Group Administrator s Manual

Transcription

1 Group Administrator s Manual An Independent Licensee of the Blue Cross and Blue Shield Association Form No (07-11)

2 Table of Contents Phone Numbers and Addresses... 2 Who is Eligible for Healthcare Coverage... 3 Who Qualifies for Healthcare Coverage... 3 Who is an Eligible Employee... 3 Who is an Eligible Dependent... 3 Enrollment Information... 4 Enrollee Certificate... 4 Identification Cards... 4 Leave of Absence... 4 Retirement... 4 Name or Address Change... 5 Transfer of Enrollment... 5 Enrollment Procedures... 6 How to Enroll Newly Hired Eligible Employees... 6 What to Do When a Newly Hired Eligible Employee Declines Coverage... 6 How to Determine the Effective Date of Coverage... 6 How to Add a New Eligible Dependent... 6 How to Enroll Late Enrollees... 7 Who Qualifies as a Late Enrollee... 7 Causes of Ineligibility... 9 Employee Termination... 9 Divorce or Death of a Covered Dependent... 9 Dependent Child Status Ends... 9 Termination of Employment and Death of Employee Consolidated Omnibus Budget Reconciliation Act What is COBRA? Qualifying Events and Periods of Continued Coverage Administration of COBRA When COBRA Continuation Ends Billing Adjustments Due Date Billing Changes Billing Reconciliation How to File Health Claims... 15

3 Claim Filing by Provider Claim Filing by Member Notification of Payment Help Avoid Delays External Review Policy Standard External Review Request Expedited External Review Request Binding Nature of the External Review Decision How to File Prescription Drug Claims Benefits Through Blue Cross of Idaho Network Pharmacies How to Use the Blue Cross of Idaho Pharmacy Network Prescription Drug Benefit How to Collect Benefits When Using a Non-Network Pharmacy Mail-order Prescriptions Transferring Prescriptions Ordering Refills Generic Drugs Ordering Prescription Refills On-line Dental Benefits Deductible Dental Option Incentive Dental Option Preferred Blue Dental Option Essential Dental Voluntary Dental Dental Maximum Carryover Orthodontic Benefits Dental Program Exclusions & Limitations Vision Service Plan Benefits Available Through VSP When Using a VSP Participating Doctor When Using a VSP Non-participating Doctor Prior Authorization What is Prior Authorization What is Inpatient Notification Sample Forms... 31

4 This Group Administrator s Manual is a general resource intended to help answer questions members may have regarding their coverage. It covers parts of the policy in general terms. Please refer to your Master Group Policy for complete details for specific information regarding your healthcare plan. Blue Cross of Idaho Group Administrator s Manual 1

5 Phone Numbers and Addresses To Submit Health Claims: Blue Cross of Idaho Blue Cross of Idaho Claims Department or Claims Department PO Box E. Pine Avenue Boise, ID Meridian, ID Blue Cross of Idaho Prior Authorization: Customer Service: Toll-Free: Boise calling area: Blue Cross of Idaho Blue Cross of Idaho Customer Services Department or Customer Services Department PO Box E. Pine Avenue Boise, ID Meridian, ID For Traditional Group Customer Service: Toll-free: Boise calling area: Preferred Provider Organization (PPO) Customer Service: Dental Customer Service To submit Dental Claims: Toll-free: Boise calling area: Toll-free: Boise calling area: Blue Cross of Idaho Blue Cross of Idaho Dental Services or Dental Services PO Box E. Pine Avenue Boise, ID Meridian, ID VSP Toll-free: Blue Cross of Idaho s website bcidaho.com Blue Cross of Idaho Group Administrator s Manual 2

6 Who is Eligible for Healthcare Coverage? Refer to your Master Group Policy for details. Who Qualifies for Healthcare Coverage? All eligible employees and their dependents qualify for healthcare coverage when meeting eligibility and enrollment criteria. Who is an Eligible Employee? An eligible employee is a full-time, regular employee who works a designated number of hours per week as agreed upon by the employer and Blue Cross of Idaho. The definition of eligible employee may also include officers and employees without regard to the number of hours worked, at the discretion of the employer. Newly hired employees qualify for coverage for themselves and their dependents after completing the group s designated probationary period, if any. Who is an Eligible Dependent? If an employer offers coverage for dependents, the following defines who is eligible as a dependent: 1. An eligible employee s lawful spouse qualifies for coverage. 2. A dependent child (natural, stepchild, adopted, or legally placed with the employee for adoption or guardianship) is eligible for coverage under either one of the following two conditions OR a) Until the end of the month a child turns 26 years old b) If medically certified as disabled due to mental disability or physical disability (subject to periodic recertification) and financially dependent upon the employee for support, regardless of age. Blue Cross of Idaho Group Administrator s Manual 3

7 Enrollment Information Enrollee Certificate The Enrollee Certificate describes your employees coverage based on your group policy. Blue Cross of Idaho provides your group with a current Enrollee Certificate to distribute to each of your enrolled employees. Identification Cards Blue Cross of Idaho sends each enrolled employee identification cards for his or her use and for the use of any insured family members. Both cards list the employee s name as the enrollee and include the enrollee identification number (managed care cards include the dependents names on the cards as well). Covered members should show the identification card to the healthcare provider whenever receiving services. If your group provides prescription drug coverage, members should show the identification card to the pharmacist whenever purchasing prescription drugs. The following generic ID card sample shows the card design: Front Back NOTE: Managed care member ID cards include the name(s) of dependents Leave of Absence An employee with an approved leave of absence may continue to receive your group s benefits for up to 90 days, unless your group policy specifies otherwise. The Family and Medical Leave Act (FMLA) of 1993 (applies to groups of 50 or more) requires continued coverage for up to 12 weeks, if eligible. Please make a notation on your billing in the Explanation column on the roster page that the employee is on an approved leave of absence and submit the appropriate amount (employee and employer contributions) with your payment. To ensure continued coverage for the employee, your group must continue making its regular payments for the employee s coverage during the approved leave of absence. We will not accept payments made directly by an employee. Retirement Enrollees who retire at age 65, have both Medicare Part A and Part B, and are Idaho residents qualify to purchase Blue Cross of Idaho s Medicare supplement coverage. They may enroll in any of our Medicare supplement programs without health statement approval during the six-month open enrollment period following their 65 th birthday or with enrollment in Part B of Medicare. Medicare supplement policyholders can pay by bank withdrawal or receive a bill in the mail. Blue Cross of Idaho Group Administrator s Manual 4

8 If the retiree has covered dependents, eligible family members under the age of 65 may have two options for continuous coverage: OR 1. If the dependent resides in Idaho, the dependent may be eligible to transfer to a Blue Cross of Idaho individual program, if Blue Cross of Idaho receives a properly completed application within 30 days from the group s coverage termination date 2. If your group qualifies, the dependent may be eligible for COBRA continuation coverage (please refer to the Consolidated Omnibus Budget Reconciliation Act Section). Name or Address Change To make a name or address change, the employee should complete a Member Name or Address Change Form (4-125), then mail the form to Blue Cross of Idaho. When an employee has a name change, the group administrator can note the change on the Group Bill Worksheet by noting the Enrollee Identification Number, former name and new name. See the example in the Forms section of this handbook. However, non-electronic enrollment groups can change information on the Blue Cross of Idaho website, bcidaho.com. For groups using electronic enrollment, direct members making any demographic changes or adding/deleting dependents with the group administrator. Transfer of Enrollment An enrolled employee or insured dependent may be eligible to transfer coverage, without lapse of coverage or health statement approval for new coverage, when one of the following two conditions applies: OR The member is no longer eligible for enrollment with the group, has no other health coverage, and still resides in Idaho The member living in Idaho may be eligible to transfer to Blue Cross of Idaho individual medical and dental plans, if a completed application is submitted to Blue Cross of Idaho within 30 days of the group coverage termination date The member lives or moves out of state The member may transfer enrollment to the Blue Cross and Blue Shield Plan that serves the state he or she is moving to. The member should check with that plan for confirmation. Credit for waiting periods already satisfied in the original state may apply in the new state. If a member moves out of state and elects new coverage from an insurance company other than the Blue Cross and Blue Shield Plan that serves the state where he or she is moving, transfer of enrollment with no lapse of coverage is not guaranteed. Transfer of enrollment gives employees continuous healthcare protection with credit for waiting periods for preexisting conditions. Please explain to the employee or insured dependents that the benefits and rates for the new coverage may differ from those offered by your group. Blue Cross of Idaho Group Administrator s Manual 5

9 Enrollment Procedures To see how to adjust your billing for new employees and new dependents, please refer to the Billing Adjustments section. How to Enroll Newly Hired Eligible Employees Each newly hired eligible employee requesting coverage must complete an application and apply for coverage within a 30-day period of becoming eligible or 30 days prior to completion of his or her probationary period, referred to as the initial enrollment period. The group administrator should send the employee s application prior to the requested effective date. The employee s effective date will be the first day of the month following receipt of a completed application, provided the employee completes any probationary periods as designated by the employer. Failure to submit a completed application during the initial enrollment period may qualify the eligible employee as a late enrollee (please refer to the Who Qualifies as a Late Enrollee section for more information). If you or the new enrollee make changes to the application, or cross out items, the enrollee must sign their initials next to the change before Blue Cross of Idaho receives the application. Even though Blue Cross of Idaho guarantees coverage, we will return applications submitted unsigned or undated, for completion, which could delay the effective date of coverage. Once Blue Cross of Idaho processes and approves the application, Blue Cross of Idaho will bill for the employee on the next statement. What to Do When a Newly Hired Eligible Employee Declines Coverage For small groups (less than 50 employees), when a newly hired employee chooses not to enroll or chooses not to enroll any eligible family members in the offered group coverage, the Small Employer Health Insurance Availability Act requires the employee complete an Employee s Waiver of Healthcare Coverage form. The employee must return the completed waiver form to Blue Cross of Idaho within 30 days from either the date of hire or completion of the probationary period. Employees in large groups (over 50 employees) are not required to submit a waiver. How to Determine the Effective Date of Coverage If the application for coverage is properly completed and submitted, a new employee s coverage is effective the first day of the month following Blue Cross of Idaho s application receipt, provided the eligible person completes the probationary period, if any. Blue Cross of Idaho will bill for the employee on the next billing statement. How to Add a New Eligible Dependent To add an eligible dependent, the employee must complete an application and apply for coverage for such eligible dependent within a 30-day, initial enrollment period. of the dependent becoming eligible for coverage. If a dependent is a newborn natural child, adopted, or is eligible because of marriage, the initial enrollment period is 60 days (see paragraph below). Failure to submit a completed application during the initial enrollment period may qualify the eligible dependent as a late enrollee (please refer to the Who Qualifies as a Late Enrollee section below for more information). Blue Cross of Idaho will return incomplete applications, including those submitted unsigned or undated, for completion. Blue Cross of Idaho Group Administrator s Manual 6

10 If the application is properly completed and submitted within 30 days of the eligibility date, coverage for a new dependent becomes effective the first day of the month following Blue Cross of Idaho s receipt of the application. To add a natural newborn or adopted child or a dependent who is eligible because of marriage, the employee must complete an application and apply for coverage within a 60-day period of the dependent becoming eligible for coverage. In the case of a newborn dependent who is the enrollee s natural child, the date of birth is the effective date, for an adopted child the date is the date of placement. In addition, children that become eligible because the parent marries become eligible on the first day of the month following the date of marriage, or first of the month following receipt of application. How to Enroll Late Enrollees Ask the employee to complete an application and submit it to Blue Cross of Idaho 30 days prior to the group s anniversary date (or renewal date). The effective date of coverage will be the group s renewal date. All other enrollment procedures apply regardless whether during or after the initial enrollment period. Who Qualifies as a Late Enrollee A late enrollee is an eligible employee or dependent who requests enrollment in your group s healthcare coverage after the initial 30-day enrollment period. Blue Cross of Idaho applies full waiting periods to coverage for all late enrollees. If an individual does not qualify as a late enrollee when applying for coverage after the initial enrollment period, we will apply credit for qualifying previous coverage to preexisting condition waiting periods. There are several common circumstances that preclude considering the employee as a late enrollee. Do not consider an eligible employee or dependent a late enrollee under any of the four circumstances described below: 1. The individual meets criteria a, b and c below: a. The individual was covered under qualifying previous coverage at the time of initial enrollment b. The individual lost the qualifying previous coverage as a result of termination of employment or eligibility, the involuntary termination of the qualifying previous coverage, or the death or divorce of a spouse c. The individual requests enrollment within 30 days after termination of the qualifying previous coverage OR 2. Your group offers multiple health benefit plans and the individual elects a different plan during an open enrollment period OR 3. The eligible employee and/or eligible dependent become eligible for a premium assistance subsidy under Medicaid or the Children's Health Insurance Program (CHIP) and the member requests coverage under the policy no later than 60 days after the date the eligible employee and/or eligible dependent is eligible for such assistance. OR Blue Cross of Idaho Group Administrator s Manual 7

11 4. Coverage under Medicaid or CHIP for an eligible employee and/or eligible dependent is terminated because of loss of eligibility for such coverage, and coverage is requested under this policy no later than 60 days after the date of termination of such coverage. If the individual does not qualify as a late enrollee when applying for coverage after the initial enrollment period, we apply the credit for qualifying previous coverage to preexisting condition waiting periods. Blue Cross of Idaho Group Administrator s Manual 8

12 Causes of Ineligibility To see how to adjust your billings for any of the examples listed below, please refer to the Billing Adjustments section. Employee Termination Group coverage terminates on the last day of the month that the group makes payment for the terminated employee, or the day specified in your group policy. Divorce or Death of a Covered Dependent In the event of a divorce or death of an insured dependent, the employee should complete the front of an enrollment application (also used as an enrollment change form), indicating the date of divorce or death under Change Request, and list any covered dependents who should remain insured. Please mail the enrolled employee s application immediately to Blue Cross of Idaho. You may also note changes on the group bill worksheet. A newly divorced ex-spouse, who is a resident of Idaho, and with no other health coverage, may be eligible to transfer to a Blue Cross of Idaho individual program if he or she submits a properly completed application to Blue Cross of Idaho within 30 days from the group coverage termination date. We will terminate group coverage for the ex-spouse at the end of the month in which the divorce was final, if Blue Cross of Idaho receives the application within 30 days of the event. A newly divorced ex-spouse may be eligible for COBRA continuation coverage (please refer to the Consolidated Omnibus Budget Reconciliation Act section). You may also note changes on the group bill worksheet Dependent Child Status Ends An insured child becomes ineligible for coverage as the employee s dependent: OR At the end of the month a dependent child turns 26 years old For stepchildren at the end of the month of the date of the divorce Blue Cross of Idaho may extend coverage for dependent children medically certified as mentally and/or physically disabled and who are financially dependent on the employee for support. Request a Certification for Mentally Disabled or Physically Disabled Dependent Form from Blue Cross of Idaho. Eligibility is subject to periodic recertification. It is the employee s responsibility to notify the group administrator or Blue Cross of Idaho when the dependent child is no longer eligible for coverage within 30 days of the event. When a child no longer qualifies for coverage, the employee should complete the change request section on the front of an enrollment application. The covered employee should include the child s name, date of marriage, or the date the child ceased to be an eligible dependent under the terms of the group policy. You may also note changes on the group bill worksheet. The insured dependent child who is terminating does have choices for continuing insurance coverage. Refer to the next section, Termination of Employment and Death of Employee. Blue Cross of Idaho Group Administrator s Manual 9

13 Termination of Employment and Death of Employee Coverage for surviving covered family members ends on the last day of the month following the employee s death. A terminated employee and his or her dependents, and surviving insured dependents of a deceased employee who live in Idaho, may: OR Transfer to a Blue Cross of Idaho individual program, if they have no other health coverage in force, and if a properly completed application is received by Blue Cross of Idaho within 30 days from the group coverage termination date Be eligible for COBRA continuation coverage if your group qualifies (please refer to the Consolidated Omnibus Budget Reconciliation Act section) A terminated employee and his and her dependents, and surviving insured dependents of a deceased employee who are either moving or are already residing out of Idaho may: OR OR Transfer enrollment to the Blue Cross and Blue Shield Plan that serves the state they are moving to after checking with that Plan for confirmation Elect new coverage from an insurance company other than the Blue Cross and Blue Shield Plan that serves the state they are moving to; however, there is no guarantee of continuous coverage Be eligible for COBRA continuation coverage if your group qualifies (please refer to the Consolidated Omnibus Budget Reconciliation Act section). Blue Cross of Idaho Group Administrator s Manual 10

14 Consolidated Omnibus Budget Reconciliation Act What is COBRA? The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) applies only to certain employers who sponsor group healthcare programs for their employees and who have employed 20 or more employees on a typical day (at least 50 percent of the time) in the previous year. If your group meets these criteria, we strongly recommend that you seek advice from your company s legal counsel about how COBRA provisions may apply to your group. Title X of COBRA amends the Internal Revenue Code, the Public Health Service Act, and Title 1 of the Employee Retirement Income Security Act (ERISA) to require certain employers to provide continuation of healthcare coverage, at the employee s expense, to certain employees and their eligible dependents that would otherwise become ineligible for coverage because of certain qualifying events listed below. Law requires employers to notify new employees and their spouses of COBRA continuation when healthcare coverage begins and to send a notice to any employee at the time of the event that qualifies the employee or dependents for COBRA continuation (see Information Concerning Group Health Coverage Continuation sample form at the end of this section). Qualifying Events and Periods of Continued Coverage COBRA health coverage continuation is available to employees and/or eligible dependents covered by their group s healthcare program at the time of a qualifying event that would otherwise result in the loss of group coverage. Qualifying events and applicable periods of continuation for eligible employees and/or dependents include one of the following: OR OR OR OR OR Employment terminates (other than for gross misconduct) Term: up to 18 months 1 for employee and eligible dependents Reduced work hours Term: up to 18 months 1 for employee and eligible dependents Death of employee Term: up to 36 months for eligible dependents Employee becomes eligible for Medicare 2 Term: up to 36 months for eligible dependents Employee and spouse divorce or legally separate Term: up to 36 months for eligible dependents Dependent child ceases to be so under the terms of the group health program; i.e., child turns age 26. Term: up to 36 months for that child. 1 Qualified beneficiaries who are or have been determined to be disabled by the Social Security Administration at any time during the first 60 days of continuation coverage may be entitled to coverage for up to 29 months instead of 18 months. This extension is dependent upon when Medicare coverage begins. 2 Please note that a person who retires before reaching age 65, elects COBRA continuation, and then turns age 65 and is eligible for Medicare, becomes ineligible for COBRA, even if he or she has not completed the COBRA continuation period. Blue Cross of Idaho Group Administrator s Manual 11

15 Administration of COBRA After receiving a notice of a qualifying event, a group administrator needs to provide the employee and/or eligible dependents with a notice and election form (see Group Health Coverage Continuation Notice and Election sample form at the end of this section) and: 1. Process billing forms according to instructions under the Causes of Ineligibility section if the employee doesn t elect COBRA continuation coverage or doesn t make the COBRA payment before the expiration of existing coverage. At that point, Blue Cross of Idaho considers the employee and/or dependents terminated from group coverage until they enroll in the COBRA continuation program. The option to elect COBRA continuation expires 60 days after the date of termination or date the employer notifies the employee of COBRA continuation eligibility. 2. Submit the Blue Cross of Idaho Group Coverage Continuation Application for COBRA along with the necessary payment when an individual elects COBRA continuation. Be sure to keep a record of the continuation notice and election form in your files. 3. Collect payment for coverage from the COBRA beneficiaries and submit it on their behalf within 45 days of election. Payment must be retroactive to the coverage expiration date in effect at the time of the qualifying event. Please note that Blue Cross of Idaho will not accept COBRA continuation payment directly from the COBRA beneficiary or apart from the group s payment. COBRA continuation payment must be included in the group s regular payment. Important note: Within six months prior to the end of the COBRA continuation term, federal law requires the group administrator to notify the beneficiaries living in Idaho, who have no other health coverage, that upon completion of the full term of COBRA continuation they may be eligible for continuous coverage under a Blue Cross of Idaho individual program. Blue Cross of Idaho must receive a properly completed application within 30 days from the termination date of COBRA health coverage to ensure continuous coverage (see Transfer of Enrollment under the Enrollment Information section). Blue Cross of Idaho administered group billings list all COBRA beneficiaries separately from active employees. Blue Cross of Idaho offers full COBRA administration and we quote pricing per active employee, per month. However, under Blue Cross of Idaho COBRA administration, groups must still notify Blue Cross of Idaho in a timely manner of COBRA qualifying events to ensure prompt notification of the newly eligible member. Blue Cross of Idaho s full service COBRA administration service includes: Informing new group subscribers and members of their COBRA rights Sending notice and election information to members at the time of a qualifying event Sending application to members who elect to accept COBRA coverage Billing COBRA enrollees at their home address and tracking payments Informing enrollees of changes in rates and/or benefits after the group s annual renewal is finalized Monitoring claims for possible other group coverage and termination of the COBRA extension upon disqualification Sending notice of termination of coverage before the end of the maximum COBRA extension period when eligibility for continuing coverage ends Sending notice of termination during the 180 days prior to the end of the COBRA extension Blue Cross of Idaho Group Administrator s Manual 12

16 Administration of COBRA ARRA benefits When COBRA Continuation Ends For group administered COBRA, when a COBRA beneficiary loses eligibility because, for example, payment isn t received or the continuation period expired, please note the enrollee ID number, enrollee name, effective date and comments on the Group Bill Worksheet, the reason for terminating COBRA continuation, and deduct the amount under the Amt deduct column. Blue Cross of Idaho Group Administrator s Manual 13

17 Billing Adjustments For your reference an example of a billing statement, including sample detail, is included in the sample billing worksheet at the end of the Forms section. Due Date Payment is due to Blue Cross of Idaho on or before the first day of the month or benefit period. Members will not receive benefits if payment isn t made, and Blue Cross of Idaho will terminate group coverage as of the last day of the month we do not receive payment. Promptly paying the amount due avoids delays in claims processing and/or payment. Billing Changes Include all changes to your group s enrollment with your Group Bill Worksheet. Billing Reconciliation 1. Enter rates that need to be added to your bill next to Amt Added for: new enrollees new eligible dependents, if addition(s) changes rates When adding a newborn to a single, two-party or two-party no spouse contract, please submit a full month s premium for the child if his or her date of birth falls on or between the 1 st and 15 th day of the month. No premium is required for the first partial month if the child s date of birth falls on or between the 16 th and the last day of the month. For some groups, a member s rates may change depending on how many dependents they add. 2. Enter rates that need subtracted from your bill (for a terminating or deceased enrollee) next to Amt deduct. These rates include: divorce death a dependent child s status ends because child marries, child turns 26, or child independent termination of employment death of employee reduction in hours worked 3. Adjust the amount for the total due under Revised amount owed to Blue Cross of Idaho for this month at the bottom of the Group Bill Worksheet. 4. Use the Explanation column on the roster page of your bill to explain the change (birth, death, divorce, or termination) and date of the event. After you make all necessary changes for the month, recheck the billing for accuracy: Amt Added The total of all your additions for the month. Amt Deduct The total of all your deductions for the month. Revised amount owed to Blue Cross of Idaho for this month : The revised total. When you send your payment, please include: 1. The yellow group bill worksheet 2. Any applications for new hires or additions and terminations; and 3. Your check for the amount due Blue Cross of Idaho Group Administrator s Manual 14

18 How to File Health Claims To receive benefits for covered services, Blue Cross of Idaho must receive claims in one of two ways. Claim Filing by Provider The healthcare provider (physician, specialist, dentist, hospital or other professional facility) files a claim and works closely with Blue Cross of Idaho to help members obtain their benefits. 1. For services supplied by an Idaho provider, the member should present his or her Blue Cross of Idaho identification card and ask the provider to submit the claim to Blue Cross of Idaho. 2. For services supplied by a provider outside of Idaho, the member should present his or her Blue Cross of Idaho identification card and ask the provider to submit the medical claims to the local Blue Cross and Blue Shield Plan. This procedure ensures the member receives any discount arrangement the provider has with the local Blue Cross and Blue Shield Plan. Submit all dental claims directly to Blue Cross of Idaho. Claim Filing by Member Members submitting their own claims should follow these steps: 1. Ask the covered provider for an itemized billing, listing each service provided and its procedure code, the date the service he or she provided the service, the diagnosis code and the charge for each service. Blue Cross of Idaho cannot accept billings that only say Balance Due, Payment Received, or similar billing notations. 2. Obtain a member claim form (see example in the Forms section of the resource handbook) from the covered provider or from any Blue Cross of Idaho office. Follow the instructions at the top of the member claim form. Complete one form for each patient. Group administrators may order a supply of member claim forms to keep on hand for their employees. 3. Send the member claim form and itemized billing to: Claims Department Claims Department Blue Cross of Idaho OR Blue Cross of Idaho PO Box E. Pine Avenue Boise, ID Meridian, ID Submit all claims directly to Blue Cross of Idaho. Blue Cross of Idaho will process Idaho provider claim(s) and forward the claims for medical services furnished by a provider outside Idaho to the Blue Cross and Blue Shield Plan in that state. 5. Members must file claims within 12 months of the date of service to be eligible for benefits. Notification of Payment As soon as Blue Cross of Idaho processes the claim, we will send the member an explanation of benefits (EOB). The EOB (see example) lists each patient, the servicing provider, date of service, type of service, charge and an explanation of how we processed the claim. The EOB will indicate if we sent payment to the provider or the member. EOBs do not contain prescription drug claim information when the Blue Cross of Idaho pharmacy management vendor processes the prescription drug claim. Blue Cross of Idaho Group Administrator s Manual 15

19 Help Avoid Delays Filing a claim and receiving payment should be a simple process for your employees. Our ongoing performance studies show that we process about 90 percent of our claims within two weeks of the day we receive them. However, delays occasionally occur. Listed below are some common reasons for delays and ways you and your employees can avoid them. 1. Blue Cross of Idaho may delay payment because the member forgets to ask the provider to submit a claim. Members should present their Blue Cross of Idaho identification card each time they visit a healthcare provider, and ask that the provider file a claim. This ensures the provider has the correct identification number. 2. An incomplete or inaccurate member claim form takes longer to process. Members submitting their own claims must give Blue Cross of Idaho all the information requested on the member claim form. Check that you provide all the requested information, especially the enrollee number. Using the wrong number slows claims processing unnecessarily. 3. In some cases, members with other insurance, or those involved in an accident, affect the amount allowed for payment. In these situations, we may need additional information. We will write and ask the member for additional information to enable the complete processing of the claim. 4. Occasionally, we may have questions or need to see medical records before processing a claim. We will write and ask the member or the provider for the information 5. Finally, it is important that we have a current address for all members. This helps us promptly notify your employees of their benefits. Members should use an enrollment address change form to notify us of address changes. Blue Cross of Idaho Group Administrator s Manual 16

20 External Review Policy If an Insured or their authorized representative requests an independent external review of a claim, the decision made by the independent reviewer will be binding and final. The Insured or their authorized representative will the right to further review of the claim by a court, arbitrator, mediator or other dispute resolution entity only if your plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA), as more fully explained below under Binding Nature of the External Review Decision." If Blue Cross of Idaho issues a final Adverse Benefit Determination of an Insured s request to provide or pay for a health care service or supply, an Insured may have the right to have Blue Cross of Idaho s decision reviewed by health care professionals who have no association with Blue Cross of Idaho. An Insured has this right only if Blue Cross of Idaho s denial decision involved: The Medical Necessity appropriateness, health care setting, level of care, or effectiveness of an Insured s health care service or supply, OR Blue Cross of Idaho s determination that an Insured s health care service or supply was Investigational. An Insured must first exhaust Blue Cross of Idaho s internal grievance and appeal process. Exhaustion of that process includes completing all levels of appeal. Exhaustion of the appeals process is not required if Blue Cross of Idaho failed to respond to a standard appeal within thirty-five (35) days in writing or to an urgent appeal within three business days of the date the Insured filed the appeal, unless the Insured requested or agreed to a delay. Blue Cross of Idaho may also agree to waive the exhaustion requirement for an external review request. The Insured may file for an internal urgent appeal with us and for an expedited external review with the Idaho Department of Insurance at the same time if any delay would seriously jeopardize your life, health or ability to regain maximum function. An Insured may submit a written request for an external review to: Idaho Department of Insurance ATTN: External Review 700 W State St, 3 rd Floor Boise ID For more information and for an external review request form: See the department s web site, doi.idaho.gov, or Call the department s telephone number, , or toll-free in Idaho, An Insured may act as their own representative in a request or an Insured may name another person, including an Insured s treating health care provider, to act as an authorized representative for a request. If an Insured wants someone else to represent them, an Insured must include a signed Appointment of an Authorized Representative form with the request. An Insured s written external review request to the Department of Insurance must include a completed form authorizing the release of any medical records the independent review organization may require to reach a decision on the external review, including any judicial review of the external review decision pursuant to ERISA, if applicable. The department will not act on an external review request without an Insured s completed authorization form. If the request qualifies for external review, Blue Cross of Idaho s final adverse benefit determination will be reviewed by an independent review organization selected by the Department of Insurance. Blue Cross of Idaho will pay the costs of the review. Blue Cross of Idaho Group Administrator s Manual 17

21 Standard External Review Request An Insured must file a written external review request with the Department of Insurance within four (4) months after the date Blue Cross of Idaho issues a final notice of denial. 1. Within seven (7) days after the Department of Insurance receives the request, the Department of Insurance will send a copy to Blue Cross of Idaho. 2. Within fourteen (14) days after Blue Cross of Idaho receives the request from the Department of Insurance, we will review the request for eligibility. Within five (5) business days after Blue Cross of Idaho completes that review, we will notify the Insured and the Department of Insurance in writing if the request is eligible or what additional information is needed. If Blue Cross of Idaho denies the eligibility for review, the Insured may appeal that determination to the Department. 3. If the request is eligible for review, the Department of Insurance will assign an independent review organization to your review within seven (7) days of receipt of Blue Cross of Idaho s notice. The Department of Insurance will also notify the Insured in writing. 4. Within seven (7) days of the date you receive the Department of Insurance s notice of assignment to an independent review organization, The Insured may submit any additional information in writing to the independent review organization that they want the organization to consider in its review. 5. The independent review organization must provide written notice of its decision to the Insured, Blue Cross of Idaho and to the Department of Insurance within forty-two (42) days after receipt of an external review request. Expedited External Review Request An Insured may file a written urgent care request with the Department of Insurance for an expedited external review of a pre-service or concurrent service denial. The Insured may file for an internal urgent appeal with us and for an expedited external review with the department at the same time. Urgent care request means a claim relating to an admission, availability of care, continued stay or health care service for which the covered person received emergency services but has not been discharged from a facility, or any Pre-Service Claim or concurrent care claim for medical care or treatment for which application of the time periods for making a regular external review determination: 1. Could seriously jeopardize the life or health of the Insured or the ability of the Insured to regain maximum function; 2. In the opinion of the Covered Provider with knowledge of the covered person s medical condition, would subject the Insured to severe pain that cannot be adequately managed without the disputed care or treatment; or 3. The treatment would be significantly less effective if not promptly initiated. The Department of Insurance will send your request to us. Blue Cross of Idaho will determine, no later than the second (2 nd ) full business day, if the request is eligible for review. Blue Cross of Idaho will notify the Insured and the Department of Insurance no later than one (1) business day after Blue Cross of Idaho s decision if the request is eligible. If Blue Cross of Idaho denies the eligibility for review, the Insured may appeal that determination to the Department of Insurance. If the request is eligible for review, the Department of Insurance will assign an independent review organization to the review upon receipt of Blue Cross of Idaho s notice. The Department of Insurance will also notify the Insured. The independent review organization must provide notice of its decision to the Blue Cross of Idaho Group Administrator s Manual 18

22 Insured, Blue Cross of Idaho and to the Department of Insurance within seventy-two (72) hours after the date of receipt of the external review request. The independent review organization must provide written confirmation of its decision within forty-eight (48) hours of notice of its decision. If the decision reverses Blue Cross of Idaho s denial, Blue Cross of Idaho will notify the Insured and the Department of Insurance of the our intent to pay the covered benefit as soon as reasonably practicable, but not later than one (1) business day after receiving notice of the decision. Binding Nature of the External Review Decision If the Group is subject to the federal Employee Retirement Income Security Act (ERISA) laws (generally, any plan offered through an employer to its employees), the external review decision by the independent review organization will be final and binding on Blue Cross of Idaho. The Insured may have additional review rights provided under federal ERISA laws. If the Group is not subject to ERISA requirements, the external review decision by the independent review organization will be final and binding on both Blue Cross of Idaho and the Insured. This means that if the Insured elects to request external review, the Insured will be bound by the decision of the independent review organization. The Insured will not have any further opportunity for review of Blue Cross of Idaho s denial after the independent review organization issues its final decision. If the Insured chooses not to use the external review process, other options for resolving a disputed claim may include mediation, arbitration or filing an action in court. Under Idaho law, the independent review organization is immune from any claim relating to its opinion rendered or acts or omissions performed within the scope of its duties unless performed in bad faith or involving gross negligence. Blue Cross of Idaho Group Administrator s Manual 19

23 How to File Prescription Drug Claims This section applies only if your group coverage includes prescription benefits. For complete details of your group s prescription coverage, please refer to your Master Group Policy. Benefits Through Blue Cross of Idaho Network Pharmacies The Blue Cross of Idaho Pharmacy Network provides your group s prescription drug benefit. Blue Cross of Idaho contracts with a third-party vendor to process claims for prescription drugs. A computerized system automatically provides the member s benefit information to Blue Cross of Idaho Pharmacy Network pharmacists. The pharmacy directory lists network pharmacies. The Blue Cross of Idaho enrollee identification card contains the information needed to verify enrollment in the pharmacy program. After the network pharmacist enters this information into the system, he or she has immediate access to: 1. A member s enrollment status; 2. If the prescription drug is covered; and 3. The amount of deductible, coinsurance and/or copayment to collect from the member. Pharmacies can verify enrollment status while the insured member is at the pharmacy. Immediate access to current information prevents the use of expired cards or payment on benefits for ineligible prescription drugs. Prescription drug benefits include reviews of prescription drug use for the member s health and safety. If there are patterns of over-use or misuse of drugs, Blue Cross of Idaho may notify the member s personal physician and pharmacist. Blue Cross of Idaho reserves the right to limit prescription drug benefits to prevent over-use or misuse of prescription drugs. Certain prescription drugs may require prior authorization. If the member s physician or other provider prescribes a drug that requires prior authorization, either the provider or the pharmacist should inform the member that prior authorization is required. To obtain prior authorization the member s physician must contact Blue Cross of Idaho. How to Use the Blue Cross of Idaho Pharmacy Network Prescription Drug Benefit Blue Cross of Idaho will issue a Blue Cross of Idaho enrollee identification card that includes enrollment information for the Blue Cross of Idaho Pharmacy Network and a pharmacy directory listing all network pharmacies for covered prescription drugs to an enrolled employee. When using the card, members should follow these steps: 1. Inform the pharmacist that he or she is a Blue Cross of Idaho member. Present the enrollee identification card along with the new or refill prescription request. 2. After the pharmacist enters the enrollee identification number in the computer, the system responds with the correct out of pocket amount the member owes the pharmacist. 3. Sign a form verifying receipt of the prescription. If the member pays the pharmacist in full at the time of purchase, the member must file a claim to collect benefits. Blue Cross of Idaho Group Administrator s Manual 20

24 How to Collect Benefits Using a Non-Network Pharmacy When an employee or dependent goes to an Idaho pharmacist who is not a Blue Cross of Idaho participating pharmacist or to an out-of-state pharmacy that is not in the network, the employee must pay the pharmacist the full cost of the prescription drugs at the time of purchase and file a claim (see Prescription Drug Claim Form in the Forms section of the Resource Handbook). To file a claim, a member should: 1. Get a Prescription Drug Claim Form from the group administrator, any Blue Cross of Idaho district office, or our website, bcidaho.com. The group administrator may order an additional supply of Prescription Drug Claim Forms from Blue Cross of Idaho; 2. Complete the form; 3. Attach the original paid pharmacy receipt, including the required drug information, to the claim form; and 4. Send the claim and recipient details to the address on the back of the form. The pharmacy network formula of payment determines reimbursement based on the pharmacy network formula, less the deductible and/or copayment, rather than on the retail price. Mail-order Prescriptions PLEASE NOTE: Mail order prescription benefits apply only if your group coverage includes this benefit. We want you to know that you can save time and money on prescriptions by ordering your medications through Express Scripts, Blue Cross of Idaho s mail-order prescription service. Express Scripts can transfer existing prescriptions from your pharmacy if you have refills remaining or you can get a new prescription from your healthcare provider for faster service. Once you establish your prescriptions under an Express Scripts account, simply order refills before you expect to run out with sufficient time (typically two weeks or more) to receive, process, fill and deliver your order. Your new prescriptions will show up on your doorstep a few days later. NOTE: Express Scripts cannot transfer refills of controlled drugs or compounded prescriptions like Darvocet, Tylenol #3 and Vicodin. If you need refills of controlled or compounded drugs, Express Scripts requires a new prescription. The mail-order prescription service Express Scripts offers Blue Cross of Idaho members is easy, fast, and economical. Please take advantage of this cost-saving program to help cut your prescription medication costs. If you have new prescription, are ready to order a refill, or have questions, call Express Scripts Member Services at (available 24/7), or visit the pharmacy portion of the Blue Cross of Idaho website, bcidaho.com, for an order form. Blue Cross of Idaho Group Administrator s Manual 21

25 Mail-order prescriptions: Save Time Medications arrive via UPS or First Class U.S. Mail. Remember, the larger the order, the less often a member has to place an order. Save Paperwork No claim forms to fill out, no receipts to save, and no waiting for reimbursement. You can order by phone, mail, or online. Prescription order forms are available from our website, bcidaho.com. Simply log on as a member, select Pharmacy Benefits and register with ExpressScripts. Choose Fill a New Prescription, Print a Prescription Order Form, then Print a Blank Order Form Now. Each blank order form has a unique barcode to help ExpressScripts identify members. Save Money Express Scripts makes generic substitutions for brand name medications whenever possible. Generic prescriptions are equally effective as their brand-name counterparts, but cost significantly less. Also, you can order a 90-day supply, which in the long run, means your copayment is less. Transferring Prescriptions If a member takes has a mail-order prescription-drug benefit, the mail order vendor can transfer existing prescriptions from your present pharmacy if there are any refills remaining or members can get a new prescription from their provider for faster service. Ordering Refills Order refills three weeks before you expect to run out. This allows sufficient time to receive, process, fill and deliver the order. PLEASE NOTE: Not all Blue Cross of Idaho policies include mail order pharmacy benefits. Please check your policy, if you are unsure, or contact customer service at Generic Drugs Most prescription drugs have a brand name (or trademark) version and a generic (or chemical name) version. By law, both brand name and generic drugs must meet the same standards for safety, purity, quality, and strength. Generic drugs can save money for the member and the group health plan. Inform your employees to ask their physician to prescribe generics whenever possible. Ordering Prescription Refills On-line Members may log-on to Express-Scripts.com for information on their retail prescription history or to manage mail order prescriptions. Blue Cross of Idaho Group Administrator s Manual 22

26 Dental Benefits This section applies only if your group coverage includes dental benefits. For complete details of your group s dental coverage, please refer to your Master Group Policy. All dental coverage provided by Blue Cross of Idaho offers cost savings based on our contracting dentist programs. Contracting dentists agree to recognize Blue Cross of Idaho s maximum allowance as their maximum fee for eligible services furnished to Blue Cross of Idaho members. Members are responsible only for any deductible (if applicable), coinsurance, and non-covered amounts. A member should never pay amounts that exceed the maximum allowance when a contracting dentist furnishes the eligible service. When members receive covered dental services from a non-contracting dentist (a dentist who has not signed an agreement with Blue Cross of Idaho or its affiliates), they are responsible for any deductible (if applicable), coinsurance amount, non-covered amounts, and amounts above the maximum allowance. Blue Cross of Idaho s dental program provides coverage options of $1,000, $1,250 or $1,500, depending on your group coverage, in dental care services per member, per benefit period. Refer to your Master Group Policy to determine which dental option your group selected, if applicable. Deductible Dental Option Your group may choose from two deductible options either $25 or $50 per member per benefit period. When three insured family members meet their deductibles, they satisfy the entire family s deductible, and no other insured family member needs to pay toward a deductible. The Deductible Dental Option pays 100 percent of the maximum allowance for routine dental care, including exams, x-rays, cleanings, fluoride for eligible dependent children, and sealants for certain teeth for eligible dependent children under age 16. Benefits are available for one oral examination and cleaning in a six-month period per member, per benefit period. Preventive care benefits are not subject to the deductible. The Deductible Dental Option pays 80 percent of the maximum allowance after meeting the benefit period deductible for frequently used services such as fillings, oral surgery (as specified in the plan/policy), root canal therapy, and periodontics. Groups may choose to include a zero or six-month waiting period for basic care services. The Deductible Dental Option pays 50 percent of the maximum allowance after meeting the benefit period deductible for prosthetic and restorative treatments, including crowns and repair of crowns; bridgework and repair of bridgework; dentures and the repair, adjustment, and relining of dentures; and dental implants. Groups may choose to include a zero, 12, or 24-month waiting period for major care services. As an option to your group plan, you may add orthodontia benefits. These benefits are available for enrolled dependent children. The orthodontic option pays 50 percent of the maximum allowance for covered services with a maximum lifetime benefit of $1,000, $1,250 or $1,500 depending on the option you chose, after meeting a 24-month waiting period. The maximum paid per benefit period is $1,000, $1250, or $1,500. Blue Cross of Idaho Group Administrator s Manual 23

27 Incentive Dental Option The Incentive Dental Option pays for preventive and basic care according to the following: Benefit payments begin at 70 percent of the maximum allowance. The benefit payment increases 10 percent each benefit year of enrollment up to 100 percent of the maximum allowance provided the member receives a covered service each consecutive calendar year. If a member does not receive a covered service in a given calendar year, the benefit payment decreases 10 percent for the next calendar year, but is never lower than 70 percent. Payment for covered preventive and basic services is never less than 70 percent of the maximum allowance. Benefit payments are never more than the maximum allowance. Preventive care services include routine dental care such as exams, x-rays, cleanings, fluoride for eligible dependent children, and sealants for certain teeth for eligible dependent children under age 16. Benefits are available for one oral examination and cleaning in a six-month period per member, per benefit period. Basic care services include fillings, oral surgery, root canal therapy, and periodontics. You may choose to include a six-month waiting period for basic care services. The Incentive Dental Option pays 50 percent of the maximum allowance for major care covered services, regardless of the incentive level the member attains. Services include prosthetic and restorative treatments such as crowns and repair of crowns; bridgework and repair of bridgework; dentures and the repair, adjustment, and relining of dentures; and dental implants. You may choose a 12-month waiting period for major care services. Preferred Blue Dental Option a Preferred Provider Organization (PPO) Dental Plan There is a deductible of $25 or $50 per person, per benefit period, depending upon the plan selected by the employer. This deductible applies to in-network services for only basic and major care services and all out-of-network services. When three insured family members meet their deductibles, they satisfy the entire family s deductible, and no other insured family member needs to pay toward a deductible. This plan pays a designated percentage of the maximum allowance for routine dental care benefits. Available benefits include oral exams, x-rays, cleanings, fluoride for eligible dependent children, and sealants for some teeth for eligible dependent children under age 16. Benefits are available for one oral examination and cleaning in a six-month period per member, per benefit period. Basic care benefits cover fillings, oral surgery, root canal therapy, and periodontics. After meeting the benefit period deductible, the program pays a designated percentage of the maximum allowance, depending upon the employer s plan. Groups may choose to include a six-month waiting period for basic care services. Major care benefits of the plan include prosthetic and restorative treatments such as crowns and crown repair, bridgework and repair of bridgework, dentures (repair, adjustment, relining), and dental implants. The plan covers a designated percentage of the maximum allowance, depending on your Blue Cross of Idaho Group Administrator s Manual 24

28 plan, after meeting the calendar year deductible. Groups may choose to include a 12 month waiting period for major care services. As an option to your group plan, you may add orthodontia benefits. These benefits are available for enrolled dependent children. The orthodontic option pays 50 percent of the maximum allowance for covered services with a maximum lifetime benefit of $1,000, $1,250 or $1,500 depending on the option you chose, after meeting a zero, 12, or 24-month waiting period. Essential Dental Essential Dental provides benefits for preventive and basic care services. While Essential Dental does not cover major care services such as crowns, bridgework, or dentures it does give you affordable premiums and the coverage your employees need the most. Essential Dental utilizes our PPO network of contracting dentists. Preventive Care Benefits Essential Dental pays 100 percent of the maximum allowance in-network, and 80 percent of the maximum allowance out-of-network after the benefit period deductible is satisfied, for routine dental care benefits. Available benefits include one oral exam every six months, x-rays, cleanings and fluoride treatments for eligible dependent children. Certain benefits are only available to dependent children with age maximums. In-network preventive care services are not subject to the deductible. Basic Care Benefits Basic care benefits cover frequently used services such as sealants for some teeth for eligible dependent children under age 16, fillings, oral surgery, root canal therapy, and periodontics. After the six-month waiting period and satisfying the deductible, Essential Dental pays 80 percent of the maximum allowance in-network and 60 percent of the maximum allowance out-of-network for basic care services. Voluntary Dental The Voluntary Dental program has no participation or contribution requirements, and because it s voluntary, employees decide whether they want to participate. To start, select the benefit plan option that is best for your employees and enroll in the plan as a group. Blue Cross of Idaho will bill you each month for the entire premium, and then deduct the appropriate premium for each participating employee's dental coverage premium from his or her paycheck. The PPO Advantage Voluntary Dental is a preferred provider organization (PPO) product, which means that to receive the most in benefit payments, members should choose their dentist from our PPO network. We have PPO agreements with dentists throughout Idaho so they don t bill our members more than an amount Blue Cross of Idaho determines to be the maximum allowance for an eligible service. When a contracting dentist provides dental services, the member is only responsible for any deductible, coinsurance, copayment and non-covered amounts. Deductible With Voluntary Dental, you can choose a $25 per person in-network and $50 per person out-ofnetwork deductible or a $50 per person in-network and $75 per person out-of-network deductible. Blue Cross of Idaho Group Administrator s Manual 25

29 Both options have a maximum of three benefit period deductibles per family. The deductible does not apply to in-network preventive covered services. Benefit Period Maximum Amount Voluntary Dental offers coverage options of $1,000, $1,250 or $1,500 per benefit period. The maximum benefit amount is per member, per benefit period, which is the 12 months following your group's effective date. Preventive Dental Benefits Voluntary Dental pays 100 percent of the maximum allowance for in-network services with a $20 or $25 copayment depending upon the option chosen. The deductible does not apply to in-network preventive services. Blue Cross of Idaho pays out-of-network services at 50 or 70 percent of the maximum allowance after satisfying the deductible. Available benefits include one oral exam every six months, x-rays, cleanings and fluoride treatments for eligible dependent children. Basic Care Benefits Depending on the plan selected, Voluntary Dental pays 40 or 80 percent of the maximum allowance for in-network services and 50 percent of the maximum allowance for out-of-network services. Basic care services are eligible for payment after satisfying the benefit period deductible and a six-month waiting period. Basic care benefits cover frequently covered services such as sealants, fillings and oral surgery. Major Care Benefits Voluntary Dental pays 50 to 60 percent of the maximum allowance for in-network major services and 30 or 40 percent of the maximum allowance for out-of-network services, depending on the plan chosen. Major care services are eligible for payment after satisfying the benefit period deductible and a 12-month waiting period. Major care benefits of Voluntary Dental include root canal therapy, periodontics, crowns, bridges and dentures. Orthodontia Benefits (Optional) As an option to your group plan, you may add orthodontia benefits. These benefits are available for enrolled dependent children. The orthodontic option pays 50 percent of the maximum allowance for covered services with a maximum lifetime benefit of $1,000, $1,250 or $1,500 depending on the option you chose, after meeting a 24-month waiting period. The maximum paid per benefit period is $500. Dental Maximum Carryover When you offer the Dental Maximum Carryover, employees and their family members enrolled in the dental plan may carry over a portion of their unused benefit dollars from one benefit period to the next. For example, when a member uses $500 or less for dental claims in a benefit period, they can carry $250 over for use in the future. If the member uses more than $500 for claims in a benefit period, he or she cannot carry any amount over. Members can use carryover dollars to pay for covered dental services after reaching the benefit period maximum. Blue Cross of Idaho Group Administrator s Manual 26

30 Guidelines A carryover account is available to every member in the dental plan. Members must enroll in the dental plan for a full twelve-month benefit period to be eligible for the Dental Maximum Carryover. Members must submit at least one claim for a covered dental service each benefit period. The total amount Blue Cross of Idaho pays during each benefit period cannot exceed the threshold amount of $500 for the member to qualify for the carryover amount. Blue Cross of Idaho credits $250 to the member s carryover account at the beginning of the next benefit period. The maximum carryover accrual is $1,000. Members cannot use carryover dollars for lifetime benefits (e.g., orthodontia). Threshold amount calculations do not include procedures identified as lifetime procedures (e.g., orthodontia). Use carryover dollars to pay for covered dental services after reaching the benefit period maximum. All dental benefit exclusions, limitations and eligibility requirements apply. There is no time limit for using dollars accrued in the carryover account as long as the member has continuous coverage and the employer continues to offer the Dental Maximum Carryover. The carryover account will be set to $0 if a member terminates or has a break in coverage. Orthodontic Benefits Orthodontic benefits are an option with the Deductible, Incentive, and Preferred Blue Dental Programs. Benefits for orthodontic services are available only to members or their dependent children. Age maximums vary depending on your plan. Orthodontic benefits apply only if your group coverage includes this benefit. The orthodontic option pays 50 percent of the maximum allowance for covered services to a $1,000, $1,250 or $1,500 lifetime benefit limit per dependent child depending on the chosen plan. Benefits cover the installation of appliances to straighten teeth and to correct abnormally positioned teeth. You may select a zero, 12- or 24-month waiting period for orthodontic benefits depending on your dental option. Dental Program Exclusions & Limitations Your Master Group Policy lists all of the dental services that have benefits paid by the program. No benefits are available for services not included in the list. If alternate procedures produce professionally satisfactory results, Blue Cross of Idaho bases payment of benefits on the procedure with the lesser charge. If a member changes dentists during a treatment program, or if more than one dentist performs the same procedure, Blue Cross of Idaho pays benefits as if only one dentist performed the services. To submit a claim, write or call us at: Blue Cross of Idaho Blue Cross of Idaho Dental Services or Dental Services PO Box E. Pine Avenue Boise, ID Meridian, ID Blue Cross of Idaho Group Administrator s Manual 27

31 Vision Service Plan This section applies only if your group coverage includes vision benefits through VSP. For complete details of your group s vision coverage, please refer to your Master Group Policy. Benefits Available Through VSP Blue Cross of Idaho provides vision benefits through Vision Service Plan (VSP). The Vision Care Plan brochure provides benefit information specific to your group policy, including copayments and reimbursement schedules. Before making an appointment for a member or a covered dependent, members should find a VSP participating doctor by using the VSP directory, calling VSP at , or using VSP s on-line doctor directory service at vsp.com. Once a member finds a doctor, he or she should call the office to schedule an appointment and provide the information below. The VSP doctor will contact VSP and verify the member s benefits before delivering any services. 1. Indicate he or she is a VSP member 2. Blue Cross of Idaho identification number 3. Date of birth Your vision policy covers eye examinations once during a benefit period, as specified in your Master Group Policy. The policy may also cover contact lenses or glasses (with frame and lenses) in accordance with the Master Group Policy. Please check your policy for benefit coverage. VSP provides no benefits for medical or surgical treatment of the eyes, however, discounts for laser surgery such as LASIK are available through VSP contracted laser centers. When Using a VSP Participating Doctor When enrolled employees choose a VSP participating doctor, they simply pay the appropriate copayments to the doctor. Your group policy lists your employees copayments. In addition to the copayments, employees are responsible for selected optional items not covered by the plan. When Using a VSP Non-participating Doctor An employee may choose to see a provider who is not participating with VSP, in which case your plan will reimburse the services at specified levels detailed in your group policy. VSP reimburses your employees for services received from any licensed optometrist, ophthalmologist, or optician. Employees must pay the non-participating doctor in full and submit an itemized bill to VSP. The reimbursement schedule does not guarantee full payment nor can VSP guarantee patient satisfaction when members receive services from a non-participating doctor. Blue Cross of Idaho Group Administrator s Manual 28

32 Prior Authorization What is Prior Authorization? Prior authorization is a request by the member s contracting provider to Blue Cross of Idaho, or delegated entity, for authorization of a member s proposed treatment. Blue Cross of Idaho may review medical records, test results and other sources of information to ensure the service is covered and make a determination as to medical necessity of the service or alternative treatments. The member is responsible for obtaining prior authorization when seeking treatment from a non-contracting provider. If contracting providers perform non-medically necessary services without the prior authorization by Blue Cross of Idaho, and Blue Cross of Idaho denies benefits, the costs of said services are not the financial responsibility of the member. However, the member is financially responsible for nonmedically necessary services provided by a non-contracting provider. Please check the Blue Cross of Idaho Web site at bcidaho.com, or call customer service at to determine if a proposed service requires prior authorization. To request prior authorization, the contracting provider must notify Blue Cross of Idaho of the member s intent to receive services that require prior authorization. The member is responsible for notifying Blue Cross of Idaho if a non-contracting provider performs the proposed treatment. The notification may be completed by telephone call or in writing and must include the information necessary to establish that the proposed services are covered services under the member s plan and medically necessary. Blue Cross of Idaho will respond to a request for prior authorization received from either the provider or the member within two business days of the receipt of the medical information necessary to make a determination. What is Inpatient Notification? As specified in your policy, your plan requires non-emergency preadmission notification or emergency admission notification for all inpatient services. Some inpatient services also require the provider to obtain prior authorization. Non-emergency preadmission notification Non-emergency preadmission notification is when the member notifies Blue Cross of Idaho and it is required for all inpatient admissions, except covered services subject to emergency or maternity admission notification. A member should notify Blue Cross of Idaho of all proposed inpatient admissions before admittance. Non-emergency preadmission notification informs Blue Cross of Idaho, or a delegated entity, of the member s proposed inpatient admission to a licensed general hospital, alcohol or substance abuse treatment facility, psychiatric hospital, or any other facility provider. This notification alerts Blue Cross of Idaho of the proposed stay. When a member provides timely notification of an inpatient admission to Blue Cross of Idaho, payment of benefits is subject to the specific benefit levels, limitations, exclusions and other provisions of this plan. For non-emergency preadmission notification, call Blue Cross of Idaho at the telephone number listed on the back of the member identification card. Blue Cross of Idaho Group Administrator s Manual 29

33 Emergency or Maternity Admission Notification When an emergency admission occurs for emergency medical conditions, an unscheduled cesarean section delivery, or maternity delivery services, and notification cannot be completed prior to admission because of the member s condition, the member, or his or her representative, should notify Blue Cross of Idaho within 24 hours of the admission. If the admission is on a weekend or legal holiday, notify Blue Cross of Idaho by the end of the next working day after the admission. If the emergency medical condition, unscheduled cesarean section delivery (if covered under this plan) or maternity delivery services render it medically impossible for the member to provide such notice, the member should immediately notify Blue Cross of Idaho of the admission when it is no longer medically impossible to do so. This notification alerts Blue Cross of Idaho to the emergency stay. Continued Stay Review Blue Cross of Idaho will contact the hospital utilization review department and/or the attending physician regarding the member s proposed discharge. If the hospital doesn t discharge the member as originally proposed, Blue Cross of Idaho will evaluate the medical necessity of the continued stay and approve or disapprove benefits for the proposed course of inpatient treatment. Payment of benefits is subject to the specific benefit levels, limitations, exclusions, and other provisions of this plan. Discharge Planning Blue Cross of Idaho will provide information about benefits for various post-discharge courses of treatment. Blue Cross of Idaho Group Administrator s Manual 30

34 Sample Forms The following forms are samples for you to reference in case you need to share or review a document with an employee. Some forms are available on the Blue Cross of Idaho Web site, bcidaho.com, however, if you need additional copies of any documents, please contact your local district office at Blue Cross of Idaho Group Administrator s Manual 31

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