Transparency in Coverage

The provider network that is available to you under the terms of your plan is made up of independently contracted doctors, hospitals and other health care providers. The contracted providers in your network do not work for or are part of BCBSTX. However, they do have agreements with us, BCBSTX, that may help save you money for covered services.

Your costs will vary depending on whether your provider is participating in the network. Please refer to Provider Finder^® to find in-network providers. You should check if your plan has out-of-network benefit coverage before scheduling a visit.

Your Network and Your Plan Type

The way you use the provider network available under your health plan may vary by your plan type. The following is a brief description of how each plan type works.

Health Maintenance Organization (HMO)

If you have an HMO, you must work with a contracted (in-network) primary care physician (PCP) to help coordinate any care you receive within your provider network. When you first sign up for an HMO, you choose, or are assigned, a PCP.

Your PCP is your partner to help guide you with your health care needs. When using your HMO plan, keep in mind the following:

• You must work with your PCP whenever you need care. When you first choose or are assigned a PCP, schedule a visit as soon as possible. Going right away will help avoid delays later when you are sick or need a referral.
• You will need a referral to see a specialist. If you need to see a specialist, you must obtain a referral from your PCP. Your PCP will usually refer you to a specialist that is in your network, but you should always check to make sure. Women don't need a referral to see an in-network OB-GYN, which is an obstetrician/gynecologist or a family practice doctor.
• You must see in-network providers. For non-emergency care, HMO members must stay in network to receive benefits, except in limited circumstances as stated in your policy. Otherwise, you will be responsible for paying the entire cost of an out-of-network provider visit. To ensure you stay in network, consult with your PCP. If you want to select a new PCP, search Provider Finder before visiting a new doctor or health care facility to make sure that the PCP is in your network.

Point of Service (POS)

If you have a POS plan, you have an HMO plan that also includes certain out-of-network benefits. When using your POS plan, keep the following in mind:

• You must work with a PCP. POS members needs to work with a primary care physician (PCP) who will help coordinate your care. Your PCP should be your first stop when you need medical care.
• You don’t need a referral to see a specialist. Even though you do not need referrals, your PCP can still help you make decisions about your treatment and recommend if a specialist is right for you. If your doctor does refer you to a specialist, you will still want to verify that the provider is in your network.
• You can receive out-of-network care. Because POS members also have out-of-network benefits, you can visit a doctor or health care facility outside your provider network with a POS plan. However, you will usually pay more for your services out-of-pocket if you do not stay in network.

To make sure a provider is in your plan's network, search Provider Finder before visiting a new doctor or health care facility.

Sometimes, to receive benefits for certain services or prescription drugs, you or your provider must call BCBSTX before you receive treatment. This is known as prior benefit authorization. It is also sometimes called pre-certification or preapproval. Note that this is different than getting a referral to see a specialist. Sometimes, you may need to get a referral to see a specialist and prior benefit authorization to receive benefits for a service from that specialist. You can work with your doctor on determining when you need each.

When you or your provider contact BCBSTX with a prior benefit authorization request, we will ask for the following:

• Information about your medical condition
• The proposed treatment plan
• The estimated length of stay (if you are being admitted)

During the prior benefit authorization process, BCBSTX reviews the requested service or medication to see if the service or medication is medically necessary.

"Medically Necessary" is defined in your benefit booklet and generally refers to health care services or supplies that:

1. are essential to the diagnosis, prevention or direct treatment of a condition or injury;
2. follow generally accepted standards of medical practice, based on credible scientific evidence;
3. are not primarily for the convenience of you or your doctor; and
4. are the most economical services or supplies that are appropriate for your safe and effective treatment.

The service or treatment must meet your plan's definition of medical necessity in order to be eligible for benefits under your plan. The prior benefit authorization process is not a substitute for the medical advice of your health care provider. The final decision to receive any medical service or treatment is between you and your health care provider.

For more information on medical necessity, see your benefit booklet.

If you are unsure which health care services or medications need prior benefit authorization, you can call the Customer Service number on the back of your BCBSTX member ID card.

Remember, even if a service or medication is authorized, if the provider is out of network you will likely pay more out of pocket. Check Provider Finder to ensure the provider is in your plan’s network. Also, a determination that a service is authorized or medically necessary is not a guarantee of coverage. The applicable terms of your plan will control the benefits that you will receive.

For HMO members: Contact your primary care physician (PCP) to coordinate your care. If you are seeking care from a specialist, ask your PCP to ensure that you have received any needed prior benefit authorization.

For all members: If your or your doctor’s request for prior benefit authorization is denied, you have the right to appeal the decision. However, you may be responsible for the cost of that service or drug. You can learn more about the appeals process in the Why Was Payment for the Service I Received Denied? section. You can also refer to your benefits documents or call the Customer Service number on the back of your BCBSTX member ID card.

The time it usually takes BCBSTX to respond to your prior benefit authorization request depends on a number of factors, including when we receive your information, the type of service or medication being requested, if additional information is needed and certain regulatory requirements.

For HMO members: Your primary care physician (PCP) helps coordinate your in-network care. If you are seeking care from a specialist, ask your PCP to ensure that you have received any needed prior benefit authorization.

For POS members: If you visit an out-of-network provider, you will be responsible for obtaining prior benefit authorization for your medical services.

The following table generally shows how soon after BCBSTX receives a prior benefit authorization request that you (or your doctor) can expect to get a response. Additional guidelines may apply to these timelines and the time periods may be affected if additional information is needed or if additional information is submitted after the initial request.

NOTE: This table is not intended as medical advice or a substitute for medical advice. The final decision about any care or treatment you receive is between you and your health care provider. Check your plan details for more information.

* Urgent care is treatment that, when delayed, could seriously jeopardize your life and health or your ability to regain maximum function.

If you and your doctor are requesting authorization after you have already received services, BCBSTX will notify you or your doctor with a coverage decision within 30–45 days.

In addition to the above, the following applies to all required prior benefit authorizations:

• prior benefit authorization does not guarantee payment by your plan. Even if a service or medication has been authorized, coverage or payment can still be affected for a variety of reasons. For example, you may have become ineligible or have different coverage as of the date of service.
• We may request additional information. BCBSTX may require more information from your doctor or pharmacist during the prior benefit authorization process. This could include a written explanation of the requested services, reasons for treatment, projected outcome, cost statements or other documents that could be helpful to decide on the medical necessity of the treatment.
• You are responsible for making sure your prior benefit authorization requirements are met. All health insurance and HMO health plans require prior benefit authorization for certain services. When you stay in network, your provider may take care of this step for you, but you should always ask your doctor to make sure. If you decide to see an out-of-network provider, you are responsible for this step as well as additional amounts the out-of-network provider may charge you. For more information, please refer to your benefit booklet.
  
  If you don’t get prior benefit authorization for a service that requires it, you may be responsible for a charge in addition to any other applicable deductibles, copayments or coinsurance. In addition, we may review the service to determine if it is medically necessary as defined in your benefit booklet. If we determine that the treatment(s) does not meet the definition of medically necessary, you may be responsible for paying for the services you received.

Whether you take medication to manage an ongoing health condition or you need a prescription for an illness, you will want to become familiar with your health care plan's drug list. This is a list of covered drugs that are available to BCBSTX members.

Both brand and generic medications are included on the drug list. The drug list has different levels of coverage, which are called "tiers." Generally, if you choose a drug that is a lower tier, your out-of-pocket costs for a prescription drug will be less.

The drug list is not a substitute for the independent medical judgment of your health care provider. The final decision on what prescription drug is appropriate for you is between your health care provider and you.

You can view your drug list here. Be sure to choose the section that describes your plan.

When You Can Request a Coverage Exception

If your medication is not on (or has been removed) from your drug list, you or your prescribing doctor may want to request a coverage exception.

To request this exception, your prescribing doctor will need to send us documentation. To begin this process, you or your doctor should call the Customer Service number on the back of your ID card for more information.

You can also fill out and submit the Prescription Drug Coverage Exception form . You will need to provide us with your doctor’s name and contact information as well as the name and, if known, the strength and quantity of the drug being requested.

BCBSTX will usually let you or your doctor know of the benefit coverage decision within the lesser of two business days or 72 hours of receiving your request. If the coverage request is denied, BCBSTX will let you know why it was denied and may advise you of a covered alternative drug (if applicable). You can also appeal the benefit determination (see below for more information).

You or your doctor may be able to ask for an expedited review if:

• You take medication for a health condition and failure to get that medication may either pose a risk to your life or health or could keep you from regaining maximum function
• Your current drug therapy uses a non-covered drug
  
  
  If your review is expedited, BCBSTX will usually let you or your doctor know of the coverage decision within 24 hours of receiving your request. If the coverage request is denied, BCBSTX will let you know why it was denied and may advise you of a covered alternative drug (if applicable). You can also appeal the benefit determination.

How to Request a Reconsideration of a Drug Coverage Exception Determination

If your coverage request is denied, you may request a reconsideration through BCBSTX verbally by calling the telephone number on the back of your ID card or by written request to:

Blue Cross Blue Shield of Texas
P.O. Box 660044
Dallas TX 75266-0044

If your request is Urgent or Expedited, an external review with an Independent Review Organization (IRO) may be requested. If your case qualifies for external review, an IRO will review your case, at no cost to you, and make a final decision.

If your standard coverage exception reconsideration is denied, you may be able to request an independent, external review by an Independent Review Organization (IRO). To request an independent review, send your completed form to BCBSTX.

For questions about your rights, you may visit the Texas Department of Insurance website or contact:

Texas Department of Insurance Consumer Protection
Mail Code 111-1A, 333 Guadalupe
PO Box 149091
Austin, Texas 78714

Phone: 1-855-839-2427
Email: ConsumerProtection@tdi.texas.gov

If you have a Multi-State Plan, you may ask for an external review with the U.S. Office of Personnel Management (OPM).

If your case qualifies for external review, OPM will review your case (including any data you’d like to add), at no cost to you, and make a final decision. To ask for an external review, you must first complete an External Review Intake Form . You have 1 year from the date you received the decision notice to file your external review request. See the OPM section in this notice for contact information.

You may file a request for External Review online or by mail. To file a request:

1. Download and complete the External Review Intake Form
2. Submit the forms to OPM by email at mspp@opm.gov, by fax at 1-202-606-0033, or mail them to:
   

   MSPP External Review
   National Healthcare Operations
   U.S. Office of Personnel Management
   1900 E Street, NW
   Washington, DC 20415

You may call OPM toll free at 1-855-318-0714 if you need help with your request for External Review.

If you have any questions about requesting a coverage exception, call the Customer Service number on the back of your member ID card.

Before you seek care, it is always best to confirm that your provider is in network in order to receive the highest level of your benefits. However, there are some times when care you receive from an out-of-network provider may be covered, such as:

• Emergency care. If you experience a medical emergency and visit an out-of-network emergency room, you do not need approval from your plan first. Afterwards, your claim may be reviewed to ensure it meets the criteria for an emergency medical condition. Once approved, your services will be paid in accordance with the terms of your plan.
• Medically necessary services that are unavailable inside your network. If you need services or treatments not covered by the independently contracted doctors or facilities in your plan’s network, you can seek approval to go out of network for these services. To learn more, see When Do I Need Benefit Approval for Medical Services? above.
• Certain services for POS plan members. POS plans may cover medical services provided by out-of-network doctors and hospitals, but you will likely pay for a greater portion of the cost. To learn more about these plan types, see the What Is a Provider Network? section.

In the above situations, you may still be responsible for the cost of your care over the allowed amount. The allowed amount is the maximum amount your plan will reimburse a doctor or hospital for a given service. Providers who are part of your network have agreed to accept the allowed amount as full payment for covered services and will only bill you for any copays, coinsurance or deductibles under your health benefit plan.

However, when you see an out-of-network provider, if he or she charges more than this allowed amount, you may have to pay the difference up to the provider's full charge. This is known as balance billing. (You will not be balance billed when you see a network provider.)

For example, if an out-of-network hospital charges $15,000 for an overnight stay and the allowed amount is $1000, you may have to pay $14,000. This is in addition to your copay, coinsurance, deductible or other amounts you may have already paid. To avoid these charges, use Provider Finder to make sure that the provider is in network.

All covered services are subject to contract benefits, limitations and exclusions. For more information regarding your benefits, please refer to your benefit booklet.

To help you better understand your health care coverage, we are providing Summary of Benefits and Coverage (SBC) documents for each of our plans. These SBCs describe key features such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions.

Information in these SBCs represents an overview of coverage. It is not a complete list of what is covered or excluded. Information is subject to change. The full terms of coverage are in the insurance policy. The full terms of the policy will govern your benefits, so it is important that you read and understand them.

When you visit a doctor or other health care provider, your provider will usually submit a claim to us on your behalf. However, if the provider fails to do so, you can submit the claim yourself. You are more likely to have to file your own claim if you get care from an out-of-network provider.

How to File a Claim

If you need to file a claim, you can download and print a medical health insurance claim form . You can also find this form through our Form Finder. You will find instructions on the form to help guide you.

Once you have filled out this form, mail it to the following address:

Blue Cross and Blue Shield of Texas
P.O. Box 660044
Dallas, TX 75266-0044

If you have any questions, you can also contact us at 1-888-697-0683.

You can submit a claim up to 12 months from the date of service.

When submitting a claim, it's important to include a copy of the original bill issued by your health care provider. Be sure to make copies for your records as documents sent in with your claim cannot be returned to you. Basic information to have handy when preparing a claim form includes:

• Date of service;
• Type of service;
• Dollar amounts charged by doctor or other health care provider for each service;
• Patient name;
• Member name; and
• Member identification number (found on ID card)

Follow these steps to avoid any delays in processing your claim:

• File your claim right away after receiving medical care. Waiting to file a claim may result in a denial of medical benefits.
• Give as much detail as you can. Including the original bill from your doctor or other health care provider helps. Be sure to make a copy for your records as any documents attached to your claim cannot be returned to you.
• If BCBSTX asks you for more information, please get back to us quickly.
• If signatures are needed, be sure to get the proper signatures before sending in your claim.

Check the Status of a Claim

You can check the status of a claim in one of the following ways:

• Visit the Claims Center in Blue Access for Members.
• Call the Customer Service number on the back of your ID card.

If your claim has been denied, you can file an appeal to have it reviewed again. The appeals information is located with your Explanation of Benefits (EOB) and your insurance policy. For more information about EOBs, see below.

An Explanation of Benefits (EOB) is a document that is usually sent to you when a medical benefits claim is processed by your health care plan. It explains the actions taken on the claim and provides information to help understand the following:

• The fees billed by your doctor or other health care provider;
• The date of service which applies to the EOB;
• The services and procedures that were covered;
• The amount that your plan will pay;
• The amount that you may still owe (if you haven't already paid); and
• Any reasons for denying payment along with the claims appeal process.

Your EOB Details

Your BCBSTX EOB is normally divided into 3 major sections:

1. Total of Claim(s) features the main financial information about your claims. It includes the total amount billed, benefits approved and what you may owe to the provider. Sometimes one EOB may contain more than one claim.
2. Service Detail for each claim describes each service you or your dependent received, the facility or doctor, the dates and the charges. It shows the savings your BCBSTX benefits plan provides for you from discounts and other reductions. And, you can see any costs that may not be covered.
3. Summary gives you a clear picture for each claim of your deductible, coinsurance, copays, and health spending accounts, if these apply to you.

The EOB statement is an important record of claims for medical services and benefit coverage. Remember to keep your EOBs for future reference, in case questions come up later about your claim or your bill. Keep your EOBs in a safe place with your other important personal documents, such as your medical records.

Understanding Your Explanation of Benefits  .

Finally, your EOBs are available both as a paper copy and online. To sign up for paperless EOBs, you may do so at any time in your Blue Access for Members account.

Typically, when you receive medical services, your provider will bill your health plan (BCBSTX) before sending a bill to you. BCBSTX then reviews the services you received and determines which services are covered by your plan. Occasionally, claims may be denied after you've received services. If the claim has already been paid, we may seek a refund from the providers and you may be responsible for the cost. This is also known as a retroactive denial and can happen for a variety of reasons, including:

• BCBSTX conducts a medical necessity review and determines that your services did not meet the definition set forth in your benefit plan. For more information, see the When Do I Need Benefit Approval for a Medical Service? section.
• You are no longer covered by your plan or eligible for benefits, or you were not covered at the time that you received medical services.
• You visited an out-of-network provider for non-emergency services and are covered by a plan that does not have out-of-network benefits.
• Another insurer or source should have been billed for your services before or in place of BCBSTX.

Note: This is not a complete list. For more information, please see your benefits booklet.

The following steps may help you to avoid having your claim denied:

• Review your plan's benefit booklet before you seek medical services.
• Verify your benefits by calling Customer Service at the phone number on the back of your ID card.
• Talk to your provider about BCBSTX's medical policy. You and your provider can access our medical policies online. These policies offer information about medical services that may have limitations based on published clinical research.

In addition to the above, your claims may be denied if you lose coverage after failing to pay your premium. For more information, see the What Happens if I Miss a Premium Payment? section.

If a claim is denied, you may be responsible for the cost of the services received. However, you also have the right to submit an appeal. An appeal is a way to have that decision reviewed. These steps will help get you started:

• Fill out the Appeal Request Form.
• Mail it to BCBSTX at the address provided on the form.

Refer to your benefit plan materials or call the Customer Service number on the back of your ID card with questions about the appeal process and plan benefits available to you.

In the case of one of the following events, you can recover premium payments you have already made to BCBSTX, also known as recoupment of overpayments.

• Through your right to examine the policy. You have 10 days after your policy is issued to review it. If, for any reason, you are not satisfied with your health care benefits, you may return your policy and your member ID card(s) to BCBSTX. This will void your coverage. BCBSTX will refund any premium you have paid, as long as you haven't had a claim paid under this policy before the end of the 10 days.
• If the policyholder passes away. BCBSTX will refund any premiums paid in advance, following the death of a plan's primary policyholder. You can request that the refund is issued to a different payee, including the deceased's estate.
• If you overpaid for your active policy. BCBSTX will refund additional premium payments up until the end of the current month. For example, if you paid your premium in advance for the month of June, you can receive a refund up until the last day in May.
• If you ask to cancel your policy. After you cancel your policy, BCBSTX will automatically refund any payments you have made for billing periods after your termination date. You do not need to request this refund.
• If you do not pay your premium and your policy is terminated. After your policy is terminated, BCBSTX will automatically refund any payments you have made for billing periods after your termination date. This would apply if you do not pay your premium on time and do not pay your outstanding notices by the end of grace period. (For more information on grace periods, please see the What Happens if I Miss a Premium Payment? ) You do not need to request this refund.

For more information and to begin the process to recover premium payments, please call us at the number on the back of your member ID card.

If you miss the due date for a premium payment, you have extra time to make that payment. This is known as the "grace period." During this time, your health care coverage will not be cancelled, although you may see some changes in your coverage, as outlined below.

The length of the additional time and the changes depend on whether you have a Marketplace plan with an Advanced Premium Tax Credit (tax credit).

For members with a tax credit: If your premium payment is past due, you have up to 3 months to pay your premium and to keep from losing your coverage. While you may get health care during those 3 months, it does not mean all your claims will be covered by your plan.

During the grace period, BCBSTX will:

• Process claims for services received during the grace period;
• Notify the Department of Health and Human Services of your non-payment of premium; and,
• Notify providers that your claims may be denied for services provided during the 2nd and 3rd months of your grace period.

If you get behind on paying your premium, you must pay all past-due premiums before the end of the 3rd month that your payment is late. If the premiums are past due for more than 3 months, your plan coverage will be terminated. If your coverage is terminated, you will not be able to enroll in a new plan until the next open enrollment period unless you qualify for a Special Enrollment Period.

For members without a tax credit: After your premium payments are late, you must get your account current within 31 days of the payment due date. After 31 days, your policy will be cancelled. If you receive health care during this 31-day period, you may be responsible for paying the entire amount of your medical bills. You must pay all of your outstanding premiums to keep your coverage. If your coverage is cancelled, you will not be able to enroll in a new plan until the next open enrollment period unless you qualify for a Special Enrollment Period.

Prescription Drug Benefits and the Grace Period

Missing your premium payment also affects your prescription drug coverage.

For members with a tax credit: During the grace period, you may not see changes to your prescription drug coverage. However, if you do not pay your premium in full by the end of the 3 month grace period, your coverage will be cancelled. In addition, we will bill you for prescriptions we covered in the 2^nd and 3^rd month.

For members without a tax credit: During the grace period, you may not see changes to your prescription drug coverage. However, if you do not pay your premium in full by the end of the 31-day grace period, your coverage will be cancelled. In addition, we will bill you for prescriptions we covered during the grace period.

If you have more than one insurance or HMO health plan, the section of your benefit booklet titled "Coordination of Benefits (COB)" will help explain how your claims are paid by each plan. For example, you and your spouse may be covered under each other's health care benefits plans. In this case, your plan is usually the primary plan for your claims. Your spouse's plan is usually for his or her claims.

In both cases, the primary plan will pay first. Afterward, the secondary plan may then pay an additional amount toward the claim, depending on its rules.

If you have dependent children covered under both your and your spouse's health care benefits plan, their primary plan will often be determined by your and your spouse's birthdays. The plan of the parent whose birthday (month and day) occurs first in the calendar year will be considered primary.

For more information about COB, refer to your benefit materials or call the Customer Service number on the back of your member ID card.

The provider network that is available to you under the terms of your plan is made up of independently contracted doctors, hospitals and other health care providers. The contracted providers in your network do not work for or are part of BCBSTX. However, they do have agreements with BCBSTX that may help save you money for covered services.

Your costs will vary depending on whether your provider is participating in the network. Please refer to Provider Finder to find in-network providers. You should check if your plan has out-of-network benefit coverage before scheduling a visit.

Your Network and Your Plan Type

The way you use your health plan network may vary by your plan type. The following is a brief description of how each plan type works.

Health Maintenance Organization (HMO)

If you have an HMO, you must work with a contracted (in-network) primary care physician (PCP) to help coordinate any care you receive within your provider network. When you first sign up for an HMO, you choose, or are assigned, a PCP.

Your PCP is your partner to help guide you with your health care needs. When using your HMO plan, keep in mind the following:

• You must work with your PCP whenever you need care.When you first choose or are assigned a PCP, schedule a visit as soon as possible. Going right away will help avoid delays later when you are sick or need a referral.
• You will need a referral to see a specialist.If you need to see a specialist, you must obtain a referral from your PCP. Your PCP will usually refer you to a specialist that is in your network, but you should always check to make sure. Women don't need a referral to see an in-network OB-GYN, which is an obstetrician/gynecologist or a family practice doctor.
• You must see in-network providers. For non-emergency care, HMO members must stay in network to receive benefits, except in limited circumstances as stated in your policy. Otherwise, you will be responsible for paying the entire cost of an out-of-network provider visit. To ensure you stay in network, consult with your PCP. If you want to select a new PCP, search Provider Finder^® before visiting a new doctor or health care facility to make sure that the PCP is in your network.

Participating Provider Option (PPO)

Under your PPO plan, there is a network of independently contracted health care providers you can use when you need care. When using your PPO plan, keep the following in mind:

• You don't have to choose a PCP. Unlike with HMOs, PPO members aren't required to select a primary care physician (PCP) to coordinate care.
• You don't need a referral to see a specialist. You don't need a referral to see a specialist or behavioral health care provider. You also don't need a referral to visit a hospital. If your doctor refers you to a specialist, you will still want to verify that the provider is in your network.
• You can receive out-of-network care. While HMO members must generally stay in their network, PPO members can receive services from out-of-network providers. However, you will usually pay more for your services out-of-pocket if you see an out of network provider.

To make sure a provider is in your plan's network, search Provider Finder before visiting a new doctor or health care facility.

Sometimes, to receive benefits for certain services or prescription drugs, you or your provider must call BCBSTX before you receive treatment. This is known as prior benefit authorization. It is also sometimes called pre-certification or preapproval. Note that this is different than getting a referral to see a specialist. Sometimes, you may need to get a referral to see a specialist and prior benefit authorization to receive benefits for a service from that specialist. You can work with your doctor on determining when you need each.

When you or your provider contact BCBSTX with a prior benefit authorization request, we will ask for some information regarding the care or treatment that is proposed. This may include the following:

• Information about your medical condition
• The proposed treatment plan
• The estimated length of stay (if you are being admitted)

During the prior benefit authorization process, BCBSTX reviews the requested service or medication to see if the service or medication is medically necessary.

"Medically Necessary" is defined in your benefit booklet and generally refers to health care services or supplies that:

1. are essential to the diagnosis, prevention or direct treatment of a condition or injury;
2. follow generally accepted standards of medical practice, based on credible scientific evidence;
3. are not primarily for the convenience of you or your doctor; and
4. are the most economical services or supplies that are appropriate for your safe and effective treatment.

The service or treatment must meet your plan's definition of medical necessity in order to be eligible for benefits under your plan. The prior benefit authorization process is not a substitute for the medical advice of your health care provider. The final decision to receive any medical service or treatment is between you and your health care provider.

For more information on medical necessity, see your benefit booklet.

If you are unsure which health care services or medications need prior benefit authorization, you can call the Customer Service number on the back of your BCBSTX member ID card.

Remember, even if a service or medication is authorized, if the provider is out of network you will likely pay more out of pocket. Check Provider Finder to ensure the provider is in your plan's network. Also, a determination that a service is authorized or medically necessary is not a guarantee of coverage. The applicable terms of your plan will control the benefits that you will receive.

For PPO members: Most PPO benefit plans require you or your provider to obtain benefit preapproval for inpatient hospital admissions (acute care, inpatient rehab, etc.). In addition, many PPO benefit plans require prior benefit authorization for services such as skilled nursing visits and home infusion therapy. Make sure to consult the terms of your plan.

For HMO members: Contact your primary care physician (PCP) to coordinate your care. If you are seeking care from a specialist, ask your PCP to ensure that you have received any needed prior benefit authorization.

For all members: If your or your doctor's request for prior benefit authorization is denied, you have the right to appeal the decision. However, you may be responsible for the cost of that service or drug. You can learn more about the appeals process in the Why Was Payment for the Service I Received Denied? section. You can also refer to your benefits documents or call the Customer Service number on the back of your BCBSTX member ID card.

The time it usually takes BCBSTX to respond to your prior benefit authorization request depends on a number of factors, including when we receive your information, the type of service or medication being requested, if additional information is needed and certain regulatory requirements.

For HMO members: Your primary care physician (PCP) helps coordinate your in-network care. If you are seeking care from a specialist, ask your PCP to ensure that you have received any needed prior benefit authorization.

For both HMO and PPO members: The following table generally shows how soon after BCBSTX receives a prior benefit authorization request that you (or your doctor) can expect to get a response. Additional guidelines may apply to these timelines and the time periods may be affected if additional information is needed or if additional information is submitted after the initial request.

NOTE: This table is not intended as medical advice or a substitute for medical advice. The final decision about any care or treatment you receive is between you and your health care provider. Check your plan details for more information.

* Urgent care is treatment that, when delayed, could seriously jeopardize your life and health or your ability to regain maximum function.

If you and your doctor are requesting authorization after you have already received services, BCBSTX will notify you or your doctor with a coverage decision within 30–45 days.

In addition to the above, the following applies to all required prior benefit authorizations:

• Prior benefit authorization does not guarantee payment by your plan. Even if a service or medication has been authorized, coverage or payment can still be affected for a variety of For example, you may have become ineligible or have different coverage as of the date of service.
• We may request additional information. BCBSTX may require more information from your doctor or pharmacist during the prior benefit authorization process. This could include a written explanation of the requested services, reasons for treatment, projected outcome, cost statements or other documents that could be helpful to decide on the medical necessity of the treatment.
• You are responsible for making sure your prior benefit authorization requirements are met. All health insurance and HMO health plans require prior benefit authorization for certain services. When you stay in network, your provider may take care of this step for you, but you should always ask your doctor to make sure. If you decide to see an out-of-network provider, you are responsible for this step as well as additional amounts the out-of-network provider may charge you. For more information, please refer to your benefit booklet.
  
  If you don't get prior benefit authorization for a service that requires it, you may be responsible for a charge in addition to any other applicable deductibles, copayments or coinsurance. In addition, we may review the service to determine if it is medically necessary as defined in your benefit booklet. If we determine that the treatment(s) does not meet the definition of medically necessary, you may be responsible for paying for the services you received.

Whether you take medication to manage an ongoing health condition or you need a prescription for an illness, you will want to become familiar with your health care plan's drug list. This is a list of covered drugs that are available to BCBSTX members.

Both brand and generic medications are included on the drug list. The drug list has different levels of coverage, which are called "tiers." Generally, if you choose a drug that is a lower tier, your out-of-pocket costs for a prescription drug will be less.

The drug list is not a substitute for the independent medical judgment of your health care provider. The final decision on what prescription drug is appropriate for you is between your health care provider and you.

You can view your drug list here. Be sure to choose the section that describes your plan.

When You Can Request a Coverage Exception

If your medication is not on (or has been removed) from your drug list, you or your prescribing doctor may want to request a coverage exception.

To request this exception, your prescribing doctor will need to send us documentation. To begin this process, you or your doctor should call the Customer Service number on the back of your ID card for more information.

You can also fill out and submit the Prescription Drug Coverage Exception form . You will need to provide us with your doctor's name and contact information as well as the name and, if known, the strength and quantity of the drug being requested.

BCBSTX will usually let you or your doctor know of the benefit coverage decision within the lesser of two business days or 72 hours of receiving your request. If the coverage request is denied, BCBSTX will let you know why it was denied and may inform you of a covered alternative drug (if applicable). You can also appeal the benefit determination (see below for more information).

You or your doctor may be able to ask for an expedited review if:

• You take medication for a health condition and failure to get that medication may either pose a risk to your life or health or could keep you from regaining maximum function
• Your current drug therapy uses a non-covered drug

If your review is expedited, BCBSTX will usually let you or your doctor know of the coverage decision within 24 hours of receiving your request. If the coverage request is denied, BCBSTX will let you know why it was denied and may advise you of a covered alternative drug (if applicable). You can also appeal the benefit determination.

How to Request Reconsideration of a Drug Coverage Exception Determination

If your coverage request is denied, you may request reconsideration through BCBSTX verbally by calling the telephone number on the back of your ID card or by written request to:

Blue Cross Blue Shield of Texas
P.O. Box 660044
Dallas TX  75266-0044

If your request is Urgent or Expedited, an external review with an Independent Review Organization (IRO) may be requested. If your case qualifies for external review, an IRO will review your case, at no cost to you, and make a final decision.

If your standard coverage exception reconsideration is denied, you may be able to request an independent, external review by an Independent Review Organization (IRO). To request an independent review, send your completed form to BCBSTX.

For questions about your rights, you may visit the Texas Department of Insurance website or contact:

Texas Department of Insurance Consumer Protection
Mail Code 111-1A, 333 Guadalupe
PO Box 149091
Austin, Texas 78714

Phone: 1-855-839-2427
Email: ConsumerProtection@tdi.texas.gov

If you have any questions about requesting a coverage exception, call the Customer Service number on the back of your member ID card.

Before you seek care, it is always best to confirm that your provider is in network in order to receive the highest level of your benefits. However, there are some times when care you receive from an out-of-network provider may be covered, such as:

• Emergency care. If you experience a medical emergency and visit an out-of-network emergency room, you do not need approval from your plan first. Afterwards, your claim may be reviewed to ensure it meets the criteria for an emergency medical condition. Once approved, your services will be paid in accordance with the terms of your plan.
• Medically necessary services that are unavailable inside your network. If you need services or treatments not covered by the independently contracted doctors or facilities in your plan's network, you can seek approval to go out of network for these services. To learn more, see When Do I Need Benefit Approval for Medical Services? above.
• Certain services for PPO plan members. PPO plans may cover medical services provided by out-of-network doctors and hospitals, but you will likely pay for a greater portion of the cost. To learn more about these plan types, see the What Is a Provider Network?

In the above situations, you may still be responsible for the cost of your care over the allowed amount. The allowed amount is the maximum amount your plan will reimburse a doctor or hospital for a given service. Providers who are part of your network have agreed to accept the allowed amount as full payment for covered services and will only bill you for any copays, coinsurance or deductibles under your health benefit plan.

However, when you see an out-of-network provider, if he or she charges more than this allowed amount, you may have to pay the difference up to the provider’s full charge. This is known as balance billing. (You will not be balance billed when you see a network provider.)

For example, if an out-of-network hospital charges $15,000 for an overnight stay and the allowed amount is $1000, you may have to pay $14,000. This is in addition to your copay, coinsurance, deductible or other amounts you may have already paid. To avoid these charges, use Provider Finder to make sure that the provider is in network.

All covered services are subject to contract benefits, limitations and exclusions. For more information regarding your benefits, please refer to your benefit booklet.

When you visit a doctor or other health care provider, your provider will usually submit a claim to us on your behalf. However, if the provider fails to do so, you can submit the claim yourself. You are more likely to have to file your own claim if you get care from an out-of-network provider.

How to File a Claim

If you need to file a claim, you can download and print a medical health insurance claim form . You can also find this form through our Form Finder. You will find instructions on the form to help guide you.

Once you have filled out this form, mail it to the following address:

Blue Cross and Blue Shield of Texas
P.O. Box 660044 
Dallas, TX 75266-0044

If you have any questions, you can also contact us by calling the Customer Service number on the back of your ID card.

You can submit a claim up to 12 months from the date of service.

When submitting a claim, it's important to include a copy of the original bill issued by your health care provider. Be sure to make copies for your records as documents sent in with your claim cannot be returned to you. Basic information to have handy when preparing a claim form includes:

• Date of service;
• Type of service;
• Dollar amounts charged by doctor or other health care provider for each service;
• Patient name;
• Member name; and
• Member identification number (found on ID card)

Follow these steps to avoid any delays in processing your claim:

• File your claim right away after receiving medical care. Waiting to file a claim may result in a denial of medical benefits.
• Give as much detail as you can. Including the original bill from your doctor or other health care provider helps. Be sure to make a copy for your records as any documents attached to your claim cannot be returned to you.
• If BCBSTX asks you for more information, please get back to us quickly.
• If signatures are needed, be sure to get the proper signatures before sending in your claim.

Check the Status of a Claim

You can check the status of a claim in one of the following ways:

• Visit the Claims Center in Blue Access for Members.
• Call the Customer Service number on the back of your ID card.

If your claim has been denied, you can file an appeal to have it reviewed again. The appeals information is located with your Explanation of Benefits (EOB) and your insurance policy. For more information about EOBs, see below.

An Explanation of Benefits (EOB) is a document that is usually sent to you when a medical benefits claim is processed by your health care plan. It explains the actions taken on the claim and provides information to help understand the following:

• The fees billed by your doctor or other health care provider;
• The date of service which applies to the EOB;
• The services and procedures that were covered;
• The amount that your plan will pay;
• The amount that you may still owe (if you haven't already paid); and
• Any reasons for denying payment along with the claims appeal process.

Your EOB Details

Your BCBSTX EOB is normally divided into 3 major sections:

1. Total of Claim(s) features the main financial information about your claims. It includes the total amount billed, benefits approved and what you may owe to the provider. Sometimes one EOB may contain more than one claim.
2. Service Detail for each claim describes each service you or your dependent received, the facility or doctor, the dates and the charges. It shows the savings your BCBSTX benefits plan provides for you from discounts and other reductions. And, you can see any costs that may not be covered.
3. Summary gives you a clear picture for each claim of your deductible, coinsurance, copays, and health spending accounts, if these apply to you.

The EOB statement is an important record of claims for medical services and benefit coverage. Remember to keep your EOBs for future reference, in case questions come up later about your claim or your bill. Keep your EOBs in a safe place with your other important personal documents, such as your medical records.

Understanding Your Explanation of Benefits  .

Finally, your EOBs are available both as a paper copy and online. To sign up for paperless EOBs, you may do so at any time in your Blue Access for Members account.

Typically, when you receive medical services, your provider will bill your health plan (BCBSTX) before sending a bill to you. BCBSTX then reviews the services you received and determines which services are covered by your plan. Occasionally, claims may be denied after you've received services. If the claim has already been paid, we may seek a refund from the providers and you may be responsible for the cost. This is also known as a retroactive denial and can happen for a variety of reasons, including:

• BCBSTX conducts a medical necessity review and determines that your services did not meet the definition set forth in your benefit plan. For more information, see the When Do I Need Benefit Approval for a Medical Service? section.
• You are no longer covered by your plan or eligible for benefits, or you were not covered at the time that you received medical services.
• You visited an out-of-network provider for non-emergency services and are covered by a plan that does not have out-of-network benefits.
• Another insurer or source should have been billed for your services before or in place of BCBSTX.

Note: This is not a complete list. For more information, please see your benefits booklet.

The following steps may help you to avoid having your claim denied:

• Review your plan's benefit booklet before you seek medical services.
• Verify your benefits by calling Customer Service at the phone number on the back of your ID card. 
• Talk to your provider about BCBSTX's medical policy. You and your provider can access our medical policies online. These policies offer information about medical services that may have limitations based on published clinical research. 

In addition to the above, your claims may be denied if you lose coverage after failing to pay your premium. For more information, see the What Happens if I Miss a Premium Payment? section.

If a claim is denied, you may be responsible for the cost of the services received. However, you also have the right to submit an appeal. An appeal is a way to have that decision reviewed. These steps will help get you started:

• Fill out the Appeal Request Form.
• Mail it to BCBSTX at the address provided on the form.

Refer to your benefit plan materials or call the Customer Service number on the back of your ID card with questions about the appeal process and plan benefits available to you.

As a member with health insurance coverage through your job, your premium payments — or some portion of your premium — may be deducted from your paycheck by your employer. Your employer then submits the payment for your coverage.

If you notice a discrepancy between what you paid for your policy premium and what you owe, please reach out to your employer for more information on recoupment of overpayments.

As a member with health insurance coverage through your job, your premium payments — or some portion of your premium — may be deducted from your paycheck by your employer. Your employer then submits the payment for your coverage.

If you have questions regarding your premium payment by your employer, please reach out to your benefits administrator or HR department for more information.

If you have more than one insurance or HMO health plan, the section of your benefit booklet titled "Coordination of Benefits (COB)" will help explain how your claims are paid by each plan. For example, you and your spouse may be covered under each other's health care benefits plans. In this case, your plan is usually the primary plan for your claims. Your spouse's plan is usually for his or her claims.

In both cases, the primary plan will pay first. Afterward, the secondary plan may then pay an additional amount toward the claim, depending on its rules.

If you have dependent children covered under both your and your spouse's health care benefits plan, their primary plan will often be determined by your and your spouse's birthdays. The plan of the parent whose birthday (month and day) occurs first in the calendar year will be considered primary.

For more information about COB, refer to your benefit materials or call the Customer Service number on the back of your member ID card.