Transparency in Coverage Rule/Consolidated Appropriations Act, 2021

If you receive services at an out-of-network healthcare provider or facility, you may be balance billed. The amount the plan pays for covered services is based on the allowed amount (an amount we use to calculate our payment of services). You may be responsible for any excess charges of the allowance for covered services, except for emergency services. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing). For example, if an out-of-network hospital charges $2,000 for an overnight stay and the allowed amount is $1,500, you may have to pay the $500 difference.

If you received care from a healthcare provider that is in network with Blue Cross and Blue Shield of Nebraska (or the local Blues Plan), the provider will submit the claim on your behalf. If the provider out of network, you may need to complete a subscriber claim form. As a member submitting claims, you have 15 months from the date of service to file your claim with Blue Cross and Blue Shield of Nebraska. If the claim is not submitted within this time frame, it will not be paid.

Medical or Dental Claims
Pharmacy Claims

Grace periods and claims pending

You are required to pay your premium by the scheduled due date. If you do not do so, your coverage could be canceled. For most individual healthcare plans, if you do not pay your premium on time, you will receive a 30-day grace period. 

A grace period is a time period when your plan will not terminate even though you did not pay your premium. Any claims submitted for you during that grace period will be pended. 

When a claim is pended, no payment will be made to the provider until your delinquent premium is paid in full.

• If you do not pay your delinquent premium by the end of the 30-day grace period, your coverage will be terminated. 
• If you pay your full outstanding premium before the end of the grace period, we will pay all claims for covered services you received during the grace period that are submitted properly. 

If you are enrolled in an individual healthcare plan offered on the Health Insurance Marketplace and you receive an Advance Premium Tax Credit (APTC), you will get a 3-month grace period, and we will pay all claims for covered services that are submitted properly during the first month of the grace period.

• During the second and third months of that grace period, any claims you incur will be pended.
• If you pay your full outstanding premium before the end of the 3-month grace period, we will pay all claims for covered services that are submitted properly for the second and third months of the grace period.
• If you do not pay all of your outstanding premium by the end of the 3-month grace period, your coverage will terminate, and we will not pay for any pended claims submitted for you during the second and third months of the grace period. Your provider may balance bill you for those services. 

What is my Grace Period?

If you receive an APTC from the Health Insurance Marketplace, your grace period is three months. If you do not receive any assistance from the Health Insurance Marketplace, your invoice is due prior to the start of coverage to ensure all claims will be processed per your benefit plan.

How can I avoid my coverage getting cancelled?

Always pay your premium timely. Premium is due the last day of each month, beginning the month prior to the coverage effective date. So, coverage for January is due December 31, and February premium would be due January 31.

A retroactive denial is the reversal of a previously paid claim. BCBSNE may reverse a previously paid claim when eligibility has changed retroactively. Eligibility can change retroactively in cases of fraud (when a member fills out an application with incorrect or fraudulent information), when members or dependents continue receiving services after losing eligibility, when members fail to meet the reporting requirements for loss of eligibility or in situations where the premium is not paid, leaving the member uncovered for services. Members can avoid retroactive denials by reporting all changes timely, paying the monthly premium and ensuring eligibility requirements are met.

If a member overpays their premium amount, they may receive a refund, depending on when BCBSNE received the overpayment. Members who overpay while coverage is still active will see the remaining premium amount credited to their next month's premium. Members who overpay - beyond their coverage  end date will receive a refund for any premium overpaid. If you believe you have overpaid your premium, please call the Member Services number on the back of your member ID card.

Medically necessary services, supplies or treatments are provided by a healthcare provider to treat an illness or injury that are reasonable, necessary and/or appropriate based on evidence-based clinical standards of care. These standards of care must be:

• Medically required and appropriate for the diagnosis and treatment of the member's illness or injury
• Consistent with professionally recognized standards of care
• Will not involve costs that are excessive in comparison with alternative services that would be effective for diagnosis and treatment of the member's illness or injury.

Certain services are subject to prior authorization before being performed. These are found in the member's benefit plan document  under the authorizations section. Services subject to prior authorization may vary from plan to plan, so attention should be given to the individual plan being considered.

Prior authorization should be obtained before the service is provided; however, if the member's medical condition does not allow them to obtain prior authorization due to an emergency admission, the member or the member's representative is requested to notify the BCBSNE of the admission during the next business day or as soon thereafter as reasonably possible to obtain authorization.

If services are not preauthorized, claims for that service will be denied. Urgent review will be completed within 72 hours. Non-urgent reviews will be completed within 15 business days.

A member with a metallic plan may ask BCBSNE to make an exception to cover a drug that is not on the Formulary. This is known as a formulary exception request. This occurs after the initial review has been completed and denied as a non-formulary drug by Prime Therapeutics (Prime), BCBSNE's Pharmacy Benefit Manager. The member's physician can request a formulary exception review by completing the request form. This form is available on NebraskaBlue.com or via Member Services by calling the number on the back of the member ID card. The completed form should be mailed or faxed to the address listed on the form.

Upon receipt of this form, BCBSNE reviews the information from Prime Therapeutics and submits the request to be reviewed internally at BCBSNE or to the Independent Review Organization (IRO) the same day.

• If the request is a standard request being reviewed internally by BCBSNE, BCBSNE will respond with their determination within 72 hours after receiving the exception request. If request is expedited or exigent, BCBSNE will complete the case within 24 hours. BCBSNE will notify the requestor of the determination within a 24-hour time frame.
• If the request is a standard request being requested through external review, an IRO will respond with their determination within 72 hours after receiving the exception request. If request is expedited or exigent, the IRO will complete the case within 24 hours. The IRO will notify BCBSNE with their determination and BCBSNE will in turn notify the requestor.

A letter is sent to the requestor and member with notification of the determination. If the decision is overturned, Prime will be notified and allow the drug to be paid. If the decision is denied, the member may follow the standard appeals process by contacting Member Services. 

To request an expedited exception: If a formulary exception request is received and an exigent circumstance exists, the decision is rendered within 24 hours of the request. Although a request may be received from a member or member designee, the request needs to be supplemented with prescriber physician or other prescriber statements supporting the exigent circumstance. Receipt of these requests can be received in writing, electronically (i.e., fax), and telephonically.  

In order for it to be an exigent circumstance the following must be met based on 45 CFR 156.122: 

1. A statement (oral or written) indicating an exigency exists by documenting that there would be harm that could reasonably come to the enrollee if the requested drug were not provided within the timeframes specified by the non-exigent procedure above, AND 
   
   
2. Rationale and documentation are provided that supports needing the non-formulary medication that also includes a statement and rationale indicating: 
   
   
3. All formulary medications will be ineffective (or all formulary medications have been ineffective), OR 
   
   
4. All formulary medications would not be as effective as the non-formulary medication, OR 
   
   
5. All formulary medications would have adverse effects not applicable to the non-formulary medication. 

A Formulary exception request that does not meet the exigent circumstance criteria is reviewed as a non-expedited formulary exception request (standard) as stated above.  

Each time we process a claim submitted by you or your health care provider, we explain how we processed it on an Explanation of Benefits (EOB) form. The EOB is not a bill. It explains how your benefits were applied to that particular claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you’re responsible for paying the provider. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.

BCBSNE sends EOBs after claims have been processed, which means the claim has been received and adjudicated.

Coordination of benefits is used when a member has two health insurance plans. This process allows the two plans to work together, getting you the most out of your coverage. One plan becomes your primary plan, paying your claims first. The second plan becomes your secondary plan, which may pay toward the remaining cost, depending on the plan. Understanding which plan is your primary and which plan is your secondary is important to help prevent delays in claims processing.

Members may complete this form online on myNebraskaBlue.com or by downloading the Coordination of Benefits Form.