Obtaining Service and Filing Claims

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 1-800-541-3742 or use our employer secure services at https://www.capbluecross.com/contactus/e-mailcustomerservice /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.

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)

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 1-800-471-2242 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)

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 1-800-471-2242 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)

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)

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, https://www.capbluecross.com/employers/employerservices/employerforms/. 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)

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 779503 Harrisburg, PA 17177-9503 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)

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)

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)

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)

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)

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)

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)

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 779503 Harrisburg, PA 17177-9503 For help in submitting these claims, Members should call our Customer Service Department at: 1-800-962-2242 (1-800-669-7061 for HMO) Teletype (TTY) 1-800-242-4816 (1-800-669-7075 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)

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 1-800-810-BLUE to locate a Participating Provider. You can also find Participating Providers at http://provider.bcbs.com. 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)

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 https://www.capbluecross.com/employers/employerservices/employerforms/ 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, 1-800-810-BLUE, 24 hours a day, 7 days a week, or go to https://international.mondialusa.com /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 1-800-810-BLUE or call collect (1-804-673-1177, available 24 hours a day, 7 days a week) if admitted. rkd/a2/8400/16.doc (10/2012)

Group Administrator s Manual 5.17 If nonemergency care is needed, call 1-800-810-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 1-800-471-2242. 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)

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 www.capbluecross.com/members /Forms and following the instructions. Send International Claim Forms to: BlueCard Worldwide Service Center PO Box 72017 Richmond, VA 23255-2017 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)

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)

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 1-800-585-5794, or downloading the form from https://www.capbluecross.com 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)

Group Administrator s Manual 5.21 ALL retail prescription drug claim forms should be sent to: CVS Caremark PO Box 52136 Phoenix, AZ 85072-2136 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: 1-800-585-5794 Teletype (TTY) 1-866-236-1069 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 1-800-378-5697, or fax the order to 1-800-378-0323. 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)

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 https://www.capbluecross.com. 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 15230-2110 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)

Group Administrator s Manual 5.23 To order by phone Call CVS Caremark at 1-800-585-5794. 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 1-877-595-3707 Monday-Friday, 8 a.m. to 9 p.m., and Saturday, 9 a.m. to 1 p.m. Visit http://www.curascript.com/ to learn more about CuraScript. rkd/a2/8400/23.doc (10/2012)

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 https://www.capbluecross.com 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 www.capbluecross.com. 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)

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)

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 52136 Phoenix, AZ 85072-2136 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 https://www.capbluecross.com/findadoctor /BlueCrossDental/. rkd/a2/8400/26.doc (10/2012)

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)

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: https://www.capbluecross.com. 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 60009 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)

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 60009 rkd/a2/8400/29.doc (10/2012)

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 https://www.capbluecross.com/, 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 https://www.capbluecross.com, 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)

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 07015 If you or a Member have questions about filing a vision claim, please call BlueCross Vision at 1-800-905-4102. 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)

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)

Group Administrator s Manual 5.33 Note: Special rules apply to COB with Medicare, which are discussed in the Medicare Secondary Payer Laws section in Chapter 1. Primary Coverage The primary insurer is the insurer that is determined to have the first responsibility for claims payment and primary coverage is provided without regard to secondary coverage. Secondary Coverage The secondary insurer will provide benefits for covered services that have not been covered in full by the primary insurer. What Coverage is Primary (How is Primacy Determined) for Dependents Medical Claims? Dependents may be covered under more than one medical insurance contract. If this is the case, it is important to understand which coverage is primary and which is secondary. There are two general rules that may apply in this situation. The Birthday Rule provides that when both parents have health insurance coverage for their dependent child(ren), the coverage of the parent with the earliest birthday in the year (month and day only) will be the primary payer for medical services received by the dependent child(ren). The Gender Rule provides that when both parents have health insurance coverage for their dependent children, the coverage of the male is always the primary payer for services rendered to the dependent child(ren). When determining the primary coverage for a dependent child and one parent s coverage follows the birthday rule and the other parent s follows the gender rule, the gender rule is applied first to determine which coverage is primary. If parents are unmarried, divorced, or separated, different primacy rules may apply. When a motor vehicle accident or a Workers Compensation claim occurs, Capital BlueCross coverage may be secondary. We do NOT apply COB or Subrogation to HMO Capitated Services. rkd/a2/8400/33.doc (10/2012)

5.34 Group Administrator s Manual Rules for Determining Primary Coverage Specific information about how primary coverage is determined for your group s program(s) is detailed in your Group Contract (and Member Certificate of Coverage). COB provisions are sometimes confusing so we are providing a summary of the general rules we apply in determining primary and secondary coverage for all medical program claims processing situations. Primary coverage will be determined in the following order: A. If the other coverage does not include a COB provision, the other coverage will be the primary coverage. B. If the other coverage does include a COB provision, then the primary plan is determined as follows: 1. The benefits covering the patient as a Subscriber will be considered primary. However, an exception to this would be the Retired/Laid Off Provision. a. The Retired/Laid Off Provision provides that if an individual is enrolled as a Subscriber under two separate health insurance coverages, the benefits of the contract which covers the person as an active employee shall be determined first before the benefits of the contract which covers the person as a retired or laid off employee. Both contracts, however, must have a provision regarding retired or laid off employees for the above to apply. Otherwise, the benefits of the contract that has covered the person for the longest period of time shall be determined first. Primacy for dependents is determined by the Subscriber s primacy. (The Subscriber must be the same Subscriber mentioned in the text immediately prior.) 2. If both contracts cover the same child as a dependent (when the parents are not separated, unmarried, or divorced), the Birthday Rule applies. If both parents have the same birthday, the benefits of the contract which covered the parent longer are determined first. If one parent s coverage follows the birthday rule and the other parent s coverage follows the gender rule, the gender rule is applied first to determine which coverage is primary. rkd/a2/8400/34.doc (10/2012)

Group Administrator s Manual 5.35 3. When two or more contracts provide benefits for a dependent child under age 18 of divorced, unmarried, or separated parents, benefits for the child are determined in the following order: a. When there is a court order specifying that a parent is responsible for providing health insurance coverage, that parent s insurance shall be determined to be primary. b. When there is a court order specifying which parent must provide health insurance and that parent has remarried, the contract benefits shall be determined in the following order: (1) Parent with the court-ordered responsibility to provide insurance. (2) Spouse of the parent with the court-ordered insurance responsibility. (3) Natural parent not under court order to provide health insurance. (4) Spouse of the parent not under court order to provide health insurance. c. When there is no court order establishing responsibility for providing health insurance, and the parent with custody has not remarried, the contract benefits of the parent with legal custody shall be determined first. d. When there is no court order establishing responsibility for providing health insurance, and the parent with custody has remarried, the contract benefits shall be determined in the following order: (1) Parent with legal custody. (2) Spouse of parent with legal custody. (3) Natural parent without legal custody. (4) Spouse of parent without legal custody. rkd/a2/8400/35.doc (10/2012)

5.36 Group Administrator s Manual e. When a court order establishes that both parents share joint legal custody, but the court order does not state which parent is responsible for providing a dependent child s health insurance, the Birthday Rule may apply with exceptions noted in number two (2) of this section. 4. Due to the new health care reform laws, children up to age 26 may remain on a parent s contract. When two or more contracts provide benefits for an overage dependent child age 18 to 26, benefits for the dependent are determined in the following order: a. An overage dependent is primary on coverage provided through his/her own employment, then, b. Coverage through parents no coverage through the dependent s spouse: (1) Primacy is based on the Birthday Rule. (2) For all parent(s)/step-parent(s) situations, use the biological parents birthday first and then the step-parents. c. Coverage through parents and spouse: (1) Primacy is determined by the earlier effective dates on the contracts. (2) If the earliest effective dates are the same, primacy reverts to the Birthday Rule. Include the spouse s and parents birthdates in the determination. Please refer to your group s contract for additional information on determining primary and secondary coverage. rkd/a2/8400/36.doc (10/2012)

Group Administrator s Manual 5.37 How Does Capital BlueCross Actually Coordinate Benefits? When Capital BlueCross receives other coverage information on enrollment applications, through claims investigation or through asking the Member for additional information, we store this information at the Member level on our enrollment file. We use this information when processing claims unless we are notified that the other coverage information we have on file is no longer applicable. Our standard method of investigating for COB is to pay claims based on the services eligible under the Capital BlueCross contract terms and then pursue recovery of payment if we discover that the Capital BlueCross medical contract is the secondary coverage. (This is called the Pay and Pursue procedure.) The recovery of payment may require that the Subscriber provide us with additional information regarding the other medical insurance carrier. If we do not have other coverage information on our files and the amount of claim payment is more than $250 (the amount we have set as being cost effective to initiate coordination processing), we may investigate for other coverage by sending a COB Questionnaire to the Subscriber. (This happens frequently for dependent children because many Members in this category have dual coverage.) We use the information we receive from these questionnaires to update our enrollment files concerning other coverage for Members. If the response we receive indicates there is no other coverage for the Member, we will not send another questionnaire for a period of twelve months. However, if more than one dependent Member receives services, additional questionnaires may be sent within twelve months. Capital BlueCross considers coordinating benefits an important part of its role in monitoring your group s health care dollars. It is very important that we receive a response when we send a Subscriber a COB Questionnaire. Please note that we send a self-addressed, postage-paid envelope with this questionnaire to simplify the process for Members to return the form to us. We also provide a toll-free number (1-888-442-1679) which the Subscriber may call to access our automated system or to have a Customer Service Representative complete the COB Questionnaire for the Subscriber. rkd/a2/8400/37.doc (10/2012)

5.38 Group Administrator s Manual We allow twenty (20) calendar days for the Subscriber to send a response to our Coordination of Benefits Questionnaire. If we do not receive a response, we will send a follow-up COB Questionnaire. If the Subscriber does NOT return either questionnaire, we suspend processing of all claims for Members enrolled on the Subscriber s contract until we receive the requested information. We recognize that anytime a claim is suspended for additional information, Subscribers may receive bills from Providers of service whose billing systems automatically generate follow-up bills after a certain period. On the following page is an example of how COB might work in a sample claim situation. rkd/a2/8400/38.doc (10/2012)

Group Administrator s Manual 5.39 Example of COB Claims Mr. and Mrs. Smith are both employed. Mr. Smith has Capital BlueCross coverage. Mrs. Smith is a dependent on Mr. Smith s coverage and is also covered through her employer by Other Health Insurance (OI). Mrs. Smith incurs a hospital stay with a total bill of $10,000. Both Capital BlueCross and the OI cover the stay and both contracts have COB provisions. The COB rule states that the OI is the primary payer because it covers Mrs. Smith as the Subscriber. In order for Capital BlueCross to determine what we will pay as a secondary payer, we use several comparisons: If we do not know the Primary Patient Liability (PPL), We Compare The Normal Contract Benefit (NCB) to the COB balance and we pay the lesser amount. If we know the PPL, we compare that amount to the NCB amount and the COB balance: If the PPL is greater than the NCB amount, we pay the NCB amount. If the PPL is less than the NCB amount, but greater than the COB balance, we pay the PPL. If the PPL is less than the NCB amount and the COB balance, we pay the PPL. Note: These examples are for demonstration purposes only to show the different methods Capital BlueCross uses when determining how to pay a COB claim. They do not apply to claims for Members of ASO groups that use nonduplication of benefits. rkd/a2/8400/39.doc (10/2012)

5.40 Group Administrator s Manual Abbreviations/Definitions used in the COB Claim Examples: COB Balance The amount due the Provider after the primary insurance has paid. The calculation waives copayments and coinsurance and may include extension of benefits. Extension of Benefits If the primary insurance covers a service that the secondary considers noncovered, the secondary will extend benefits and also consider the charges as covered. Normal Contract Benefit (NCB) What Capital BlueCross pays on a claim as primary. Other Insurance (OI) The secondary coverage in the examples. Primary Patient Liability (PPL) The amount the patient (Member) owes the Provider after the primary insurance has paid. This would be deductibles, coinsurance, copayments, and noncovered services. rkd/a2/8400/40.doc (10/2012)

Group Administrator s Manual 5.41 Example 1 The OI covered $10,000, applied a $5,000 deductible, and paid with an 80 percent payment/20 percent coinsurance (a payment of $4,000 and $1,000 coinsurance). The PPL is $6,000 ($5,000 deductible + $1,000 coinsurance). Capital BlueCross covers $9,250 due to a $750 noncovered charge. The facility allowance is $6,475 with a $500 deductible and an 80 percent payment/20 percent coinsurance. COB NCB Calculation Charges $10,000 Noncovered -750 Covered Charges $ 9,250 Facility Allowance $ 6,475 Deductible -500 Copayment 20% -1,195 [Allowance - deductible x 20%] NCB $ 4,780 COB Balance Calculation Covered Charges $10,000 Charges are covered in full due to extension of benefits. Facility Allowance $ 6,475 Deductible -500 Assume covered by primary payment. OI Paid -3,500 OI paid amount would be adjusted to reflect the primary paid the charges applied to the secondary deductible. COB Balance $ 2,475 Although the COB balance is $2,475, payment would be made for the NCB amount. The NCB amount of $4,780 is greater than the COB balance, but is less than the $6,000 PPL. This covers the maximum amount of the PPL possible. rkd/a2/8400/41.doc (10/2012)

5.42 Group Administrator s Manual Example 2 The charge amount is $10,000. The OI covered $8,000, applied a $1,000 deductible, and paid with an 80 percent payment/20 percent coinsurance (a payment of $5,600 and $1,400 coinsurance). The PPL is $2,400 ($1,000 deductible + $1,400 coinsurance). Capital BlueCross covers $9,250 due to a $750 noncovered charge. The facility allowance is $6,475 with a $500 deductible and an 80 percent payment/20 percent coinsurance. COB NCB Calculation Charges $10,000 Noncovered -750 Covered Charges $ 9,250 Facility Allowance $ 6,475 Deductible -500 Copayment 20% -1,195 [Allowance - deductible x 20%] NCB $ 4,780 COB Balance Calculation Covered Charges $10,000 Charges are covered in full due to extension of benefits. Facility Allowance $ 6,475 Deductible -500 OI Paid -5,600 COB Balance $ 375 PPL Balance Calculation Covered Charges $10,000 Charges are covered in full due to extension of benefits. Facility Allowance $ 6,475 Deductible -500 Assume covered by primary payment. OI Paid -3,575 OI paid amount would be adjusted to reflect the primary paid charges applied to the secondary deductible. PPL Balance $ 2,400 OI paid would be adjusted to pay the PPL. Claim payment amount would be for the PPL amount since it is less than the NCB amount but greater than the actual calculated COB balance. rkd/a2/8400/42.doc (10/2012)

Group Administrator s Manual 5.43 Example 3 The charge amount is $10,000. The OI paid $4,000 with no PPL listed on the claim. Capital BlueCross covers $9,250 due to a $750 noncovered charge. The facility allowance is $6,475 with a $500 deductible and an 80 percent payment/20 percent coinsurance. COB NCB Calculation Charges $10,000 Noncovered -750 Covered Charges $ 9,250 Facility Allowance $ 6,475 Deductible -500 Copayment 20% -1,195 [Allowance - deductible x 20%] NCB $ 4,780 COB Balance Calculation Covered Charges $10,000 Charges are covered in full due to extension of benefits. Facility Allowance $ 6,475 Deductible -500 Assume covered by primary payment. OI Paid -3,500 OI paid amount would be adjusted to reflect the primary paid the charges applied to the secondary deductible. COB Balance $ 2,475 Claim payment amount would be for the COB balance as it is less than the NCB amount. Since there is no PPL listed, the balance is paid up to the facility allowance. rkd/a2/8400/43.doc (10/2012)

5.44 Group Administrator s Manual Example 4 Both contracts have Capital BlueCross coverage using the regular COB method to coordinate benefits. The contracts cover $10,000. The facility allowance is $7,000 with a $500 deductible and an 80 percent payment/20 percent coinsurance. The PPL is $1,800 ($500 deductible + $1,300 coinsurance). COB NCB Calculation For two Capital BlueCross contracts with matching benefits, this is what the primary pays. Covered Charges $10,000 Facility Allowance $ 7,000 Deductible -500 Copayment 20% -1,300 [Allowance - deductible x 20%] NCB $ 5,200 COB Balance Calculation Covered Charges $10,000 Facility Allowance $ 7,000 Deductible -500 Coinsurance waived. OI Paid -5,200 COB Balance $ 1,300 PPL Balance Calculation Covered Charges $10,000 Facility Allowance $ 7,000 Deductible -500 OI Paid -4,700 OI paid would be adjusted to pay the PPL. PPL Balance $ 1,800 Claim payment amount would be for the PPL balance of $1,800. In a Blue on Blue situation, the deductible will be applied to the same charges on both claims to be credited to the deductible. rkd/a2/8400/44.doc (10/2012)

Group Administrator s Manual 5.45 Questions Concerning a COB Claim? Call our COB service line at 1-866-494-7254. Coordination of Benefits for Prescription Drug Claims The Capital BlueCross Rx product (administered by CVS Caremark) processes and pays claims under the contract number billed. We do not routinely coordinate benefits for prescription drug services (except in connection with our SeniorBlue HMO and SeniorBlue PPO Medicare Advantage products, as required by CMS). The administrative costs of initiating COB investigation and follow-up are currently greater than the COB savings we can recover for our group customers. Coordination of Benefits for Dental Claims Dental claims processing includes COB processing. The specific terms of how COB is processed are included in the group dental contract. COB is completed to ensure the combined amount paid by the dental plans does not exceed the total amount charged by the dentist. In most situations, the product that covers the claimant as the employee would be primary. For dependents, most dental coverages use the birthday rule to determine primacy. Please refer all questions relating to claims processing to: BlueCross Dental 1-800-613-2624 Coordination of Benefits for Vision Claims Vision products that are available through Capital BlueCross do not include COB provisions. Typically, the administrative costs associated with COB exceed the value to the group customer in attempting to determine primacy. Vision claims are processed based on the contract number under which services are submitted. rkd/a2/8400/45.doc (10/2012)

5.46 Group Administrator s Manual Subrogation Subrogation of Medical Claims There are three basic categories of medical claims that are included in Capital BlueCross Subrogation processing. These include: Auto/Motor Vehicle Workers Compensation Third Party Liability (i.e., injuries or illness caused by a third party) Capital BlueCross may receive information about an accident, injury, or illness from a Provider, an attorney representing Capital BlueCross Member, through another involved party, or through a search of court records. When we receive information that indicates Capital BlueCross is not responsible for primary claim payment, we add the information to our files and begin the process of payment recovery and claims reprocessing. Questions should be directed to our Subrogation Service area at 1-866-787-9875. Identifying Claims For Subrogation Investigation A standard piece of information that appears on all Capital BlueCross claim forms is a question concerning whether services were received as a result of an accident. In addition, standard diagnosis and procedure codes used in claims processing include accident indicators. When we receive a claim that includes an accident, injury, or work-related illness diagnosis, we generate an Other Party Liability Report to the Subscriber for completion. This report is generated when the payment value of the claim is $100 or more. Subscribers have twenty (20) calendar days to respond to our questionnaire. If no response is received, a second questionnaire is generated and mailed to the Subscriber. rkd/a2/8400/46.doc (10/2012)

Group Administrator s Manual 5.47 It is very important that we receive a response to the Other Party Liability Report so that benefits are paid under the insurance plan that has first responsibility for payment. Please encourage your employees to appropriately complete this form if it is received. We include a self-addressed, postage-paid envelope to assist Members in returning information to us. It is important that your group not incur costs under your medical insurance program that are not necessary. As an employer, you may be carrying coverage for auto or Workers Compensation programs and it is less costly to allocate charges to the correct benefit program initially than to incur later costs of opening investigations months after services are received. A claim that includes information that a motor vehicle accident or a work-related injury or illness has occurred will be denied. These claims are reconsidered when information is received from the auto insurer or Workers Compensation insurance carrier. Pennsylvania Motor Vehicle Financial Responsibility Law (MVFRL) Under Pennsylvania law, all owners of motor vehicles are required to obtain motor vehicle insurance providing coverage of at least $5,000 for medical expenses resulting from a motor vehicle accident. Health care coverage provided by Capital BlueCross is secondary to the motor vehicle coverage. When the sum of the benefits payable under the motor vehicle insurance is exhausted, the remaining charges may be considered under the health care coverage provided through Capital BlueCross. If the Member has purchased extraordinary medical expense coverage under his or her motor vehicle insurance, this coverage applies when medical coverage EXCEEDS $100,000. Capital BlueCross tracks claim expenses to determine when the total reaches $100,000. At that point, the motor vehicle insurer again becomes the primary payer. If the Member does not have extraordinary medical expense coverage, Capital BlueCross continues to pay eligible charges in accordance with the terms and conditions of your group contract. Capital BlueCross will consider claims related to a motor vehicle accident when a statement is received from the auto insurer or the provider that all first party benefits have been exhausted. The MVFRL applies to all Capital BlueCross Members who are Pennsylvania residents. Claims for non-pennsylvania residents are reviewed on an individual basis. rkd/a2/8400/47.doc (10/2012)

5.48 Group Administrator s Manual Workers Compensation Pennsylvania state law assigns the liability to the employer for injuries, illnesses, or conditions resulting from an on-the-job accident or illness. Capital BlueCross maintains information regarding the injury or illness and all claims related to the Workers Compensation illness/injury are denied. If the Workers Compensation insurance carrier rejects a claim because the injury or illness was not job-related, Capital BlueCross may consider the charges in accordance with your group s contract benefits. Capital BlueCross requires a copy of the Workers Compensation carrier s denial and information on any possible appeal by the patient. If a denial is appealed, a Third Party Liability case is established by Capital BlueCross. Capital BlueCross will not provide benefits if the Workers Compensation carrier rejects the claim because: The employee did not use the Provider specified by the employer or the Workers Compensation carrier. The timely filing limit was not met (i.e., one hundred twenty (120) calendar days for the patient to notify the employer; seventy-two (72) hours for the employer to notify the Workers Compensation carrier). The employee has entered into a settlement with the employer or Workers Compensation carrier that covers future medical expenses. Third Party Liability Cases The right of subrogation under Capital BlueCross contracts entitles us to recover the amounts we paid in benefits for injuries caused by a third party. This provision is applicable when the Member recovers amounts attributable to the injury from another person, organization, or the other party s insurance carrier. rkd/a2/8400/48.doc (10/2012)

Group Administrator s Manual 5.49 Subrogation and Prescription Drug Claims Capital BlueCross does not utilize Subrogation for prescription drug claims. Subrogation for Dental Claims Dental claim processing identifies claims, which, in the opinion of the dental carrier, may involve Subrogation. The specific terms on how Subrogation claims are handled can be found in the group dental contract. Please refer all questions relating to claims to: BlueCross Dental 1-800-613-2624 Subrogation for Vision Claims Vision programs that are available through Capital BlueCross do not include subrogation provisions. Appealing Claim Decisions Members may appeal when services are denied and appear eligible under the terms of your group contract. General information about the appeal process is included below. Group contracts have specific information about time limits pertaining to appeals. ALWAYS refer Members to the group contract and/or Member Certificate of Coverage for specific rules for individual programs. New Notification Adverse Benefit Determinations Members may receive an Adverse Benefit Determination (ABD) Notice along with, or in place of, the regular Explanation of Benefits (EOB) when there is a denied service within a claim. rkd/a2/8400/49.doc (10/2012)

5.50 Group Administrator s Manual An Adverse Benefit Determination is any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for a benefit, including any such denial, reduction, termination of, or a failure to provide or make payment that is based on a Member s eligibility to participate under the group contract. This includes a denial, reduction, termination of, or a failure to provide or make payment (in whole or in part) for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary. The ABD Notice lists services that were denied as a result of an internal policy, rule, guideline, or criteria during the Capital BlueCross Claim Adjudication Process. The new Notice is similar to the EOB, and is geared toward helping Members understand which services were denied in the event they wish to submit an appeal. If a claim has a partial denial, the ABD Notice will be issued along with an EOB. If a claim is a full denial, only an ABD Notice will be issued, and an EOB will not be sent. In both of these scenarios, claim detail is still posted on the Member s personal and secure online profile at mycapbluecross.com. If a Member receives an ABD Notice, he/she is entitled to submit a written internal appeal within 180 days following receipt of the determination. Capital BlueCross will respond within 60 days after receiving the appeal. A denial on appeal is called a Final Internal Adverse Benefit Determination (FIABD). If the Member is still dissatisfied and part of a group subject to the Patient Protection and Affordable Care Act (PPACA), an appeal to an independent external review organization can be requested for an FIABD that involves medical judgment (such as an FIABD based on requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit or a determination that a treatment is experimental or investigational). If a Member is unsure of the appeal process, he/she should review plan documents, such as the How to File an Appeal attachment in the Member s Certificate of Coverage, contact his/her plan administrator, call Customer Service at the number found on the back of the Member ID Card, or call our General Customer Service Department at 1-800-962-2242 (1-800-669-7061 for HMO Members). rkd/a2/8400/50.doc (10/2012)

Group Administrator s Manual 5.51 See the Forms and Reports chapter for examples of: Authorization of Designated Appeals Representative (ADAR) Form for Traditional/Indemnity Lines of Business (NF-631). Appeals Form for Traditional/Indemnity Lines of Business (NF-632). Appeals Form for POS and HMO Lines of Business (NF-633). Document Requests As part of full and fair review of an appeal, Capital BlueCross will, as a matter of course, provide Members of groups subject to PPACA, free of charge, with any new or additional evidence we considered, relied upon, or generated in connection with the claim, as well as any new rationale adopted to deny the claim on appeal in enough time so that the Member can respond prior to receiving an FIABD. Any Member, whether subject to PPACA or not, is entitled to copies of documents, records, or other information in connection of his/her claim free of charge. To receive copies of all documents, records, and other information related to a medical claim adverse benefit determination, mail a request to: Capital BlueCross PO Box 779519 Harrisburg, PA 17177-9519 A request for information alone is NOT considered an appeal but may assist Members by providing information concerning an appeal. rkd/a2/8400/51.doc (10/2012)

5.52 Group Administrator s Manual Medical Claim Appeal Guidelines Appeals from an adverse benefit determination must be filed within one hundred eighty (180) calendar days of the date the Member received notice of the adverse benefit determination. (Special rules apply to adverse determinations involving concurrent care decisions. ) The appeal MUST BE IN WRITING, unless it is a Concurrent Care Claim Determination Appeal and/or it involves a denial of preauthorization of medical services involving urgent care. Capital BlueCross and KHP Central make staff available to record an oral appeal for a Member who is unable, by reason of disability or language barrier, to file a grievance in writing. The Member has the right to submit written comments, documents, records, and other information relating to the claim for benefits. For medical claims (not related to Other Party Liability), mail the appeal to: Member Appeal Capital BlueCross PO Box 779518 Harrisburg, PA 17177-9518 For Other Party Liability related appeals (e.g., COB, auto accident, Workers Compensation, or other third party liability claims), mail the appeal to: Other Party Liability Department Capital BlueCross PO Box 775523 Harrisburg, PA 17177-5523 rkd/a2/8400/52.doc (10/2012)

Group Administrator s Manual 5.53 Internal Review Time Frames If the appeal involves a medical or pharmacy claim and is filed after receipt of the medical service or prescription drug in dispute, we notify the Member of our final internal decision within sixty (60) calendar days of receiving the appeal. If the appeal involves a preauthorization determination and the appeal is filed prior to receiving the medical service or prescription drug in dispute, we notify the Member of our final internal decision within thirty (30) calendar days of receiving the appeal. A denial of the appeal is called a Final Internal Adverse Benefit Determination. External Review Process (Available for Members of Groups Subject to PPACA) A Member may request an external review by an Independent Review Organization (IRO) of a final internal Adverse Benefit Determination that involves an issue of medical necessity, appropriateness, health care setting, level of care, effectiveness of a covered benefit, or which deals with a finding that a service that is experimental or investigative. In order to request an external review, within four (4) months from receipt of the Notice of Final Adverse Benefit Determination, the Member must write to Capital BlueCross at: Capital BlueCross PO Box 779518 Harrisburg, PA 17177-9518 Capital BlueCross will forward the documentation pertaining to the denial to an IRO. The Member will have five (5) business days to submit additional information to the IRO for consideration in the external review. The IRO must notify the Member of its decision on the appeal (in writing) within forty-five (45) days from receipt of the request for external review. rkd/a2/8400/53.doc (10/2012)

5.54 Group Administrator s Manual Expedited Appeal Process for Claims Involving Urgent Care Initial Determination for Claims Involving Urgent Services Capital BlueCross will notify the Member of a determination, whether adverse or not, regarding a claim that qualifies for an expedited process within seventy-two (72) hours of receipt of the claim, unless the Member fails to provide sufficient information. For this purpose, a claim that qualifies for an expedited process is a claim for medical care or treatment, for which the application of the time periods for making standard internal appeal determinations could seriously jeopardize the life or health of the Member or their ability to regain maximum function, or in the opinion of a physician with knowledge of the Member s medical condition would subject the Member to severe pain that cannot be adequately managed without the care and treatment that is the subject of the claim. Expedited Internal Appeal Process for Claims Involving Urgent Services The Member may seek an expedited internal review of the determination of a claim involving urgent services, and may also request a simultaneous external review by contacting Capital BlueCross at 1-800-962-2242. Capital BlueCross will respond with an internal review determination within seventy-two (72) hours. Expedited External Appeal Process For Claims Involving Urgent Services For an external review of a Notice of Final Internal Adverse Benefit Determination involving an urgent services claim, the Member must contact Capital BlueCross at 1-800-962-2242. Capital BlueCross will transmit the file to the assigned IRO, and the Member may submit additional information to the IRO as well. The IRO will issue a determination within seventy-two (72) hours from receipt of the request for an expedited external review. rkd/a2/8400/54.doc (10/2012)

Group Administrator s Manual 5.55 Complaint and Grievance Procedures POS and HMO Members enrolled in the Capital BlueCross Point-of-Service (POS) product, or the Keystone Health Plan Central HMO product, are covered under the special provisions of Pennsylvania s Act 68 of 1998, and related Pennsylvania Department of Health, and Pennsylvania Insurance Department regulations. Act 68 and these regulations provide very specific complaint and grievance procedures. There are first and second level Capital BlueCross and Keystone Health Plan Central (KHP Central) complaints and grievance committee procedures, including a right to attend a hearing at the second level. A POS or HMO Member or the Member s representative may request that Capital BlueCross or KHP Central review an adverse benefit determination. The request must be made within 180 days of receipt of the determination. If the adverse benefit determination is a denial of reimbursement for a health care service based on a lack of medical necessity and appropriateness, the review will be processed as a Grievance as described below. (Please note that a Grievance may be filed by the Provider acting on the Member s behalf with the Member s consent, which requires an Authorization of Designated Appeals Representative (ADAR) Form for Traditional/Indemnity Lines of Business (NF- 631).) If the adverse benefit determination is regarding benefit coverage or the operations and management policies of Capital BlueCross (POS), or KHP Central (HMO), the review will be processed as a Complaint as described below. Please note the specific Department of Health and Pennsylvania Insurance Department Grievance regulations no longer apply to POS and HMO Members subject to PPACA. Members of groups who are subject to PPACA follow the appeals process set forth in page 5.49 5.56 of this chapter. The Complaint process detailed in this section applies to all POS and HMO Members whether or not the employer group health plan is subject to PPACA. rkd/a2/8400/55.doc (10/2012)

5.56 Group Administrator s Manual Capital BlueCross will, as a matter of course, provide Members of groups subject to PPACA, free of charge, with any new or additional evidence we considered, relied upon, or generated in connection with the claim, as well as any new rationale adopted to deny the claim on appeal in enough time so that the Member can respond prior to receiving a final internal adverse benefit determination. Members are entitled to a copy of the Policy/Criteria used to make the adverse benefit determination. Upon request, it will be provided at no charge. Members may submit written comments, documents, records, and other information relating to the Complaint or Grievance at any stage of the review process. The Member may request an expedited review at any stage of the Capital BlueCross POS or KHP Central HMO review process if (1) the Member s life, health, or ability to regain maximum function will be placed in jeopardy by following the timeframes in the review process described below, or (2) in the opinion of a physician with knowledge of the Member s condition, the Member would be subject to severe pain that cannot adequately be managed without the care or treatment for which coverage is being sought. A request for a Capital BlueCross POS or KHP Central HMO appeal should be mailed to: HMO Appeals: Keystone Health Plan Central PO Box 779869 Harrisburg, PA 17177-9869 POS Appeals: Capital BlueCross PO Box 779518 Harrisburg, PA 17177-9518 rkd/a2/8400/56.doc (10/2012)

Group Administrator s Manual 5.57 Grievance Process (for POS/HMO Group Members Not Subject to PPACA) First Level Grievance Review: The first level grievance review must be requested in writing to Capital BlueCross or KHP Central within 180 days and will follow the timeframes identified below: Pre-Service Grievance (service has not yet been rendered): A review and notification of the decision occurs within 30 days of receipt of the request. Post-Service Grievance (service has been rendered): This grievance is decided within 30 days and notification of the decision occurs within five business days of the decision. The Decision may be appealed to the Capital BlueCross (POS) or the KHP Central (HMO) Second Level Grievance Review Committee within 60 days of receipt of the decision. Second Level Grievance Review: The second level grievance review must be requested in writing to Capital BlueCross (POS) or KHP Central (HMO). A decision will be completed within 45 days. Notification of the decision will be completed within five business days of the decision. The decision may be appealed to Capital BlueCross (POS) or KHP Central (HMO) for an External Grievance Review within 15 days of receipt of the decision. External Grievance Review: The external grievance review, as of January 2012, must be requested in writing to Capital BlueCross (POS) or KHP Central (HMO). Capital BlueCross or KHP Central will forward it to an Independent Review Organization (IRO) to conduct the review and to issue a written decision within 45 days. rkd/a2/8400/57.doc (10/2012)

5.58 Group Administrator s Manual Expedited Review Process (for POS/HMO Group Members Not Subject to PPACA) Expedited Internal Review: The Member or the Member s representative may request an expedited review at any stage of the review process: (1) If the Member s life, health, or ability to regain maximum function would be placed in jeopardy by following the timeframes applicable to the standard Complaint or Grievance Process, or, (2) in the opinion of a physician with knowledge of the Member s condition, the Member would be subjected to severe pain that cannot adequately be managed without the care or treatment for which coverage is being sought. The request should include a written certification from the physician indicating such. Investigation and notification of the decision will be completed within 48 hours of receipt of the request. The decision may be appealed to Capital BlueCross (POS) or KHP Central (HMO) for an expedited external review within two days of receipt of the decision. Expedited External Review: The expedited external review may be requested in writing or communicated orally to Capital BlueCross or KHP Central. Within 24 hours of the request, Capital BlueCross or KHP Central will submit the review request to an IRO to conduct the review and issue a written decision. rkd/a2/8400/58.doc (10/2012)

Group Administrator s Manual 5.59 Complaint Process (for POS/HMO Group Members Not Subject to PPACA) First Level Complaint: A first level complaint must be requested in writing or orally to Capital BlueCross (POS) or KHP Central (HMO) within 180 days and will follow the time frames identified below: Pre-Service Complaint (service has not yet been rendered): A review and notification of the decision occurs within 30 days. Post-Service Complaint (service has been rendered): This complaint is decided within 30 days and notification of the decision occurs within five business days of the decision. The decision may be appealed to the Capital BlueCross/KHP Central Second Level Complaint Review Committee within 60 days of receipt of the decision. Second Level Review: A second level review must be requested in writing or communicated orally to Capital BlueCross or KHP Central. Investigation and notification of the decision will be completed within 45 days of receipt of the appeal request. The decision may be appealed within 15 days of receipt of the decision to the Pennsylvania Insurance Department (PID) or the DOH. External Review: An external review may be requested in writing or communicated orally to the PID or DOH. Upon request by the PID or the DOH, Capital BlueCross or KHP Central will forward all records of the Complaint Review decision within 30 days of the request. Prescription Drug Appeal Guidelines Prescription Drug Appeals must be filed within one hundred eighty (180) calendar days of the date the Member received notice of the adverse benefit determination. rkd/a2/8400/59.doc (10/2012)

5.60 Group Administrator s Manual Prescription Drug Appeals MUST BE SUBMITTED IN WRITING. Urgent Care Prescription Drug Appeals may be submitted verbally. If the Member wishes to submit an Urgent Care Prescription Drug Appeal, he or she may contact the Capital BlueCross Customer Service Department at 1-800-962-2242. We notify the Member s Provider and the Member of the outcome of the appeal via telephone or facsimile no later than seventy-two (72) hours after we receive the appeal. The Member has the right to submit written comments, documents, records, and other information relating to the claim for benefits. For prescription drug claims, mail the appeal to: Pharmacy Appeal Capital BlueCross PO Box 779518 Harrisburg, PA 17177-9518 Dental Claim Appeals BlueCross Dental Refer to the summary of BlueCross Dental claim appeal information in BlueCross Dental Appeal Procedures in the Forms and Reports chapter of this manual. All written dental appeals should be mailed to: Director of Member Services c/o BlueCross Dental 115 South Union Street, Suite 300 Alexandria, VA 22314 rkd/a2/8400/60.doc (10/2012)

Group Administrator s Manual 5.61 Vision Claim Appeals To Appeal an Adverse Benefit Determination An Adverse Benefit Determination is a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) under coverage with Capital BlueCross for a service: Based on a determination of a Member s eligibility to enroll under the group contract. Not provided because it is determined to be investigational or not of optical necessity. Members who disagree with an Adverse Benefit Determination, with respect to benefits available under this coverage, may seek review of the Adverse Benefit Determination by submitting a written appeal within 180 days of receipt of the Adverse Benefit Determination. Members must mail their written appeal to the appropriate address below: BlueCross Vision PO Box 2187 Clifton, NJ 07013 Members have the right to submit written comments, documents, records, and other information relating to their claim for benefits. Members also have the right to receive, upon request and free of charge, copies of all documents, records, and other information related to their Adverse Benefit Determination. A request for information does not constitute an appeal. To receive copies of this information, requests must be mailed to: BlueCross Vision PO Box 2187 Clifton, NJ 07013 rkd/a2/8400/61.doc (10/2012)

5.62 Group Administrator s Manual If the notice of an Adverse Benefit Determination advises the Member that he/she needs to submit additional information in order to perfect the claim, then the Member should make arrangements to submit all requested information if and when he/she files an appeal. Failure to promptly submit any additional information may result in the denial of the Member s appeal. The following time frames apply to the Capital BlueCross review of the Member s appeal. Capital Blue Cross will notify the Member of its decision within: Sixty (60) days of receiving the Member s appeal if the appeal involves a vision claim and the Member files the appeal after receiving the vision service. Thirty (30) days of receiving the Member s appeal if the Member files an appeal prior to receiving the vision service. Members who are dissatisfied with the outcome of the appeal are encouraged to voluntarily pursue further appeals through our Customer Service Department. For information about the available voluntary appeals process, Members can call our Customer Service Department at 1-800-905-4102. The Member s decision as to whether or not to submit a benefit dispute to the voluntary level of appeal will not affect his/her rights to other benefits under his/her coverage. If the Member s coverage is an employer-sponsored group plan subject to ERISA, and if the Member remains dissatisfied upon completion of the mandatory appeal process described above, the Member has the right to bring a civil action under ERISA Section 502(a). rkd/a2/8400/62.doc (10/2012)