Capital BlueCross service area, it s simple to locate a BlueCard Participating Provider. Call BLUE to locate a Participating Provider. You can also find Participating Providers at Services From Non-Participating Providers In certain situations, it may not be possible to reach a BlueCard Participating Provider, or your out-of-area resident employee may choose to receive services from a non-participating Provider. HMO Members do not have coverage for services from a non-participating Provider. If services are received from a non-participating Provider, the Member may be required to submit a claim for the services received. rkd/a2/8400/15.doc (10/2012)

16 5.16 Group Administrator s Manual Send a Capital BlueCross claim form to us for non-participating Provider services. Claim forms are available from our Web site at and sample forms are included in the Forms and Reports chapter of this manual. Travel Outside the United States BlueCard Worldwide provides Capital BlueCross Members with access to network health care services around the world. Members traveling or residing outside the United States have access to doctors and hospitals in more than 200 countries. (HMO Members must reside within the Capital BlueCross service area or participate in the Away From Home Care Guest Membership Program. See Chapter 4 for more details. HMO Members may use BlueCard for urgent or emergent care only.) To locate Providers outside the United States Call the BlueCard Worldwide Service Center, BLUE, 24 hours a day, 7 days a week, or go to /bcbsa/index.asp?page=login, accept the Terms & Conditions, enter your Alpha Prefix, and login to locate a Provider outside the United States. Here are some simple steps to remember if services are needed outside the United States: Members should always carry their Capital BlueCross ID Card when traveling. If emergency care is needed, go to the nearest hospital. Call the BlueCard Worldwide Service Center at BLUE or call collect ( , available 24 hours a day, 7 days a week) if admitted. rkd/a2/8400/16.doc (10/2012)

17 Group Administrator s Manual 5.17 If nonemergency care is needed, call BLUE. A medical coordinator, in conjunction with a medical professional, will assist the Member in locating appropriate care. The BlueCard Worldwide Service Center is staffed with multilingual representatives and is available 24 hours a day, 7 days a week. HMO Members should only call BlueCard for urgent or emergent care. Nonemergency (or routine) care must be coordinated by the HMO Member s PCP. Call Capital BlueCross to obtain preauthorization if services require preauthorization. The number is Filing Claims for Out-of-Country Services There are special requirements in filing claims for services received outside the United States. Inpatient Hospital Claims Inpatient hospital claims arranged through the BlueCard Worldwide Service Center require the Member to pay only the usual out-of-pocket expenses (e.g., deductibles, copayment, coinsurance, etc., according to the group s contracted benefits). The hospital Provider files the claim for the Member. The Member may have to pay the hospital and submit a claim for inpatient care if inpatient hospital services were received from a nonnetwork facility or not coordinated through the BlueCard Worldwide Service Center. Professional Provider Claims For all outpatient and professional medical care, the Member pays the Provider and the Member must submit the claim. The claim should be submitted showing the currency used to pay for services (i.e., if traveling in Europe and payment was made in Euros, our claims processing accommodates converting the Euros to United States currency amounts). rkd/a2/8400/17.doc (10/2012)

18 5.18 Group Administrator s Manual International Claim Form There is a specific claim form that must be used to submit international claims. Itemized bills MUST be submitted with the claim form. The International Claim Form can be accessed at /Forms and following the instructions. Send International Claim Forms to: BlueCard Worldwide Service Center PO Box Richmond, VA USA The BlueCard Worldwide Service Center will coordinate with Capital BlueCross to process the claim. Prescription Drug Claims Capital BlueCross Rx programs are administered by CVS Caremark, 1,2 one of the largest Pharmacy Benefit Managers (PBMs) in the nation. Our programs typically have three primary components: Retail Service, the Mail Service Program, and specialty drugs through CuraScript 3 Pharmacy. Rx programs also may have copayment, coinsurance, deductible, and/or ancillary charge requirements for prescription medication. Many times the Member cost sharing amounts differ depending on whether the dispensed drug is generic, brand preferred, or brand nonpreferred. 1 Capital BlueCross continually evaluates vendor capabilities. As such, vendors identified here reflect entities providing goods and/or services as of the date of document publication. Vendors are subject to change at Capital BlueCross discretion. 2 On behalf of Capital BlueCross, CVS Caremark assists in the administration of our prescription drug program. CVS Caremark is an independent pharmacy benefit manager. 3 On behalf of Capital BlueCross, CuraScript, Inc. assists in the delivery of specialty medications directly to our Members. CuraScript is an independent company. rkd/a2/8400/18.doc (10/2012)

19 Group Administrator s Manual 5.19 Generic drugs contain the same active ingredient(s) as their corresponding brand name drug and have been approved by the Food and Drug Administration (FDA) for therapeutic equivalency to their brand name product. Brand Preferred drugs have been reviewed by Capital BlueCross Pharmacy and Therapeutics Committee and found to have therapeutic advantage or overall value over nonpreferred brands, factoring safety, effectiveness, and cost. Brand Nonpreferred drugs have been reviewed by Capital BlueCross Pharmacy and Therapeutics Committee and found not to have significant therapeutic advantage or overall value over alternative generic, preferred brands, or overthe-counter medications. Retail Service When a Member with a Prescription Drug Card Program obtains prescription drugs from a network (participating) retail pharmacy, the Member does not have to complete a claim form. The Member simply shows his Capital BlueCross ID Card and the pharmacy will access program information (e.g., copayment/coinsurance/deductible/ancillary charge amounts, benefit program limitations/exclusions, etc.) electronically. The cost of the prescription drug is subject to the plan allowance under the pharmacy benefit program. Capital BlueCross Members can access the participating pharmacy directory by visiting the Members page. There they should look for the Pharmacy Directory link under Pharmacy Network. For drug card programs, the Member is responsible for any deductible, copayment, coinsurance, and/or ancillary charge as defined in the group s drug benefit program design. The deductible, copayment, coinsurance, and/or ancillary charge is collected by the dispensing pharmacist at the time the prescription is dispensed. When a nonnetwork (nonparticipating) pharmacy is used by the Member, or if the Member does not present his/her Capital BlueCross ID card at a participating pharmacy, the Member will pay the pharmacy s charge and the Member will have to complete a claim form (Prescription Reimbursement Claim Form) for reimbursement. rkd/a2/8400/19.doc (10/2012)

20 5.20 Group Administrator s Manual The Member with a drug card program is responsible for any deductible, copayment, coinsurance, and/or ancillary charge that applies to the group s drug benefit program. In addition, the Member is responsible for the difference between the pharmacy s charge and the allowable amount. Submitting a Retail Prescription Drug Claim The Prescription Reimbursement Claim form (see an example in the Forms and Reports chapter of this manual) and the original prescription receipt are needed to file a prescription drug claim. Prescription Reimbursement Claim forms can be obtained by calling CVS Caremark Customer Service at , or downloading the form from in the Members section, under Pharmacy Information, Drug Formulary Information and Forms, scroll to the bottom of the page to General Documents & Forms and click the link for the Prescription Claim Form. The original retail prescription receipt must include: Pharmacy name, address, and NCPDP (National Council of Prescription Drug Programs) number. Date prescription was filled. Drug name, strength, and NDC (National Drug Code) number. Prescription number. Quantity dispensed. Days supply dispensed. Total charge. Patient s first and last name. If a foreign claim, include the country name, type of currency, and amount. rkd/a2/8400/20.doc (10/2012)

21 Group Administrator s Manual 5.21 ALL retail prescription drug claim forms should be sent to: CVS Caremark PO Box Phoenix, AZ Please note sending prescription claims to Capital BlueCross delays claim processing. CVS Caremark, our Pharmacy Benefit Manager, processes claims according to the benefits your group has selected from us. To obtain prescription drug claim forms, or for drug claim assistance, Members should call CVS Caremark Customer Service at: Teletype (TTY) Submit prescription drug claims as they occur. Claims MUST be submitted within 12 months of the date of filling the prescription. Prescription Drug Mail Service Prescription Drug Mail Service is easy to use. Here are the steps Members should remember when using the Mail Service option: Mail Service prescriptions are generally for up to a 90-day supply. Ask the doctor for a new prescription to begin using the Mail Service option. (Or, ask the doctor to call in the prescription, using , or fax the order to Always give the doctor the ID number on your Capital BlueCross ID Card to use when placing the order.) The doctor may indicate refills on the prescription according to the terms of your group benefit program. IMPORTANT NOTE: Certain controlled substances and other prescribed medications may be subject to dispensing limitations through the Mail Service option. rkd/a2/8400/21.doc (10/2012)

22 5.22 Group Administrator s Manual Complete all applicable sections of the Mail Service Order Form with the first Mail Service order. Update this information as necessary when adding or changing a Mail Service drug. Forms are available from our Web site at Click Members. At left side navigation panel, click Pharmacy Information. Under Drug Formulary Information & Forms, look for the Mail Order Documents subheading, then click the appropriate mail order form. Examples are located in the Forms and Reports chapter. Place the prescription(s) to be filled and a check (made payable to CVS Caremark), money order, or credit card (or check card) information on the completed Mail Service Order Form. Place in an envelope and mail it to: CVS Caremark PO Box 2110 Pittsburgh, PA Mail Service prescriptions are usually delivered to Members through the United States mail. Allow fourteen (14) days for delivery from the time the prescription is mailed. Mail Service Refills Obtaining a Mail Service refill is easy and can be completed one of three ways: To order by mail The Member should enclose the refill notice/slip provided with the first supply of medication and payment for the correct copayment/coinsurance amount for each prescription. Mail the refill notice/slip in the preaddressed envelope that was provided with the initial Mail Service prescription. rkd/a2/8400/22.doc (10/2012)

23 Group Administrator s Manual 5.23 To order by phone Call CVS Caremark at The Member should have his or her Capital BlueCross ID Card number and the prescription number (i.e., the 12-digit number on the refill notice/slip). If paying by credit card, he or she should also have the credit card number and expiration date on hand. To order through the Internet Log on to mycapbluecross.com to link to CVS Caremark. Complete the Login information and click Rx Information at the top of the page. Connect to the CVS Caremark Web site to order the prescription. When a prescription is filled through Mail Service, the Member receives a notice that shows the number of times the prescription can be refilled. CuraScript Specialty Medication Prescription Drug Benefit When your Member is using oral and self-administered specialty medications, Capital BlueCross makes it simple for him/her to get the individualized service he/she deserves. We have a special arrangement with CuraScript Pharmacy to offer many products and services that are not usually available from the Member s local pharmacy. A Patient Care Coordinator serves as the Member s personal advocate and point of contact. The Coordinator works with the Member s physician to obtain prior authorization, coordinate billing, and will even contact the Member when it s time to refill his/her prescription. CuraScript maintains a complete specialty pharmacy inventory with many specialty medications not readily available at a local pharmacy. The specialty medications are delivered directly to the Member. The Member is also provided with the necessary supplies needed to administer his/her medications at no additional cost. For more information on starting service, call Monday-Friday, 8 a.m. to 9 p.m., and Saturday, 9 a.m. to 1 p.m. Visit to learn more about CuraScript. rkd/a2/8400/23.doc (10/2012)

24 5.24 Group Administrator s Manual Accessing Prescription Drug Internet Services The first time a Capital BlueCross Member uses the Internet to access their prescription drug benefit services, the Member must register to use the Member-specific services. This allows a Member to obtain information about prescription drug benefits, shipment status, or to order a refill. The CVS Caremark Prescription Drug Claim Form (2011 Prescription Claim Form) along with other important forms and documents are available from the Members section of under Pharmacy Information. Special note about the Web site for Capital BlueCross Members: We have made it easier for Members to access their prescription drug benefits through our online Member Services Center. Members can register for a single sign-on to access both mycapbluecross.com and the tools and information available through CVS Caremark. For access to such features as check drug costs, view prescription history, refill mail order prescriptions, and much more, Members should Go to Complete the Login information. Members who are not registered will need to complete the registration process first. Once logged in, Members can access their prescription drug information by clicking on the Rx Information tab located at the top of the mycapbluecross.com Web page. From the Pharmacy Information page, Members can access the CVS Caremark Web site by clicking the red CVS Caremark logo located under the Rx News & Updates box. Members who want to access a specific topic can also choose one of the direct links that are located on this page under the CVS Caremark logo. Members will be asked to agree to the Terms and Conditions the first time they access the Web site. rkd/a2/8400/24.doc (10/2012)

25 Group Administrator s Manual 5.25 Please note that when viewing online prescription information, each registered adult can only view prescription coverage information for themselves and dependent children 17 years of age and younger. For example, a husband cannot access the wife s prescription information until she grants him permission and vice versa. If one adult on the contract would like to grant or limit access to another adult on the contract, please follow these steps: Log in to the mycapbluecross.com account and click on the red CVS Caremark logo located under the Rx News and Updates box. In the new window, click on Family Access in the left-hand navigation menu. Select the appropriate checkboxes under an individual s name to grant them access to specific information (e.g., view my orders, view prescription history, etc.). Click Save to save choices. Access can be changed or removed at any time by repeating these steps and selecting the appropriate checkboxes to remove access. After registering, Members can access a variety of information, such as find a local pharmacy, drug/health information, claims history, and Check Drug Costs. The Check Drug Costs feature is a tool that allows Members to find the estimated cost of medications at a retail pharmacy. For Members with the Mail Service benefit, this tool allows them to compare the estimated cost of medications at a retail pharmacy versus the cost from Mail Service. International Prescription Drug Service For medications purchased while traveling outside of the United States, drug identification and benefit determination are performed manually at the CVS Caremark paper claims processing facility. (Note: There may be program limitations on medications purchased outside the country.) rkd/a2/8400/25.doc (10/2012)

26 5.26 Group Administrator s Manual The Member completes a paper claim form and submits it to CVS Caremark along with the foreign country prescription receipt. This claim is routed to the paper claims processing facility. Reimbursement is based upon the billed amount minus the applicable deductible, copayment, coinsurance, and/or ancillary charge amount. Foreign currency is converted to United States dollars using applicable currency exchange rates. Mail all retail prescription drug claim forms to: CVS Caremark PO Box Phoenix, AZ Dental Claims There are several key features of your dental benefits that are important to remember. If your group has selected a dental product through Capital BlueCross, you will find helpful information about dental claims processing in this section. Product Name Provider Choice BlueCross Dental Members are free to select any dentist but enjoy the greatest out-of-pocket savings when a participating dentist is used. Participating dentist information can be accessed through the Web at /BlueCrossDental/. rkd/a2/8400/26.doc (10/2012)

27 Group Administrator s Manual 5.27 Paperwork Participating dentists handle all the paperwork and receive payment directly from the dental carrier, BlueCross Dental. With a nonparticipating dentist, the Member is responsible for paying the dentist s full fee and the Member may have to send in the dental claim form (the BlueCross Dental Claim Form ) to receive payment for eligible amounts. Amounts Paid for Member Participating dentists agree to accept BlueCross Dental s allowances as full payment. Nonparticipating dentists may balance-bill Members for dental services. Predetermination Predetermination is a review process performed to verify eligible benefits before a service is performed. This provides the Member and the dentist with information specifically about how the Member s group contract will support the dentist s proposed treatment plan. A predetermination review is recommended for all treatment plans that exceed $300. The dentist submits the treatment plan to BlueCross Dental in advance of performing services The treatment plan is reviewed to determine patient eligibility, contract benefits, and the specific amount of the benefit as of the date of the predetermination. The patient and dentist are notified of the predetermination decision. Submitting Claims for Dental Services Participating dentists have agreed to submit claims for Members. The claim payment allowance is mailed directly to the dentist, and the Subscriber receives an EOB indicating what has been paid on the Member s behalf and the amount that the Member must pay, if applicable. rkd/a2/8400/27.doc (10/2012)

28 5.28 Group Administrator s Manual If a nonparticipating dentist performs the services, your employee should do the following: Obtain a dental claim form from your group human resources area or from the Web at: Go to Members, Forms, and click More. Look for Other Downloadable Forms, find Claim Forms (Dental and Vision), and click the link for BlueCross Dental. Complete the Member sections of the claim form. Give the partially completed claim form to the dentist at the appointment. If the dentist will not submit the claim form, send the claim form directly to: BlueCross Dental PO Box 1126 Elk Grove Village, IL Work in Progress Dental Claims Member transition to BlueCross Dental is intended to be a seamless process for participants with treatment in progress. Typical benefit categories that have procedures that overlap carriers include endodontics (root canals), major restorative (crowns), prosthodontics (bridges), and orthodontic services (teeth straightening). Confusion sometimes develops because various dental carriers have different timetables for incurring liability on a Therapy Treatment Plan. BlueCross Dental considers itself liable for a procedure when the procedure irrevocably begins. For example, when a tooth is prepared for a crown (i.e., impression made), the carrier assumes responsibility. However, if the tooth is prepared by the prior dental benefits carrier, before the effective date with BlueCross Dental, the prior carrier is considered responsible for the crown. For orthodontic treatment, BlueCross Dental takes into account the date the treatment began and the amount already paid toward the treatment. rkd/a2/8400/28.doc (10/2012)

29 Group Administrator s Manual 5.29 When submitting a work in progress claim from a nonparticipating dentist, include the following information on the claim form: Patient name. Relationship to Subscriber. Patient date of birth. Patient full-time student status (if a dependent). Subscriber name. Subscriber Identification Number (and Member Identification Number if applicable). Subscriber address. Name of prior dental carrier(s). International Dental Claims If dental claims are incurred outside of the United States, the Member will pay the dentist s charge in full and the Member will need to complete a claim form for reimbursement for eligible amounts. Send the claim form directly to: BlueCross Dental PO Box 1126 Elk Grove Village, IL rkd/a2/8400/29.doc (10/2012)

30 5.30 Group Administrator s Manual Vision Claims If your group has selected a vision product through Capital BlueCross, you will find helpful information about vision claims processing in this section. Members are free to select any licensed vision care Provider but enjoy the greatest out-of-pocket savings when a Participating vision care Provider is used. Important information for Members to know about their vision product: Participating Vision Provider Participating Providers submit claims on behalf of individuals enrolled in vision products. For eye examinations, Participating Providers accept the allowances as full payment when services are performed within the frequency limitations specified in your group contract (subject to applicable copayments also defined in your contract). Frames generally have a specific dollar allowance associated with this service. The Member is responsible for any amount over the vision allowance for a vision service. Participating vision Provider information can be found at by clicking the Find a Provider link, finding the Vision section, and clicking the BlueCross Vision link. Nonparticipating Vision Provider When a Member uses a nonparticipating vision provider, he/she will need to complete and submit the BlueCross Vision Claim for Vision Care Expense form. Your employee should obtain a vision claim form from your group human resources area or from our Web site at under Members, Members Home, Forms, More Information, Other Downloadable Forms. Click the link for BlueCross Vision. The Member needs to know that he/she is responsible for the total cost at the time of service. Reimbursement of eligible amounts is made directly to the Subscriber. rkd/a2/8400/30.doc (10/2012)

31 Group Administrator s Manual 5.31 To receive reimbursement for eligible services, the Member should obtain a Claim for Vision Care Expense form, complete the employee section of the claim form, sign and date the form, attach a copy of an itemized receipt, and submit the claim to the address below. Send all completed vision claims to: BlueCross Vision PO Box 2187 Clifton, NJ If you or a Member have questions about filing a vision claim, please call BlueCross Vision at International Vision Claims If vision claims are incurred outside of the United States, the Member will pay the Provider s charge in full and the Member will need to complete a claim form for reimbursement. Send the claim form directly to the address above for reimbursement of eligible amounts. rkd/a2/8400/31.doc (10/2012)

32 5.32 Group Administrator s Manual Other Party Liability Other Party Liability (OPL) refers to situations where Members have coverage under more than one insurance contract or where another entity should be the first payer of claims. We generally separate other party liability into categories. OPL Category What is it? Coordination of Benefits The purpose of Coordination of Benefits is to administer benefits, as intended under a group s plan to ensure that individuals (covered by more than one health insurance plan) do not receive more in benefits than the actual cost of the care they receive. Subrogation or Third Party Liability Subrogation is the right of recovery from a third party responsible for an injury or illness. The most common Subrogation situations involve third party liability, auto/motor vehicle, or Workers Compensation claims. Note: Subrogation and Coordination of Benefits do not apply to HMO Capitated Services. Coordination of Benefits (COB) When a Capital BlueCross Member is enrolled in more than one health plan, a situation referred to as duplicate coverage exists. The payment of his or her benefits is coordinated between Capital BlueCross and the other health insurer (or between two separate Capital BlueCross health care plans, if applicable). COB processing prevents duplicate payments for the same services while effectively providing up to 100 percent of the Provider allowance for the Member s covered services under the appropriate plans. When a Member has health insurance coverage under more than one benefit program, Capital BlueCross COB must determine which insurance coverage should pay first (primary liability) and which coverage should pay second (secondary liability). rkd/a2/8400/32.doc (10/2012)