An affordable health care plan designed to provide uninsured people with access to basic medical care

Transcription

1 An affrdable health care plan designed t prvide uninsured peple with access t basic medical care Business Owner s Reference Manual 2007

2 Table f Cntents CverTN Plan Overview... 2 CverTN PPO Plan Overview... 2 Eligibility Requirements... 3 Eligibile Emplyees... 3 Enrllment... 4 Initial Enrllment Perid... 4 Open Enrllment Perid... 4 New Eligibility... 4 Adding Spuse... 4 Late Enrllment... 4 Effective Dates... 5 Cverage fr Children Offered Thrugh CverKids... 6 Maternity Cverage Offered Thrugh CverKids HealthyTNBabies... 7 Identificatin Card... 9 Billing Prcedures Premium Payment and ACH Debit Payment Due Dates Delinquency Ntificatins Statement f Accunt Accunt Summary Explanatin Accunt Detail Explanatin Miscellaneus Billing Items Current Member Details Explanatin Retractive Adjustment Explanatin Claims Filing Prcedures...22 General Infrmatin Claims Payment r Denial Explanatin f Benefits Grievance Frequently Asked Questins Frequently Asked Questins CverTN Business Owner s Reference Manual 1

3 CverTN Plan Overview CverTN PPO Plan Overview BlueCrss BlueShield f Tennessee s preferred prvider rganizatin (PPO) plans give members freedm f chice, value, and security. We have cntracted with a netwrk f health care institutins and prfessinals, called netwrk prviders, wh agree t special pricing arrangements. PPO plans ffer the fllwing advantages: Freedm t chse dctrs and hspitals. N referrals required t see certain dctrs r specialists. Valuable wellness benefits: Mammgrams Prstate cancer screenings Well-wman exams Under CverTN, members nly receive benefits when using a netwrk prvider. A directry f netwrk prviders will be prvided t yu r yur enrlled emplyees. This directry can als be viewed n bcbst.cm. The term plan in this Business Owner s Reference Manual means the administratrs f the CverTN prgram. CverTN Business Owner s Reference Manual 2

4 Eligibility Requirements Eligible Emplyees Fr purpses f this Business Owner s Manual, the term emplyee means an emplyee f a participating business wner, r a qualified self-emplyed business wner. A member is an enrlled emplyee r his r her enrlled spuse. Any emplyee and his r her spuse, wh meet the requirements f the CverTN prgram, are eligible fr cverage under CverTN nce they have enrlled and paid the required premium. If there is a questin abut whether a persn is eligible fr cverage, CverTN shall make the final determinatin. T be eligible fr CverTN, the emplyee must satisfy the fllwing eligibility requirements. The emplyee must: Wrk mre than 20 hurs each week; Be a U.S. citizen r qualified alien; Live in Tennessee r a brdering state; Wrk fr a participating CverTN emplyer; Nt have health insurance; and Nt have chsen t terminate any health insurance in the last six mnths. Cmmit t paying ne-third f premium, unless the emplyer agrees t pick up the emplyee third. An emplyee wh has had insurance cverage within the past six mnths may enrll in this prgram immediately if he r she: Lst health insurance after lsing his r her jb; Was in the TennCare prgram during the past six mnths; Was in the U.S. Armed Frces during the past six mnths. Only the emplyee and his r her spuse, as recgnized by Tennessee law, are eligible t enrll. N ther dependents are eligible fr cverage under CverTN, and n maternity benefits are ffered thrugh CverTN. See the Cverage fr Children Offered Thrugh CverKids sectin f this manual fr infrmatin n pssible cverage fr dependent children under the age f 18. See the Maternity Cverage Offered Thrugh CverKids HealthyTNBabies sectin f this manual fr details n pssible maternity cverage. An emplyee s spuse must meet the same eligibility requirements as the emplyee, with the exceptin f wrking mre than 20 hurs each week and wrking fr a participating CverTN emplyer, befre he r she can becme eligible fr cverage. An emplyee r spuse wh des nt permanently reside in Tennessee r a brdering state is nt eligible fr cverage. CverTN Business Owner s Reference Manual 3

5 Enrllment Enrlling in Cverage Eligible emplyees and their eligible spuses may enrll in cverage as set frth in this sectin. Initial Enrllment Perid Eligible emplyees may enrll within the first 90 days frm the state s apprval date f their emplyer s qualificatin as a participating emplyer/business wner under the CverTN prgram. T enrll, the emplyee must submit a signed CverTN enrllment frm, cmplete with all requested infrmatin, t the plan within that 90-day perid after the state s apprval date. The apprval date is printed at the bttm f the cver letter fr the pre-enrllment packet that yu received frm BlueCrss BlueShield f Tennessee. Open Enrllment Perid After the initial enrllment perid, eligible emplyees may nly enrll during the annual CverTN pen enrllment perid, which will take place every Octber, unless therwise determined by the State. T enrll, the emplyee must submit a signed CverTN enrllment frm, cmplete with all requested infrmatin, during that pen enrllment perid. Newly Eligible Emplyees If an emplyee r his r her spuse becmes eligible t enrll in cverage utside f an pen enrllment perid (see Eligibility Requirements), he/she will have 31 days t submit an enrllment frm frm the date he/she became eligible. If the enrllment frm is nt submitted within 31 days, the emplyee must wait fr the next pen enrllment perid t enrll. Adding Spuse A newly married emplyee may enrll his r her spuse utside f an pen enrllment perid if the member cmpletes and submits a signed enrllment frm t BlueCrss BlueShield f Tennessee within 31 days f the date f marriage. The emplyee s spuse must meet all eligibility requirements befre he r she can enrll in CverTN. Late Enrllment Emplyees wh d nt enrll when becming eligible fr cverage, based n the guidelines utlined abve, can nly be enrlled during a subsequent pen enrllment perid. CverTN Business Owner s Reference Manual 4

6 Effective Dates Cverage shall becme effective n the earliest f the fllwing dates if the participating business wner and member are eligible, have cmpleted enrllment, and have paid the premium fr cverage. When this Manual uses the phrase, prcesses the enrllment frm, it means that the frm has been received by the administratr, reviewed, has been determined t be cmplete, and infrmatin has been laded int the claims prcessing system. Effective Date f Participating Emplyer Agreement (PEA) Initial cverage in CverTN begins n the effective date f the PEA, if all eligibility requirements are met as f that date. Enrllment During an Open Enrllment Perid Cverage is effective n January first f the fllwing year. Enrllment During an Initial Enrllment Perid If the plan prcesses the CverTN enrllment frm frm the first thrugh the fifteenth f the mnth, cverage is effective n the first day f the mnth fllwing the prcessing f the enrllment frm. If the plan prcesses the CverTN enrllment frm frm the sixteenth thrugh the end f the mnth, cverage is effective n the first day f the secnd mnth fllwing the prcessing f the enrllment frm. Newly Eligible Emplyees and Eligible Spuses If the plan prcesses the CverTN enrllment frm frm the first thrugh the fifteenth f the mnth, cverage is effective n the first day f the mnth fllwing the plan s prcessing f the enrllment frm. If the plan prcesses the CverTN enrllment frm frm the sixteenth thrugh the end f the mnth, cverage is effective n the first day f the secnd mnth fllwing the plan s prcessing f the enrllment frm. Newly Eligible Spuses Applicatin fr enrllment must be received within 31 days f the date f marriage. If the plan prcesses the CverTN enrllment frm frm the first thrugh the fifteenth f the mnth, cverage is effective n the first day f the mnth fllwing the plan s prcessing f the enrllment frm. If the plan prcesses the CverTN enrllment frm frm the sixteenth thrugh the end f the mnth, cverage is effective n the first day f the secnd mnth fllwing the plan s prcessing f the enrllment frm. CverTN Business Owner s Reference Manual 5

7 Cverage fr Children Offered Thrugh CverKids While members cannt purchase cverage fr their dependent children thrugh CverTN, members may be able t enrll their dependent children in CverKids. This prgram prvides cmprehensive health cverage fr uninsured children 18 and under, as well as maternity cverage fr pregnant wmen. The maternity prtin f CverKids is called CverKids HealthyTNBabies. Dependent children may be eligible if they are: 18 years r yunger; A U.S. citizen r qualified alien; A Tennessee resident; Nt eligible fr TennCare r ther state-spnsred insurance prgram; and Uninsured fr three mnths*. *This requirement is waived fr newbrns up t fur mnths after birth and fr children mving t CverKids frm TennCare. Hw much des CverKids cst? There is n mnthly premium if the family incme f an emplyee des nt exceed 250 percent f federal pverty level (FPL). Please visit the CverKids sectin f cvertn.gv r the Cver Tennessee sectin f bcbst.cm t see the chart f FPL qualifying family incmes. Plan Benefits CverKids members have: N deductible; N pre-existing cnditin waiting perids; and Lw cpays fr cvered services and prescriptin drugs*. *Cpay amunts vary depending n family incme. Please refer t the CverKids Benefit Summary at cvertn.gv and bcbst.cm t determine which cpays apply. Hw are children enrlled in CverKids? T start the enrllment prcess, call r COVERTN. Hurs f peratin are 7 a.m. t 6 p.m. Central Time, Mnday thrugh Friday. Visit the CverKids sectin f cvertn.gv r the Cver Tennessee sectin f bcbst.cm fr mre infrmatin The CverKids applicatin prcess is separate frm the CverTN enrllment prcess: please d NOT send CverKids applicatins t BlueCrss BlueShield f Tennessee. CverTN Business Owner s Reference Manual 6

8 Maternity Cverage Offered Thrugh CverKids HealthyTNBabies Fr members wh becme pregnant, maternity benefits are nt ffered thrugh CverTN. Hwever, members are eligible t receive maternity benefits under the CverKids HealthyTNBabies prgram, the matenity prtin f CverKids. T apply fr these benefits, members must fllw these instructins: Step 1 Cmplete the CverKids Applicatin (HealthyTNBabies Questins Only) Members wh have Web access can find the applicatin n the state's Web page at cvertn.gv/cverkids_app.html. They shuld print it ut and cmplete the maternity sectin. Members wh d nt have Web access can call the state's CverKids tll-free service number at fr an applicatin. The hurs are Mnday thrugh Friday, frm 7 a.m. t 6 p.m. (CT). Step 2 Cmplete the Pregnant Wman Prvider s Statement Frm Members wh have Web access can find this frm als n the state s Web page at cvertn.gv/cverkids.app.html. Members must print the Pregnant Wman Prvider s Statement Frm and then take this frm t their physician's ffice t be filled ut t cnfirm their pregnancy. Members wh d nt have Web access, can call the CverKids eligibility vendr s tll-free number at The hurs are Mnday thrugh Friday, frm 7 a.m. t 6 p.m. (CT). Step 3 Mail bth cmpleted frms (CverKids Applicatin and Pregnant Wman Prvider s Statement) t: CverKids P.O. Bx 2010 Cleveland, TN Members Enjy Perks Even When Benefits Run Out It's imprtant fr members t cntinue their cverage with CverTN even if they exhaust their benefits. That's because CverTN can still be f great benefit t them in several different ways. Cntinuatin will allw members t: Avid anther 12-mnth waiting perid fr cverage f a pre-existing health cnditin. Get the cntractual discunted rate fr services frm Blue Netwrk V prviders. Receive discunts fr brand and generic drugs thrugh a natinwide pharmacy netwrk. Avid a six-mnth waiting perid t re-enrll in CverTN. CverTN Business Owner s Reference Manual 7

9 CverTN Enrllment Frm Enrllment frms shuld be mailed t BlueCrss BlueShield f Tennessee: Attn: Membership Administratin CverTN 2M BlueCrss BlueShield f Tennessee 801 Pine Street Chattanga, TN Scannable Enrllment Frms: T enhance the enrllment prcess, CverTN enrllment frms are designed t take advantage f Optical Character Recgnitin (OCR) technlgy. Enrllment frms are scanned directly int the system, eliminating the pprtunity fr data entry errrs. Listed belw are tips fr filling ut the enrllment frm t maximize the advantage f the OCR technlgy. Please pass these tips n t yur emplyees: 1. Original frms are preferred. Faxed frms will be accepted, but cannt be scanned, which will slw dwn the enrllment prcess. 2. Frms are available frm BlueCrss BlueShield f Tennessee by calling Emplyees shuld use blck style printing fr legibility, and shuld write in blue r black ink. The OCR scanner cannt read red ink. 4. D nt highlight data n the frm. Ding s may make the frm unscannable, and will slw dwn the enrllment prcess. CverTN Business Owner s Reference Manual 8

10 Identificatin Cards Imprtant: Belw yu will see an example f a Member Identificatin (ID) card frm BlueCrss BlueShield f Tennessee. It s imprtant that yu ask yur emplyees t: 1. Always carry their ID card with them. If a card is lst r stlen, have the member call Member Services immediately. Members can als rder a replacement card thrugh BlueAccess at bcbst.cm. 2. Knw Their Blue Netwrk. CverTN members will use Blue Netwrk V. Check the netwrk directries at bcbst.cm fr a listing f dctrs and health care prviders by using the Find A Dctr tl. 3. Knw Their Pharmacy Netwrk. CverTN cvers prescriptin drugs, but thrugh a limited list, s make sure members shw their ID card t their pharmacist. The prescriptin cdes may have changed, s the pharmacist may need t update an emplyee s infrmatin. CverTN members will use the pharmacy netwrk RX04. Check the pharmacy sectin f the netwrk directries at bcbst.cm fr a listing f pharmacies in the specific pharmacy netwrk. 4. Knw hw t use the BlueCard r BlueCard PPO prgram befre traveling. Members can easily access care utside the Tennessee area, acrss the U.S. and many cuntries wrldwide, thrugh the BlueCard prgram r BlueCard PPO prgram. Advise members t check fr details in the Member Handbk. Mst recgnized and trusted brand fr health care. Member Identificatin Card The emplyee s name is here. This is the member s Member Identificatin number. This grup number helps identify CverTN members. The PPO in a suitcase lg lets yu knw yur benefits travel with yu. These are the amunts that yu are expected t pay when yu receive these services. CverTN members use Prvider Netwrk V and Pharmacy Netwrk RX04. Member Services. Prir Authrizatins are imprtant! Call this number t lcate a prvider utside Tennessee. (Back f Card) CverTN Business Owner s Reference Manual 9

11 Billing Prcedures Premium Payment Cst sharing f premiums is utlined belw: Participating emplyer/business wner emplyee lives in Tennessee Emplyee Member The state pays 1/3 f the premium. The emplyer pays 1/3 f the premium. The member pays 1/3 f the premium. Spuse Member The state pays 1/3 f the premium. The member pays 2/3 f the premium. The emplyer is nt required t pay 1/3 f the spuse s premium. Participating emplyer/business wner - emplyee lives in ne f the brdering states: Emplyee Member The state pays n premium. Either the emplyer r the member will pay the state s 1/3 f the premium, in additin t their 1/3 f the premium. Spuse Member The state pays n premium. The member pays the entire premium. The emplyer is nt required t pay 1/3 f the spuse s premium. Emplyee terminates emplyment emplyee lives in Tennessee: Emplyee and Spuse wh are Members The state pays 1/3 f the premium. Member pays 2/3 f the premium. Nte: members living utside Tennessee will lse their CverTN cverage if they terminate emplyment. Emplyer stps being part f the CverTN prgram, emplyee living in Tennessee keeps CverTN cverage: Emplyee and Spuse wh are Members The state pays 1/3 f the premium. Member pays 2/3 f the premium. Nte: members living utside Tennessee will lse their CverTN cverage if the emplyer stps being part f the CverTN prgram. The state determines the premium amunts and hw much f the premium it will pay. We will let yu knw in advance if these amunts change. CverTN Business Owner s Reference Manual 10

12 ACH Debit A prtin f the PEA is the ACH debit agreement which allws BlueCrss BlueShield f Tennessee t draft mnthly premiums frm yur accunt. This is the nly acceptable methd f premium payment. Yu will need t include a check frm the accunt yu wish t use when yu submit yur PEA. Be sure t write VOID r CANCEL n the check. The fllwing infrmatin will be required fr BlueCrss BlueShield f Tennessee t be able t draft yur accunt: Accunt infrmatin savings, checking, etc. Accunt name the accunt hlder s name, exactly as it appears n the bank statement Bank name ABA number the bank ruting number Accunt number yur bank accunt number Subgrup number fund at the bttm f the cver letter fr the pre-enrllment packet Signature frm respnsible party at grup Nte: If the ACH debit infrmatin changes, BlueCrss BlueShield f Tennessee requires ten days ntice f this change. If this infrmatin is nt received within ten days prir t a draft, the accunt culd be drafted in errr. Payment Due Dates Payment is due the first day f each mnth. We will draft frm yur accunt the secnd wrking day f each mnth. Changes r terminatins shuld be reprted n later than the fifteenth f the mnth t ensure an accurate statement f accunt. Delinquency Ntificatins T ensure timely payment and avid interruptins in health cverage, BlueCrss BlueShield f Tennessee has established a warning ntificatin prcedure fr alerting grups when their premium payments are past due. Because CverTN participating emplyers/self-emplyed individuals are set up with ACH debit, this prcess refers t insufficient funds ntificatins. Delinquency Letter: This letter is sent t bth yu and yur enrlled emplyees when yur mnthly payment culd nt be drafted due t insufficient funds by the fifteenth f the mnth. Our cllectins department will attempt t call yu t reslve the matter ver the phne. If n payment has been received by the fifteenth f the current mnth, a letter will be sent t each enrlled emplyee (if applicable) and t yu. The letter t the enrlled emplyee will infrm the emplyee that yu have failed t make a timely premium payment. T retain cverage, the enrlled emplyee may elect t submit the payment that is due by the end f the current mnth, and the letter will ffer ptins fr making future payments. Terminatin Letter: This letter will be generated if payment has nt been received within 60 days f the due date. The letter infrms the emplyer/emplyees that the grup cverage has been canceled. If yur cverage is terminated, yu will nt becme eligible t participate in the CverTN prgram until the anniversary f yur initial enrllment (r six mnths if the anniversary date is less than six mnths away). If yu find that claims payments have been suspended and yu think yur payment shuld have already been received, please call the number listed n the letter. CverTN Business Owner s Reference Manual 11

13 Statement f Accunt The statement f accunt cnsists f the fllwing sectins: Accunt Summary - summarizes the ttal amunt due as f the date the statement was generated. This is the ttal amunt that will be drafted frm yur accunt. Accunt Detail - lists the number f members within each plan ID fr the business, and the amunt due fr each plan. If yur business has mre than ne plan ID, they will be listed alphabetically. The plan ID is an internal cde used by BlueCrss BlueShield f Tennessee that identifies the type f benefits and cverage yu r yur emplyees have selected. Miscellaneus Billing Items - is used fr infrequent ccurrences f manual adjustments. Manual adjustments may be used t bill amunts nt directly related t the members f a plan, activity that ccurred befre the new billing system, r billing adjustments. An example f a miscellaneus billing item is a fee fr special reprts, printed material, etc. Yu will nt receive this page each mnth unless there is a manual adjustment made t yur grup. Current Member Detail - lists each member, his/her identificatin number, type f cverage, plan ID, and premium amunt. Retractive Adjustments - lists premium additins/subtractins fr members nt reflected n the previus statement f accunt. The credit fr the difference in premiums will shw n the fllwing mnth s statement f accunt as a retractive credit fr each mnth a premium credit is due. CverTN Business Owner s Reference Manual 12

14 The fllwing pages shw hw yur statement f accunt will appear, and explain hw each sectin relates t the thers. The explanatin pages are numbered t crrespnd with the statement example pages. Accunt Summary Explanatin The fllwing infrmatin will appear n yur statement f accunt and accunt summary. Billing Address and Recipient - yur billing address and the name f the persn respnsible fr submitting changes and adjusting the statement. Grup ID - grup number that identifies CverTN participating business wners. Subgrup - subgrup number that identifies yur accunt. Each business is assigned a subgrup number. Due Date - date yur payment is due. Billing Frm/Thru - perid being billed. Statement Number - used by BlueCrss BlueShield f Tennessee t identify current statement f accunt. (Julian date and subgrup ID) Phne N - business telephne number. Previus Ttal Due - date prepared and ttal due (line 8) frm yur last statement. The first time yu are billed, n date r amunt due will be indicated. Payments/Adjustments/Reversals/Refunds - amunts listed individually. Payments - payments psted t yur business accunt. Reversal/Adjustments - if a payment has been psted t yur grup/subgrup and shuld have been allcated t multiple subgrups, the adjusting entry will appear as a reversal. Fr example, if yu have multiple subgrups and yur payment was psted t subgrup 0001, the adjusting entry t crrect this will shw as a reversal n subgrup 0001, and the payment applied t ther subgrups will be reprted as an adjustment. Refunds - requested by grup fr verpayments r cancellatins. Outstanding balance as f (mm/dd/yy) the date yur current mnthly statement was generated. This balance represents amunts wed but nt psted as f the last billing statement (line 8 plus/minus all f line 9 s payments, adjustments, reversals, refunds). Current Mnth Billing - the ttal fr the current mnth nly. It includes: Miscellaneus billing items, manual adjustments. Current member detail. Any retractivity since yur last statement was generated. Ttal Amunt t be Drafted - the amunt yu currently we. It is made up f utstanding balance (line 10) plus/minus current mnth wed (line 11). This is the amunt that will be drafted frm yur accunt. CverTN Business Owner s Reference Manual 13

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16 Accunt Detail Explanatin The tp prtin f this sectin is the same as explained in the previus accunt summary sectin, indicating grup infrmatin and billing perid. Grup Name Grup ID Subgrup ID Due Date Billing Frm/Thru date Statement Number Phne Number Accunt detail -premium due summary. Infrmatin abut yur billing shwn in six clumns: Cl. 1 - Plan ID - an internal cde used by BlueCrss BlueShield f Tennessee that identifies the type f benefits and cverage that yur grup has selected. Several plan IDs may be listed if yur grup has mre than ne benefit structure. If yu have mre than ne plan ID, they will be listed in alphabetical rder. Cl. 2 - Number f Member Emplyees n statement fr this plan ID Cl. 3 - Number f Member Spuses n statement fr this plan ID Cl. 4 - Current Billing is the amunt billed fr each plan ID (this ttal cmes frm the Current Member Details sectin f yur statement) Cl. 5 - Retractive amunts billed fr this plan ID (this ttal cmes frm the retractive adjustments ttal) Cl. 6 - Net is the sum f the current billed amunt and the retractivity fr this plan ID Ttal fr All Cverage - the ttal f current premiums and retractive adjustments. Ttal Miscellaneus Billing Items manual adjustments that cannt be autmatically calculated thrugh the billing system. These are detailed in the miscellaneus billing sectin f yur statement f accunt. Outstanding Balance as f MM/DD/YY - the utstanding balance as f the date the statement was generated. Ttal Credit Balance credit t be applied n the next mnth s invice. Ttal Amunt t be Drafted - includes ttal fr all cverage, miscellaneus billing items, and utstanding balances frm prir perid(s). CverTN Business Owner s Reference Manual 15

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18 Miscellaneus Billing Items 1. The tp prtin f this sectin will be the same as the ther pages f yur statement, indicating grup infrmatin and billing perid. 2. Items - any type f manual adjustment that cannt be handled thrugh the autmated billing system. 3. Miscellaneus Items Ttal - increases/decreases in current ttal due, included as a separate line n the accunt detail page. EXAMPLE OF MISCELLANEOUS BILLING ITEMS CverTN Business Owner s Reference Manual 17

19 Current Member Details Explanatin The tp prtin f this sectin will be the same as the ther pages f yur statement, indicating grup infrmatin and billing perid. Infrmatin abut yur billing is shwn in nine clumns: SP* used t identify a member spuse wh is listed separately frm the member emplyee. Member Emplyee ID Member Emplyee SSN Member Emplyee Name - emplyee name as shwn in BlueCrss BlueShield f Tennessee s recrds. Type Cverage - determines premium rate t bill. B = Member Emplyee & Member Spuse C = Member Only Previus Due ttal amunt due n the previus billing statement. Payment reflects any payment received since the previus billing statement. Premium Amunt - current premium due fr each plan ID. Ttal Due ttal amunt due at this time. Ttal ttal premium due fr current billing cycle. Ttal f Cverage - a cunt by cverage type is summarized at the end f each grup/subgrup. CverTN Business Owner s Reference Manual 18

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21 Retractive Adjustment Explanatin The tp prtin f this sectin will be the same as the ther pages f yur statement, indicating grup infrmatin and billing perid. Infrmatin abut yur billing is shwn in six clumns: SP* - used t identify a member spuse wh is listed separately frm the member emplyee. Member ID Member SSN Member Name - name as shwn in BlueCrss BlueShield f Tennessee s recrds (spuse name will be listed as SPOUSE ). Type Cverage - determines premium rate t adjust. B = Member Emplyee & Member Spuse C = Member Only Frm/Thru Dates - dates that retractive premium adjustments are due. A separate line will be shwn fr each mnth fr which retractivity is due. Sme reasns fr a retractive adjustment include: Members added since the last bill. Member terminatins. Changes in cverage (frm Member Emplyee Only t Member Emplyee and Member Spuse, Member Emplyee and Member Spuse t Member Emplyee Only). Rate Changes. Premium Amunt - premium adjustment (debit/credit) due fr each plan ID fr the date range. Ttal ttal premium due fr current billing cycle. CverTN Business Owner s Reference Manual 20

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23 Claims Filing Prcedures General Infrmatin Netwrk prviders have agreed t file claims fr members. If a member receives services frm an ut-f-netwrk prvider (either within r utside the service area), he r she can cntact Member Services fr assistance with filing a claim. The nly benefits prvided fr services received frm an ut-f-netwrk prvider are emergency services. Claims Payment r Denial After a claim has been filed, BlueCrss BlueShield f Tennessee will determine if the expense is eligible fr payment. If additinal infrmatin is needed frm the prvider, the infrmatin will be requested and a determinatin made when it is received. If a claim is partially r ttally denied, the member may request a recnsideratin f the denial in accrdance with the grievance prcedure utlined in his r her Member Handbk. In all cases, an explanatin f benefits will be sent t the member illustrating the actin taken n the claim. Explanatin f Benefits The Explanatin f Benefits (EOB) infrms members f ur actin taken n each f their claims. Members shuld keep their EOBs in case questins arise as t hw the claims were handled. Members can als elect t receive their EOBs electrnically and avid being mailed paper EOBs. T sign up fr electrnic EOBs, members can g t bcbst.cm. Grievance Prcedure The grievance prcedure fr CverTN is intended t prvide a fair, quick, and inexpensive methd f reslving any and all disputes. Such disputes include: any matters that cause the Member t be dissatisfied with any aspect f the relatinship with CverTN; any adverse benefit determinatin cncerning a claim; r any ther claim, cntrversy, r ptential cause f actin the Member may have. The member shuld cntact the Member Services Department, at the number listed n the membership ID card: (1) t file a claim; (2) if the Member has any questins abut any dcuments received frm us (e.g. an explanatin f benefits); r (3) t initiate a grievance cncerning a dispute. The Member Handbk prvides detailed infrmatin and instructins fr filing a grievance. CverTN Business Owner s Reference Manual 22

24 Mst Frequently Asked Claims and Benefit Questins 1. Where can I get a cpy f the CverTN Frmulary? Yu may btain a cpy f the frmulary by visiting BlueCrss BlueShield f Tennessee s Web site at bcbst.cm. Just click n Members, chse Cver Tennessee, g t Find Pharmacy Details, and click n CverTN Frmulary. 2. What d I need t d t disenrll a member frm CverTN? T disenrll a member, a business wner must simply fllw these steps: Write a written ntice f cancellatin f the emplyee s CverTN cverage t BlueCrss BlueShield f Tennessee that includes the fllwing infrmatin: a. Emplyee s name b. Member ID card number c. Disenrllment date Mail r fax the ntice f cancellatin t: Address Attn: Membership Administratin CverTN 2M BlueCrss BlueShield f Tennessee 801 Pine Street Chattanga, TN Fax CverTN members will be terminated as f their paid t date. S, if an emplyee leaves the emplyment f a participating emplyer in the middle f a mnth, CverTN will disenrll the emplyee at the end f that mnth. 3. Can an emplyee wh has been disenrlled frm CverTN re-enrll in the prgram? If s, des the emplyee have t wait a certain perid f time befre he/she can re-enrll? Yes. An emplyee wh has been disenrlled frm CverTN can re-enrll in the prgram, as lng as he/she has had cverage fr at least ne mnth. CverTN is prtable, meaning that an emplyee can cntinue enrllment even thugh he/she n lnger wrks fr a participating emplyer. Once the emplyer ntifies us that an emplyee is terminating frm the emplyerspnsred CverTN plan, we will bill the member directly fr bth the emplyee s third f the premium and the emplyer s third f the premium. The emplyee keeps the same member ID number and ID card since the cverage is exactly the same, except the emplyee will nw be paying tw-thirds f the premium. CverTN members wh are billed directly have 31 days in which t make a premium payment. If the member des nt pay the premium, he r she will be disenrlled and will nt be able t re-enrll in CverTN until the anniversary f his/her initial enrllment (r six mnths if the anniversary date is less than six mnths away). 4. Hw des a member request a predeterminatin? A predeterminatin is a request made befre a service is perfrmed t determine if a particular service is medically necessary. Usually, the member s physician submits the predeterminatin request with medical infrmatin shwing why the service is needed. BlueCrss BlueShield f Tennessee usually respnds within 14 days after receiving a predeterminatin request. CverTN Business Owner s Reference Manual 23

25 5. D emplyees traveling utside f the cuntry have cverage? Yes, benefits fr services received by members utside the United States are eligible fr reimbursement, as lng as the member ges t a netwrk prvider. 6. Is the member liable fr medical csts if a pre-certificatin r prir authrizatin is nt btained fr ut-f-state prviders? Yes. When a member seeks medical care frm a prvider utside the Tennessee service area, the member is respnsible fr btaining prir authrizatin and pre-certificatin. If the prir authrizatin r pre-certificatin is nt btained, the member may be respnsible fr all charges. Members are respnsible fr instructing ut-f-netwrk prviders t call the number n the back f their ID card fr prir authrizatin. 7. What is a pre-existing cnditin? Any physical r mental cnditin, regardless f cause, that was present during the six-mnth perid immediately befre the earlier f when the member s cverage became effective under the Member Handbk, r the first day f any pre-existing cnditin waiting perid, fr which medical advice, diagnsis, care, r treatment was recmmended r received frm a prvider f health care services. 8. Are prescriptin drugs purchased utside the U.S. cvered? Prescriptin medicatin purchased utside f the U.S. and its territries is excluded frm reimbursement and ineligible per the Member Handbk. Prducts purchased utside f the U.S. bypass the cntrl f the FDA. Currently, U.S. law des nt allw citizens t imprt drugs frm ther cuntries since these medicatins are cnsidered unapprved, and may be misbranded and/r impure. Fr members wh are traveling and/r living utside the U.S. and purchase a prescriptin drug, the prescriptin will be reviewed fr benefits; hwever the prescriptin drugs shuld be assciated with crrespnding medical bills. Member Services If yu have additinal questins, yu may cntact Member Services at We can respnd mre quickly t yur questins if yu have the fllwing infrmatin available when yu call: Name f member Identificatin number Date f service Claim number Brief reasn fr inquiry r explanatin f circumstances CverTN Business Owner s Reference Manual 24

26 bcbst.cm 801 Pine Street Chattanga, TN BlueCrss BlueShield f Tennessee, Inc., an Independent Licensee f the BlueCrss BlueShield Assciatin Registered marks f the BlueCrss BlueShield Assciatin, an Assciatin f Independent BlueCrss BlueShield Plans This dcument has been classified as public infrmatin (8/07)