Claims and Appeals
One of the most convenient aspects of our health plans is that there are virtually no claim forms for members to file when they seek care from in-network health care professionals and show their member ID card.
Plus, we typically pay in-network health care professionals directly, so members can pay their copay and/or coinsurance at the time of the visit and let us take care of the rest!
When Claims Are Filed For Members
When a member of your group receives care from an in-network doctor, hospital or other health care professional, or when a member has a prescription filled at an in-network pharmacy, the provider typically files a claim with us on the member’s behalf. We then reimburse that professional directly.
When a Member May Need to Manually File a Claim
Your employees may have to pay for services and file a claim if they:
| Do not present their member ID card when services are received |
| Receive treatment from an out-of-network doctor, hospital or other health care professional |
| Fill prescriptions with an out-of-network pharmacy |
The claim form, known as Member Health Expense Report, can be downloaded from the Commonly Requested Forms
section of this ERG and sent to us either by mail or fax.
P.O. Box 9907
Columbus, GA 31908-6007
F: (877) 868-950
For claims filed by members, we send reimbursement checks and Explanations of Benefits (EOBs) to the member. It is his or her responsibility to pay the health care professional, if applicable.
Additionally, if your group’s plan provides coverage for services received out-of-network, the out-of-network health care professionals may balance-bill the member. Balance-billing can occur when the fee the professional charges is more than what we have agreed to pay in-network doctors for the same services, and there is a balance remaining after receiving reimbursement from us.
Prescription Drug Claims
Prescription drug programs are managed independently of your group’s health care coverage. However, the prescription drug plan information is included on the member’s ID card.
When a member of your group presents his/her member ID card at an in-network pharmacy and pays the appropriate copay at the time the prescription is filled, the pharmacy will file a claim directly on the member’s behalf. If a member does not show his/her member ID card or if the pharmacy is not in our network, the member may need to pay for the prescription in full and then file a Member Health Expense Report
. The amount reimbursed may be less than the amount the member paid.
Prescription drug claims must be filed within 15 months of the date the prescription was filled.
Members should include any receipts and a written explanation of the claim with the claim form.
In most cases, an in-network dental professional will file a claim on the member’s behalf. If the dental professional cannot file a claim, the member must submit a completed claim form
and attach itemized bills for covered services. Each itemized bill must contain the following information:
| Name of the patient receiving services or supplies |
| Dental professional’s name and address |
| Date services or supplies were provided |
| Charge for each type of service or supply |
| Description of the services received |
| A description of the patient’s condition |
The dentist can assist the member with the information needed on the claim form (dental codes, for example). Claims for dental services should be sent to the address shown on the member’s ID card.
Filing an Appeal – Review of a decision made by BCBSGa/BCBSHP
As a BCBSGa/BCBSHP member, your employee has the right to express dissatisfaction and to expect unbiased resolution of his/her issue. The process, which BCBSGa/BCBSHP has established to ensure that we give the highest level of attention is as follows:
| Call customer care and explain the problem. We will work diligently to resolve it as quickly as possible. |
| If your employee is not completely satisfied with our response, he/she may file a formal complaint, preferably in writing to the Statewide Appeals Coordinator. The Coordinator will then pull all related information, including medical records, and report the case to the Member Review Committee. The Member Review Committee will subsequently meet to make a final decision. |
| If, depending on the nature of the complaint, your employee remains dissatisfied after receiving our response, he/she will be offered the right to appeal the decision. BCBSGa/BCBSHP has established mechanisms for reviewing and processing multiple types of member issues that may arise. |
For instance, member concerns about claims payment of medical services are handled through the Utilization Management department. Administrative issues are handled through the Managed Care Administration. The timeframes for response to the member, as well as the opportunity to appeal vary, depending upon the issue itself. However, for all member appeal requests, unless expedited, we will acknowledge receipt within five (5) working days and send a formal response within 30-45 working days (depending on whether medical records must be obtained for committee review).
| If your employee remains dissatisfied upon conclusion of the first appeal level, he/she may again request an appeal of our decision. At the second appeal level, the member will have the opportunity to represent his/herself or designate someone to represent on his/her behalf in a formal Grievance Committee setting. The member is allowed to present their personal perspective in an effort to bring the matter to a satisfactory resolution. |