Individual Plan
PW_AD048773
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 websupport@bcbsga.com. 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 the most commonly prescribed formulary 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 formulary. The phone number for customer service is listed on your member ID card.
Enrollment
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 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 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 websupport@bcbsga.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 Healthcare Plan 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?
| PPO Members: |
| | 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. |
| FlexPlus Members: |
| | 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. |
| Hospital/Surgical Members: |
| | 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. What is the difference between generic and brand name drugs and how does that difference affect my benefits?
Brand name drugs are those drugs that are marketed under a specific trade name by a pharmaceutical manufacturer. In most cases, these drugs are still under patent protection, meaning the manufacturer is the sole source for the product. Generic drugs are safe, effective and equivalent to brand name medications that may cost considerably less than the brand name medications. Generic drugs must meet the same high standards of quality as brand name drugs and are formulated to have the same effect in the body as the brand name version. Generic drugs often become available when a brand name drug's patent expires.
The difference in your benefits is the amount of your copay. Generally, the cost of your copay for generic drugs is less than that of brand name drugs.
2. Can I get reimbursed for drugs I got from a pharmacy not in the network?
It will cost you more if you go to an out-of-network pharmacy. Take a claim form with you to the out-of-network pharmacy. If you need a claim form, you can download one from our Forms section of this Web site. Once completed, send the claim form to BCBSGa, P.O. Box 9907, Columbus, GA 31908-6007. 3. If I am going to be out of town for an extended time, how do I get an extra supply of drugs to cover me through that period?
If you are out of state and you need medicine, call the customer service number on your member ID card to find a nearby participating national pharmacy. If there is not a national pharmacy, pay for the prescription and send us a claim form. If you are planning to go out of the country, go to your local network pharmacy prior to your trip. Pay for the extra supply and send us a claim form. If you should need to purchase drugs while out of the country, pay for drug, and send us a copy of the letter indicating your prescription, receipt and a claim form.
4. What is a drug formulary (or preferred drug list) and how does that affect me?
A prescription drug formulary is used to help your doctor make prescribing decisions. This list of drugs is updated quarterly by a committee of doctors and pharmacists so that the list includes drugs that are safe and effective in the treatment of disease. The goal of the formulary list of prescription drugs, as established for the Pharmacy Program, is to identify and promote prescription drugs which are therapeutically appropriate and cost-effective.
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 Healthcare Plan of Georgia for reimbursement. Visit our Forms section to download and print a claim form. If services were performed in Georgia, mail claims to: | BCBSGA
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 time 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. |
| BCBSHP 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 is 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. |
| Hospital/Surgical Members: |
| | 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.
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