Individual Plan FAQs
Note: if you would like to obtain a written copy of any information provided on this website, please call (800) 441-CARE from 7:30 AM to 7 PM and a customer care associate will be happy to assist you.
If you need to submit a claim, provide medical records, request customer assistance, simply use our toll-free fax: (877) 868-7950.
Member Access allows members to manage your health benefits through our secure online member self-service program. We have a variety of secure resources available to active members, to include:
| Update Your Account |
| Request New ID Card |
| Change Your Primary Care Physician |
| Check Member's Eligibility Status and *Benefits |
| Check Member's Accumulations |
| Check Claims/Encounter Status |
| Member Certificate Booklets |
| Healthcare Advisor |
| Print Online Agreement |
| Pharmacy Member Self Service |
1. How do I get additional information about my plan or benefits?
You can verify your benefits using our on-line service, Member Access
. You will need to register for a username and password if you haven't already done so. You can also call customer service at the number listed on your member ID card from 7:30 AM to 7 PM, Monday through Friday (excluding holidays).
2. How and when can I contact the health plan?
Our friendly, helpful and knowledgeable customer service associates are available to answer your questions from 7:30 AM to 7 PM, Monday through Friday (excluding holidays). Simply call the customer service number listed on your member ID card for assistance, or email us at firstname.lastname@example.org
3. How do I change my name or address?
To change your address, simply call the customer service number listed on your member ID card. Our customer service associates stand ready to help you with your needs. If you need to change your name, you will need to complete a Member Change form and submit legal documentation as well. Customer service can provide you with the appropriate form.
4. What are your customer service hours?
Our associates are available from 7:30 AM to 7 PM, Monday through Friday (excluding holidays).
5. How do I get a provider directory?
You can search our Provider Directory
24-hours a day, seven-days a week, or you can call customer service and request a printed version be sent to your home or office.
6. How do I get a list of preferred drugs (formulary information)?
A list of preferred drugs
is available on our Web site. This list is updated throughout the year. You can also contact our customer service associates to find if a particular drug is included on our drug list. The phone number for customer service is listed on your member ID card.
1. How can I cover my newborn from birth?
First, congratulations on the birth of your baby! To add your child to your health care coverage policy, simply contact your group administrator or customer service within the first 31 days after your baby's birth. If you do not add your baby within the first 31 days, you will have to wait until your company's next open enrollment period. To complete your newborn's enrollment, you will need to complete a member change form.
2. How do I obtain coverage for my newly adopted child?
All you need to do is contact your group administrator or customer service within the first 31 days of the official adoption date. If you do not add your baby within the first 31 days, you will have to wait until your company's next open enrollment period. Legal documentation of the adoption will be required to complete your new child's enrollment.
3. How do I add or delete family members?
Please contact your group administrator or call customer service at the number listed on your member ID card. You will need to complete a member change form to add or delete dependents.
4. Can I cover a dependent who lives out-of-state or my child away at school?
Your unmarried child is covered while in college, provided that he or she is enrolled as a full-time student and is age 25 or younger whether living out-of-state or not.
Access the information through www.bcbs.com, the Blue Cross Blue Shield Association's Web site. Simply click on the BlueCard Doctor & Hospital Finder hotlink and complete the requested information to locate a PPO or participating provider as close as five miles from the location. You can also call BlueCard Provider Access toll-free at (800) 810-BLUE (2583).
5. How often can I change benefit plans?
You can change your existing benefit plan as often as you like. There are different steps involved in changing your plan depending on if you are upgrading or downgrading your plan. If you have questions on changing your existing plan, please contact a dedicated customer service associate at (800) 718-8831.
6. How long can my children remain covered?
Your children remain covered if they are unmarried, under 19 years old, or under 25 years old, as long as they qualify as dependents for income tax purposes and are full-time students (12 or more credits) at an accredited college, university, vocational or technical school. BCBSGa requires written proof of student status annually. Please see your Contract for more details.
The age limit for children to remain on your policy is 25 years old. At that time, they may transfer to their own individual policy.
7. How long can my child be covered if he or she has disabilities?
If your child has a physical handicap or mental retardation and reaches the age limits (19 years, 25 years if in college), your child can continue coverage if he or she is: covered under this plan, still dependent on you or your spouse, not able to get a job to self-support him or herself because of the handicap or mental retardation. Please see your Contract for more details.
1. What are my monthly premium payment options?
| You can mail in a check or money order |
| You can set up an automatic bank draft using a checking account |
| You can pay by phone using credit card (Visa, MasterCard or Discover) or checking account information (Routing # and Account # required) |
| You may also set up online bill payment through your bank’s website |
2. How do I set up my account to be on an automatic bank draft?
Please print out the draft request form
. Once you fill out the form, please mail to the address or fax to number provided on the form.
3. How do I make a premium payment over the phone?
| Call (800) 718-8831|
| Choose a language selection – press 1 for English - 2 for Spanish|
| Then press 1 to indicate you are the Member|
| Choose your member options – press 4 for “Premium”|
| Choose subject selection – press 1 for “Billing Options”|
| Enter your Member ID number located on your ID card without the first three letters|
| Enter your Date of Birth|
| Enter the zip code of the policy holder|
| You will hear your payment history first. Then press 3 for “Payment”.|
| To pay by checking account, press 1 for “Check” |
| To pay by credit card press 2 for “Credit”|
| Follow the steps to enter your payment information.|
4. Are there any ways to change my policy information online when I use my login?
No. If you would like to make a change to your current policy, please contact Customer Service at (800) 718-8831.
5. How do I write a check for multiple policies?
In the memo field on the check, please list the names, policy numbers and the amount that is needed to post to each account. Also, please attach the premium notices with the payment if available.
6. When are my bills due?
1. How do I order additional ID cards?
Simply visit the Member Access
portion of this Web site. If you do not have a username and password to the service, request one today and then call customer service to request a replacement member ID card(s), or request one by emailing us at email@example.com
2. Do I need to carry my ID card with me at all times?
While it's not a requirement, it is good practice to have your member ID card with you in the event of an emergency. However, if you do have an emergency and do not have your member ID card, do not worry. Your provider of care can call Blue Cross Blue Shield of Georgia to verify your benefits.
1. How do I find a network provider?
You have three options:
1. Visit our on-line Provider Directory and follow the steps to find the provider of your choice.
Select Blue Choice Preferred Provider Organization (PPO) or Traditional if you are enrolled under an Indemnity plan.
Under Provider Type, select what you are looking for.
From there you can search by city, county, name or other criteria.
2. Look in the printed Provider Directory.
3. Call customer service at (800) 718-8831.
2. What are the advantages of using network or participating providers?
Receiving services from a network or participating provider can substantially reduce your out-of-pocket costs. These lower costs are due to negotiated rates that network and participating providers agree to accept instead of their typical fees, and generally, benefits paid for non-participating providers are more limited. BCBSGa network and participating providers will file claims to BCBSGa for our members, then bill you for the remaining portion of their charges. You do not have to file a claim form for services received at BCBSGa network or participating providers.
3. What happens if my current physician is not a network provider?
In order to receive the benefits of your HMO plan, you will need to select a network provider to act as your PCP. Please call customer service at the number listed on your member ID card for more information.
Under the POS plan, you may continue to see your current physician. However, you will receive the greatest benefit when you use a network provider.
4. Can I go to a non-network provider?
Under the HMO plan, you are only covered for services through a network provider, unless you need emergency services or urgent care. If you go to an out-of-network provider, you will have to pay for it yourself.
If you are a POS plan member, you have the freedom to visit any licensed provider. However, you will receive the greatest benefit if you use a network provider.
1. What services require prior approval or a referral?
Women may go to a network OB/GYN doctor for pregnancy, gynecological problems or annual exams without a PCP referral.
Required for ALL hospital admissions. Emergency or maternity admissions must be certified within 48 hours.
Required for specified procedures as listed in the Pre-Admission Certification (PAC) of your Contract.
Required for ALL hospital admissions. Emergency care admissions must be certified within 48 hours. If you are hospitalized and pre-admission certification was not obtained, all charges will be denied.
Required for ALL hospital admissions. Emergency care admissions must be certified within 48 hours. If you are hospitalized and pre-admission certification was not obtained, all charges will be denied.
2. How do I get prior approval or a referral?
Instruct your physician to request prior authorization by calling (800) 722-6614.
3. What if I don't get prior approval or a referral?
You are always responsible for initiating prior authorization. Failure to obtain pre-admission certification may result in your being liable for all charges.
4. When do I need a referral from my PCP?
Except for the following situations, you must always receive a referral from your PCP.
| Women may go to a network OB/GYN doctor for pregnancy, gynecological problems or annual exams without a PCP referral. |
| You may see a network dermatologist for covered services without a PCP referral. |
| You may go to a network ophthalmologist for covered services without a PCP referral. |
| If you have vision coverage, you may go to a network optometrist for exams, glasses or contact lenses without a PCP referral. (Note: Check your Benefit Summary, member ID card or Certificate Booklet to determine if you have vision coverage.) |
1. What do I do in case of an emergency?
Call 911 or go to the nearest hospital emergency room. You, or someone else, should call your PCP the next business day to inform him/her of the visit and arrange follow-up care.
2. Do you cover emergency care?
Yes. If you or a covered family member has a medical emergency, you should call 911 or go to the nearest emergency room for immediate care.
A medical emergency is defined as "a condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that failure to obtain immediate medical care could result in their health being in serious jeopardy, serious impairment to bodily functions, or serious dysfunctions of any bodily organ."
Non-emergency use of the emergency room is not a covered benefit.
1. What do I do if I need care while traveling?
If you have an emergency while traveling, you should call 911 or go to the nearest hospital emergency room for treatment. If you become ill or need urgent care, follow these easy steps to receive care:
| Always carry your current member ID card for easy reference and access to service. |
| Call your PCP for prior authorization and/or pre-certification, if necessary. |
To locate a provider of nearby doctors, visit the BlueCard Doctor and Hospital Finder Web site (www.bcbs.com
) or call BlueCard Access at (800) 810-BLUE (2583). When you arrive at the participating doctor's office or hospital, simply present your member ID card.
2. What routine coverage do I have while I am traveling?
Specific benefits vary from plan to plan but rest assured that if you have an emergency or need urgent care, you are covered. If you have a specific question, please call customer service at (800) 718-8831.
3. What emergency coverage do I have while I am traveling?
If you have a medical emergency while away from home, you are covered. All you need to do is call 911 or go to the nearest hospital emergency room for treatment.
1. How do members use their prescription benefits?
The health plan’s pharmacy services and network is administered by Express Scripts, one of the nation’s largest pharmacy benefit managers. The combined experience and commitment to the member services of Anthem and Express Scripts will help promote better health and value for millions of members.
If members’ coverage includes a pharmacy benefit, their health benefit plan ID card is also their prescription drug card. Simply present the ID card and prescription at a participating retail pharmacy of choice. The pharmacist will use the prescription and member information to determine the co-payment or co-insurance. Most plans allow members to receive up to a 30-day supply of covered medications at a retail pharmacy. Depending on members’ benefit, they may also be able to order medications using the Express Scripts Home Delivery pharmacy (home delivery). Members should consult the terms of their policy and any related riders or Schedule of Benefits for full details about prescription drug benefits, if they apply.
2. How do members access their retail pharmacy network?
We offer access to a broad retail pharmacy network that includes thousands of pharmacies throughout the United States. That means members have convenient access to prescriptions wherever they are - at home, work or even on vacation. For a list of participating pharmacies, access the Express Scripts website in the "My Pharmacy" section. No additional login is required. Then, select "Find a Pharmacy" in the "My Prescription Plan" section.
Members will get the most from their benefits by using a participating pharmacy. Choosing a non-network pharmacy means they’ll pay the full cost of the prescription up front. Then they must submit a claim form to the health plan for reimbursement.
3. How do members order medications using home delivery?
If their coverage includes a pharmacy benefit and they take maintenance medications, members can typically get a 90-day supply of medication for the same price as two 30-day prescriptions filled at a retail pharmacy. Home delivery is a service for members who take maintenance medications such as for hormone replacement, asthma, diabetes, high blood pressure, arthritis, and any other conditions that require them to take a drug on an ongoing basis. It offers the convenience of having prescriptions filled using home delivery. Members can simply pick up the phone or submit their order online, and medications are delivered directly to their home, office or anywhere in the United States. To order refills of medications online if members have home delivery, log in to the Express Scripts website in the "My Pharmacy" section. No additional login is required. Then, select "Order Refills" in the "My Prescriptions" section.
4. What is a Drug List?
The health plan uses what is called a "Preferred Formulary" that we also refer to as the "drug list." This drug list contains brand-name and generic medications approved by the
Food & Drug Administration (FDA) that have been reviewed and recommended by our Pharmacy and Therapeutics (P&T) Committee. Our P&T Committee is an independent group of practicing doctors, pharmacists, and other health care professionals responsible for the research and decisions surrounding our drug list. This group meets regularly to review new and existing drugs and chooses the medications for our drug list - based on various factors, including their safety, effectiveness and value.
If physicians prescribe a drug that is not listed on the drug list, members may be subject to extra out-of-pocket cost. Because the medications on the drug list are subject to periodic review, members should call the Customer Service number on the back of their ID card to determine which medications are included. To obtain a copy, members can also get this information online by logging in to their health plan’s website.
5. How much will members pay for prescriptions?
In most cases when members use a participating pharmacy, they will be required to pay a fixed co-payment. (Depending on their policy, coinsurance may apply). In general, members will pay the least amount for generic medications and the highest amount for non-preferred medications not on the drug list. However, there may be exceptions based on our drug list tiers. Having their physicians prescribe generic drugs or drugs listed on their plan’s drug list can help reduce members’ total prescription out-of-pocket costs.
6. What is a tiered drug list?
A tiered drug list assigns medications to specific levels, such as Tier 1, 2 or 3, based on various factors. Generic medications have the most affordable copay; brand-name medications, both preferred and non-preferred, usually cost more. Each of these medications is placed on tiers based on certain factors. These include, but are not limited to, the absolute cost of the drug, the cost of the drug relative to other drugs in the same therapeutic class, the availability of over-the-counter alternatives, and other clinical and cost-effectiveness factors.
7. What if members’ medications are not on the drug list?
If a drug prescribed for members is not on their drug list, we offer an "open drug list" that allows members and their physicians to choose a prescription medication that is not on the drug list, as long as it is approved by the FDA. But it’s important to note that choosing medications that are not on our drug list will increase members’ out-of-pocket costs. Members should talk with their doctor about prescribing a medication that is on the drug list when appropriate. If a medication is selected that is not on the drug list, members will be responsible for the applicable non-drug list cost share amount.
Members or their physicians may submit a request to add a drug to the drug list either in writing or on our web site. Requests are taken into consideration by the P&T Committee during the drug list review process.
Inclusion of a medication on the drug list is not a guarantee of coverage. Some drugs, such as those used for cosmetic purposes, may be excluded from benefits. Please refer to your Certificate or Evidence of Coverage for coverage limitations and exclusions.
8. What is a prior authorization and step therapy?
Certain prescription drugs (or the prescribed quantity of a drug) may require "prior authorization" before members can fill prescriptions. Some drugs require prior authorization because they may not be appropriate for every patient or may cause side effects. The physician should have a current list of drugs requiring prior authorization. However, the physician may call our referral number for authorization and information regarding these requirements. Prior authorization helps promote appropriate utilization and enforcement guidelines for prescription drug benefit coverage.
In addition, "step therapy" involves medication that is prescribed only after members try a "first-line" drug. With step therapy, our P&T Committee recommends certain drugs as the first ones to try when starting or changing medication treatment. In instances in which one of these medications isn’t effective and/or appropriate for a particular member, the step therapy requirements allow the physician to then prescribe a different medication.
The drug rider to the policy contains additional detail regarding prior authorization and step therapy, and lists the drugs that are subject to these requirements. For additional information, members should call the telephone number listed on the back of their ID cards.
At the time members fill prescriptions, the pharmacist is informed of the prior authorization or step therapy requirement through the pharmacy's computer system and is instructed to contact the health plan. The health plan will review the request and communicate the approval criteria to the requestor. If additional information is needed, the pharmacist may contact the prescribing physician.
Physicians may also request exceptions to the prior authorization/step therapy requirements, such as in instances in which members have allergic or adverse reactions to medication, or another documented reason that prevents them from following the prior authorization and/or step therapy requirements.
9. What do members need to do if their prescriptions require a prior authorization or step therapy?
The physician should have a current list of drugs requiring prior authorization or step therapy. The drug rider to the policy that explains the drug benefit also lists these drugs. When members fill their prescriptions at a retail pharmacy, the pharmacist will be notified that the medication requires prior authorization and will take the necessary steps to request it. If members use home delivery, the physician must obtain prior authorization or follow the step therapy requirements before members can fill prescriptions.
10. What is dose optimization?
When clinically appropriate, dose optimization typically involves changing from twice-daily dosing to a once-daily dosing schedule. For example, a 10mg dose taken twice per day would be changed to a 20mg dose taken only once per day.
For a few specific drugs, it is common practice for doctors to initially prescribe a lower strength of medication and then gradually move to higher strengths over a period of time. In these cases, the goal of dose optimization is to help ensure that as higher dosages are prescribed, the member takes a single dose at the higher strength.
If a member submits a prescription that exceeds the dosing limits set by the dose optimization program, the pharmacy’s computer will receive an electronic message that the prescription claim is being rejected due to Drug Utilization Review (DUR). The pharmacist may contact the doctor to determine if a different dose consistent with dose optimization guidelines is appropriate. If so, the drug is prescribed and filled at the new dosage. Or if there are medical reasons for the drug dosing schedule as originally prescribed, the doctor can request prior authorization review.
11. What are medication quantity limits?
Taking too much medication or using it too often isn’t safe and may even drive up members’ health care costs. Quantity limits regulate the amount of medication covered by the plan for a certain length of time. Most plans cover a 30-day retail pharmacy supply or up to a 90-day supply using home delivery. Quantity limits follow U.S. Food and Drug Administration (FDA) guidelines, as well as manufacturer recommendations.
If members refill prescriptions too soon or their doctors prescribe an amount higher than recommended guidelines, our pharmacy system will reject the claim. When this happens, the pharmacist receives an electronic "Invalid/Excessive Quantity" message. If the physician believes the situation requires an exception, he or she may request prior authorization review. To avoid disrupting treatment, members will be covered for the approved amount while review takes place.
12. When I submit a prescription, and my pharmacist receives an age or gender edit, what does that mean?
Certain drugs approved by the FDA or other prescribing guidelines include provisions that they are not appropriate for use based on a person’s age or sex.
If members submit prescriptions that are impacted by these requirements, the pharmacy computer will receive an electronic message of "Indication Not FDA Approved" (gender edit) or "Non-Covered Prescription Item" (age edit). This lets the pharmacist know that the prescription drug plan will not cover the medication as prescribed. However, the prescribing physician may determine that important medical reasons exist for prescribing this medication as written. If this is the case, the physician may request prior authorization review.
13. What is the difference between generics and brands and how does it affect members’ benefits?
| Brand-name Drug: A brand-name drug is usually available from only one manufacturer and may have patent protection.|
| Generic Drug: A generic drug is required by law to have the same active ingredients as its brand-name counterpart but is normally only available after the patent expires on a brand-name drug. Members can typically save money by using generic medications. |
Members should check their Schedule of Benefits to see how the use of generic versus brand-name drugs may affect their benefits and out-of-pocket costs. They may save money by using generic medications.
14. Are generic medications as safe and effective as brand-name drugs?
Yes. Generic medications are regulated by the FDA. In order to pass FDA review and be A-rated, the generic drug is required to be therapeutically equivalent to its counterpart brand-name medication in that it must have the same active ingredients, and the same dosage and strength.
15. Why are generic medications less expensive?
Normally, a generic drug can be introduced to the market only after the patent has expired on its brand-name counterpart and can be offered by more than one manufacturer. Generic drug manufacturers generally price their products below the cost of the brand-name versions.
16. Why are generic drugs important?
Depending on members’ benefit design, they can help control the amount they pay for prescriptions by requesting that their physicians prescribe generic medications whenever appropriate.
17. How can members request a generic medication?
The physician and pharmacist are the best sources of information about generic medications. Members can simply ask one of them if their prescriptions can be filled with an equivalent generic medication. Members may be subject to higher cost sharing for brand drugs.
18. Can members request a brand-name drug?
Depending on the terms of their drug coverage, members may request that their physicians prescribe the brand-name drug even when a generic version is available. However, if a generic is available, members may have to pay the difference in cost between the generic and brand-name drug plus the generic co-payment.
19. Can members have their prescriptions switched to a drug with a lower co-payment?
If their current prescription medication is not a generic, members can call their physicians and ask if it's appropriate for them to switch to a lower cost generic drug. The decision is up to members and their doctors.
Members can also select the "Save on My Prescriptions" link on Express Scripts’ website where they manage their current prescriptions. They’ll get information to discuss with their physicians and the tools to get started. To access Express Scripts’ website, members should visit the "My Pharmacy" section of their health plan website. No further login is required. On the Express Scripts site, they should select "Save on my Prescriptions" in the "My Prescriptions" section.
20. Can members get reimbursed for drugs they got from a pharmacy that is not in the network?
If their benefits include out-of-network coverage, members can get reimbursed for prescriptions filled at a non-network pharmacy, but it may cost them more. Members should take a claim form with them to the out-of-network pharmacy, complete it and mail the completed form to the address listed on the form. They can download a claim form by accessing the Express Scripts website in the "My Pharmacy" section. No additional login is required. Then, they should select the Claim Reimbursement Form" in the "Printable Forms" section. Members can also call the phone number on the back of their health plan ID cards.
21. If members are going to be out of town for an extended time, how do they get an extra supply of drugs to cover them through that period?
If members are going to be out of town for an extended period and need medication, they should call the customer service number on the back of their health plan ID cards to find a nearby participating national pharmacy. If they are planning to go out of the country, they can go to their local network pharmacy prior to the trip. Members should pay for the extra supply and send us a claim form. If they need to purchase drugs while out of the country, they should pay for the drug and send us a letter indicating the prescription, along with a receipt and a claim form.
If their coverage includes home delivery service, members can typically obtain up to a 90-day supply of their prescription maintenance drugs with their doctor’s prescription.
22. Why did members only receive part of their order through home delivery?
Members may receive a partial order if a medication within their order cannot be filled right away while the other prescription is shipped separately to help avoid delay. The Prescription History page on Express Scripts’ website where they manage, and order and fill prescriptions enables them to see when orders are partially shipped or if we need more information.
1. How do I file a claim?
If you visit a network provider, they will file the claim for you. In the HMO plan, there are no covered benefits if you visit a non-network provider.
Under the POS plan, if you visit an out-of-network provider, you may need to pay for the services in full at the time they are rendered. You will then need to file a claim with Blue Cross Blue Shield of Georgia for reimbursement. Visit our Forms
section to download and print a claim form. If services were performed in Georgia, mail claims to:
P.O. BOX 9907
Columbus, GA 31908-6007
or fax to (877) 868-7950
If services were performed outside of Georgia, please mail to the appropriate Blue Cross and/or Blue Shield plan. The plan listing is available at www.bcbs.com
. Mailing to BCBSGa will delay processing.
2. How long do I have to file a claim?
Claim forms submitted by the member or a provider must be received by us within 90 days of the date the expense is incurred in order to be eligible for benefits. If it is not reasonably possible to submit the claim within that time frame, an extension of up to twelve months will be allowed. We are not liable for the benefits of the plan if claims are not filed within this period.
3. A provider has billed me; how do I know how much of the bill to pay?
Under the HMO plan, your provider will bill us directly. If you should receive a bill, please call customer service at the number listed on your member ID card and we will answer your questions and ask you to forward the bill to us.
If you are a POS plan member and you accessed services from an out-of-network provider, you are responsible for the charges incurred minus your co-insurance. Please call customer service at the number listed on your member ID card for assistance.
4. How can I check the status of my claim?
Visit the Member Access page of this Web site. To safeguard your personal information, you must have a username and password to use Member Access
. If you do not already have one, you can request one be sent to you. You can also call customer service at the number listed on your member ID card to check on the status of your claim.
5. What are copayments?
A copayment is a cost-sharing arrangement in which a member pays a specified charge for a covered service, such as $20 for an office visit. The member is usually responsible for payment of the copayment at the time the health care is rendered. Typical copayments are fixed or variable flat amounts for physician office visits, prescription drugs or hospital services. Copayments are distinguished from coinsurance as flat dollar amounts rather than percentages of the charges for services rendered.
6. What is a deductible?
A deductible is the portion you must pay each calendar year before we will begin to provide benefit payment.
7. What is Coordination of Benefits (COB)?
Coordination of Benefits (COB) is the anti-duplication provision to limit benefits for multiple group health insurance in a particular case to 100% of the covered charges and to designate the order in which the multiple carriers are to pay benefits. Under a COB provision, one Plan is determined to be primary and its benefits are applied to the claim. The unpaid balance is usually paid by the secondary Plan to the limit of its liability. Benefits may be coordinated between two contracts at the same Blue Plan, different Blue Plans or between a Blue Plan and a commercial carrier.
8. Why did I receive a Coordination of Benefit questionnaire and do I have to return it?
The Coordination of Benefit Questionnaire is used to determine if you are covered by more than one group health insurance carrier. Please fill it out and return to us so that we may process your claims correctly.
9. What do I do with a foreign medical bill for care I received outside of the U.S.?
When receiving services in a foreign country, the member should ask for the claim to be written in English and:
| Submit the itemized bill with the policyholder's ID number clearly displayed. A claim form may also be submitted with the itemized bill if it is available, but it is not required. |
| Use a separate form for each enrolled family member and each provider of service. |
| Submit the form to the customer service address printed on your member ID card. |
| BCBSGa is not able to pay benefits in the local currency of the claims submission site. The claims amounts are converted into dollars using the Wall Street Journal exchange rate on the day services were rendered. |
1. What is the procedure for lodging a grievance against a provider or against the Plan?
Fax the details of your grievance to (877) 868-7950 or call the customer care number on your member ID card. Your inquiry should be resolved within 21 calendar days.
2. How do I express dissatisfaction regarding a denial of services?
As a member, you have a right to express dissatisfaction and to expect fair resolution of your issues. BCBSGa established the inquiry, formal complaint, and appeal process to be used any time you are displeased with any aspect of services rendered:
| Inquiry: You may call customer care at the phone number listed on your member ID card. Describe your concern and we will make every effort to respond within 21 calendar days.|
| Formal complaint: If you are not satisfied with our response, you may file a formal complaint, preferably, in writing. Fax the details of your request, along with supporting documentation, to (877) 868-7950 or you may call customer care number on your member ID card.|
| Appeal: If you choose to appeal, your written request with comments, documents, records, or other relevant information should be faxed to (877) 868-7950. The request may also be mailed to BCBSGa, PO Box 9907, Columbus GA 31908.|
| At the conclusion of this appeal review, a written response addressing your specific concerns will be provided within 30 calendar days of receiving your request. |
3. What if waiting for you to decide on my appeal would harm my health?
If your condition is of emergent or urgent nature, you, along with your physician will decide on the most appropriate treatment plan.
4. My Explanation of Benefits (EOB) says I received services that I did not have. What should I do?
Call the customer service number located on your member ID card. Our associates will review your EOB and fix any errors that may have occurred.
1. What happens to my coverage if I move out of the area?
Please call customer service and request that your information is updated with your new address. You may also need to change your PCP if his/her location is no longer convenient to your home or office.
2. What happens to my coverage if I turn 65?
If you are age 65 or over and eligible for Medicare, you will get the benefits of this plan without taking into account Medicare unless you've chosen Medicare as your primary plan. If you've chosen Medicare as your primary health plan, you won't be able to get any benefits under this plan.
3. What if my spouse and I divorce?
The dependent spouse may transfer to his/her own Individual plan. Please contact customer service at (800) 718-8831 to receive instructions.
4. Is my child covered while in college?
He/she is covered as long as:
| he/she is an unmarried child of the subscriber or the enrolled spouse and |
| is under 25 years of age, and |
| qualifies as a dependent for federal income tax purposes. |
5. Do I have coverage for pre-existing conditions?
BlueChoice PPO and FlexPlus Members:
Coverage is not available until you've been enrolled in the plan for 12 months.
Coverage is not available until you've been enrolled in the plan for 24 months.
6. How do I know what benefits are non-covered?
The following items represent a generic list of non-covered items. For a complete list, please refer to your Certificate Booklet.
| Acupuncture- Although not covered, BCBSGa does offer discounted health and wellness services. Click here for more information. |
| Blood pressure monitors |
| Smoking cessation and add weight loss programs. Although not covered, BCBSGa does offer several wellness programs to assist with your goals. Click here for more information. |
| Eye refraction |
| Air filters |
| Central or unit air conditioners, Hepa-Filters, Humidifiers, Dehumidifiers or purifiers |
| Hydro-Air Vacuum |
| Radial Keratotomy |
| Heating pads, hot water bottles, band aids, tape, thermometers, sterile water, bed boards, non-sterile gloves |
| Pools, spas, whirlpools and or saunas |
| Special toilet seats |
| Routine physical exams, screenings, procedures and immunizations necessitated by employment, foreign travel, participation in school athletic programs, recreational camps or retreats |
| Services rendered by public health department, nurse midwife, social worker and or professional counselors |
| Physical fitness, exercise, massage, ultraviolet and or tanning equipment |
| Hypo-allergenic pillows, mattresses and or waterbeds |
| Escalators, elevators, ramps, stair glides, emergency alert equipment, motor-driven chairs or beds, and or handrails |
Note, even if these services are deemed as medically necessary, if it is excluded from your contract, your benefits do not provide coverage of these items.
Please review your Certificate Booklet or contact your Employer Representative with questions.
Note: if you would like to obtain a written copy of any information provided on this Website, please call (800) 441-CARE from 7:30 AM to 7 PM and a customer care associate will be happy to assist you.
If you need to submit a claim, provide medical records, request customer assistance, simply use our toll-free fax: (877) 868-7950.