Transparency in Coverage

Out-of-network liability and balance billing

Benefits for covered services from an out-of-network provider will be based on the out-of-network allowance.  The covered person is responsible for payment of the out-of-network deductible, coinsurance, and/or copayment as well as charges for noncovered services, and any excess charge over the allowable amount under the contract.

Exception: Emergency care at an out-of-network facility is considered as having been provided by an in-network provider, however the covered person remains responsible for amounts over the allowable charge. Covered persons that receive short-term care (48 hours or less) outpatient care by an out-of-network physician/provider for an emergency medical condition or accidental injury, are responsible for the in-network deductible, coinsurance and/or copayment.  Inpatient services will also be subject to the in-network cost sharing, as long as the services are for an emergency medical condition.  In addition, covered services provided by an out-of-network urgent care physician, and/or out-of-network professional provider will be subject to the in-network cost sharing when the corresponding facility charges are paid subject to the in-network benefits amount.  In all cases, the covered person remains responsible for any amounts over the allowable charge payable under the contract.

To request an estimate for the out-of-network allowance for a covered service, contact our Member Services Department at the number on the back of your ID card for a good faith estimate.  The request must include the service or procedure code number or diagnosis-related group provided by the out-of-network health care provider, along with an estimated charge.

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Enrollee claims submission

Medical claims should be filed within 120 days of the time the services are provided. If the covered person does not file a claim within 15 months of the date of service (except in the absence of legal capacity), and it was reasonably possible to do so, benefits will not be paid.  It is suggested that all claims be filed with Blue Cross and Blue Shield of Nebraska as soon as possible after expenses are incurred.

In-network Pharmacies will submit claims to Blue Cross and Blue Shield of Nebraska for a Covered Person's purchase of Covered Prescription Drug Products, if the Covered Person presents his or her identification card at the time of purchase.    The covered person must submit a claim to Blue Cross and Blue Shield of Nebraska for Covered Prescription Drug Products purchased from an Out-of-network Pharmacy, or for purchases from an In-Network Pharmacy if the identification card is not presented at the time of purchase.  Prescription drug claims should be filed within 90 days of the service; if not filed within 15 months, and it was reasonably possible to do so, benefits will not be paid.


Claims should be sent to:  Blue Cross and Blue Shield of Nebraska, P.O. Box 3248, Omaha, Nebraska 68180-0001

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Grace periods and claims pending policies during the grace period

A grace period is the period of time after the due date that a person may pay their premium.

For subscribers enrolled through the Health Insurance Marketplace and receiving advance payment of premium tax credits, there is a grace period of three months from the due date to pay the premium in full. Contracts will continue in force during this grace period as described in this paragraph. To be entitled to this grace period, the subscriber must have paid his or her share of at least one full month’s premium. Pending claims, a claim that has not been settled or is awaiting confirmation, and claims for services received during the grace period, may be placed in a pend status. If full payment is not received during the grace period, the contract will terminate on the last day of the first month of the 3-month grace period. If the contract is terminated, benefits will be provided for covered services received only in the first month of the grace period; benefits will not be provided for services received during the second or third month of the grace period.

For subscribers enrolled through the Health Insurance Marketplace, but NOT eligible for advance payment of premium tax credits, there is a 10-day grace period from the monthly due date to pay the premium.  Failure to pay premiums within the grace period will result in cancellation of coverage and will be effective at midnight on the last day the premium was paid.

Reinstatement: If any renewal premium is not paid within the time granted for payment, Our later acceptance of the premium will reinstate the Contract. If We require an application for reinstatement and We issue a conditional receipt for the premium paid, the coverage will be reinstated upon Our approval of such application. If We have not approved the application or previously notified You in writing of disapproval of such application, coverage will be reinstated on the 45th day following the date of such conditional receipt.

The reinstated coverage will include only loss resulting from an Injury sustained after the date of reinstatement and loss due to an Illness that begins more than ten days after such date. In all other respects, the parties will have the same rights as they had immediately before the due date of the defaulted premium, subject to any provisions applicable to reinstatement. Any premium accepted in connection with reinstatement will be applied to a period for which a premium has not been previously paid, but not to any period more than 60 days prior to reinstatement.

We will provide written notice of cancellation to you by first class mail at Your last known address, as shown by Our records. Notice will be given at least 30 days prior to the effective date of cancellation, except in those cases where cancellation is due to your failure to pay premiums, as stated above.

If this Contract is canceled, cancellation will not affect any valid Claim for services provided prior to the effective date of cancellation.

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Retroactive denials

All benefits payable will be paid as soon as possible after the claim has been filed.  Situations may require a retroactive denial (or reversal) of a previously paid or processed claim.  This may occur for various reasons, such as inaccurate information on the claim, additional information is obtained regarding the services or claim, ineligibility for coverage, a termination of coverage following non-payment of premium, duplicate payments, or other errors. To help prevent retroactive denials, covered person should provide accurate and timely claim information; make premium payments within the grace period allowed for payment; make timely enrollment changes; and keep other membership eligibility information up-to-date with the Marketplace and/or Blue Cross and Blue Shield of Nebraska.

Payments made in error may be recovered as provided by law.  In some cases, the covered person may be responsible to refund payments made in error.  Duplicate or erroneous payments not recovered will be considered as benefits paid under the contract.

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Enrollee recoupment of overpayments

Blue Cross and Blue Shield of Nebraska will refund any premium paid if provided with proof in writing that the premium was collected as the result of a Blue Cross and Blue Shield of Nebraska error.  If it is determined the reason for a valid refund request was not the result of a BCBSNE error, any refund of premium is limited to the 12-month period before receipt of such written request.

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Medical necessity and prior authorization timeframes and enrollee responsibilities

Services provided by all health care providers are subject to utilization review, which is an evaluation of the medical necessity, appropriateness and efficiency of the use of health care services.  Blue Cross and Blue Shield of Nebraska will determine whether if the covered services requested, or submitted on a claim, are medically necessary under the terms of the contract, and if benefits are available.

Certification (prior authorization) is required for certain services prior to the service being provided.  Certification procedures are intended to determine if health care services or supplies are appropriate under the terms of the contract.

Before services or supplies are received, all hospital stays, certain surgical procedures and specialized services and supplies must be certified by Blue Cross and Blue Shield of Nebraska.  The subscriber is responsible for making sure certification occurs.  However, a hospital or provider may also initiate the certification.  Certification of a proposed service or supply does not necessarily mean that benefits are payable.  Eligibility for coverage for a particular service or supply, and fulfillment of all other contract requirements, are also necessary for benefits to be payable.

Under all circumstances, the covered person and their providers are ultimately responsible for the medical decisions regarding treatment of the covered person.  Blue Cross and Blue Shield of Nebraska is not responsible for treatment or diagnosis of a covered person, regardless of any case certification, review or management.

Prior to receiving any services, supplies or drugs listed below, Blue Cross and Blue Shield of Nebraska must be contacted by phone or in writing with notice of the intended receipt of services.  It may be required that the certification includes written documentation from the covered person’s physician, dentist or other medical provider validating the medical necessity of the procedure or service and should indicate the location of the service. During an ongoing in-patient admission, care should be certified to assure that it is being provided in the most appropriate setting.

The following services, supplies or drugs must be certified:

  1. Organ and tissue transplants
  2. Pulmonary rehabilitation
  3. Subsequent purchases of Durable Medical Equipment
  4. Certain prescription drugs as defined by Blue Cross and Blue Shield of Nebraska
  5. Skilled nursing care in the home
  6. Skilled nursing facility care
  7. Hospice Care
  8. All Inpatient Hospital admissions
  9. Inpatient physical rehabilitation
  10. Long term acute care
  11. Services subject to surgical or other preauthorization programs, as defined by Blue Cross and Blue Shield of Nebraska

Get a list of services subject to certification or preauthorization.  Certification and preauthorization requirements are subject to change.

If services are not properly certified by Blue Cross and Blue Shield of Nebraska, a penalty may apply and the covered person may be responsible for unanticipated costs associated with the expense incurred. Certain surgical or other preauthorization programs require that benefit approval be obtained prior to the service being provided.  A failure to do so will result in a denial of benefits for the service.  The subscriber will be responsible for charges denied for their failure to obtain prior authorization, unless the provider is a contracting provider with Blue Cross and Blue Shield of Nebraska.

For outpatient prior authorizations with the appropriate documentation, the timeframe includes:
Urgent request: review determination within 72 hours
Non-urgent request: review determination within 15 calendar days

For inpatient prior authorizations with the appropriate documentation, the timeframe includes:
Urgent request: review determination within 72 hours
Non-urgent request: review determination within 15 calendar days

Urgent concurrent inpatient review:

  • Determination and notification: not more than 24 hours:
  • Notification of need for additional information: this must be done immediately by phone.

The term “Medically Necessary” is defined in the contract as:

Medically Necessary (or used as "Medical Necessity"):
 Health care services ordered by a treating physician exercising clinical judgment, provided to a covered person for the purposes of prevention, evaluation, diagnosis or treatment of that covered person's illness, injury or pregnancy, that are:

  1. Consistent with the professionally recognized standards of medical practice; and, known to be effective in improving health care outcomes for the condition.  Effectiveness will be determined by validation based upon scientific evidence, professional standards and consideration of expert opinion
  2. Clinically appropriate in terms of type, frequency, extent, site and duration for the prevention, diagnosis or treatment of the covered person's illness, injury or pregnancy.  The most appropriate setting and level of service, considering the potential benefits and harms to the covered person.  When this test is applied to the care of an inpatient, the covered person's medical symptoms and conditions must require that treatment cannot be safely provided in a less intensive medical setting
  3. Not more costly than alternative interventions, including no intervention, and are at least as likely to produce equivalent therapeutic or diagnostic results to the prevention, diagnosis or treatment of the covered person's illness, injury or pregnancy, without affecting the covered person's medical condition
  4. Not provided primarily for the convenience of any of the following:
    1. the covered person
    2. the physician
    3. the covered person's family
    4. any other person or health care provider
  5. Not considered unnecessarily repetitive when performed in combination with other prevention, evaluation, diagnoses or treatment procedures.

Blue Cross and Blue Shield of Nebraska will determine whether services are medically necessary.  Services will not automatically be considered medically necessary because they have been ordered or provided by a treating physician.

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Drug exceptions timeframes and enrollee responsibilities

The health plan uses a “drug formulary” which is a continually updated list of pharmaceutical products which are covered under the contract.

The covered person or his or her physician may request a formulary exception for a prescription drug identified as an essential health benefit, if not otherwise excluded under the contract. Click here to view the formulary exception form. Any drug exclusion requests must be in writing and mailed to: Blue Cross and Blue Shield of Nebraska, Attn: Pharmacy Department - UM, 1919 Aksarben Drive, P.O. Box 3248, Omaha, NE 68180-0001 or faxed to Toll Free Fax: 800-424-7106 or Phone: 877-999-2374.

The health plan will make its determination on the formulary exception request and notify the covered person and the prescribing physician of the decision no later than 72 hours following receipt of the request.

If the exception request is an expedited request based on urgent circumstances, the covered person and the prescribing physician will be notified of the decision no later than 24 hours following receipt of the request.

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Information on Explanations of Benefits (EOBs)

An Explanation of Benefits (EOB) is a statement provided to the covered person by Blue Cross and Blue Shield to explain how a claim was processed.  When a claim is processed, an EOB is sent to the covered person.  It gives a summary of the payment or denial, including:

  1. Patient’s name and claim number
  2. The name of the provider
  3. The total charges
  4. The covered and allowable amounts
  5. The amount that the covered person is responsible for, such as deductible, coinsurance or copayments
  6. Deductible and out-of-pocket amounts that have accumulated to date
  7. Other general messages

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Coordination of benefits (COB)

Coordination of Benefits (COB) applies when a person has health care coverage under more than one plan.    The plan that pays first is called the Primary Plan.  The Primary Plan must pay benefits within policy terms without regard to the possibility that another plan may cover some expenses.  The plan that pays after the Primary Plan is the Secondary Plan.  The coordination of benefit rules determine the order in which each plan will pay claims for the individual – which plan is primary and which plan is secondary.  The contract includes the rules for determining the order of the plans.

Secondary Plan may reduce its benefits so that the total benefits paid or provided by all plans for any claim are not more than the total allowable expenses.  The amount to be paid on the Secondary Plan is calculated by taking the benefits it would have paid in the absence of other health care coverage and apply that amount to the allowable expense under its plan that will be unpaid by the Primary Plan. The Secondary Plan may reduce its payment by this amount so the payment by both the Secondary Plan and Primary Plan do not exceed the total allowable expense for that claim.  

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HEALTH INSURANCE TERMS


COINSURANCE

The percentage of the bill you pay after your deductible has been met.

COPAY

A fixed amount you pay when you get a covered health service.

Tiered benefit plan

A health care plan featuring multiple levels of benefits based on the network status of a particular provider. 

DEDUCTIBLE

The annual amount you pay for covered health services before your insurance begins to pay.

emergency care services

Any covered services received in a hospital emergency room setting.

SUBSTANCE ABUSE DISORDER SERVICES

Includes behavioral health treatment, counseling, and psychotherapy


in-network provider

A provider contracted by your insurance company to accept an agreed upon payment for covered services. 

OUT-OF-network provider

A term for providers that aren’t contracting with your insurance company. (Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.)

out-of-pocket

Your expenses for medical care that aren’t reimbursed by insurance, including deductibles, coinsurance and co-payments.

penalty

If you can afford health insurance, but choose not to buy it, you must have a health coverage exemption or pay a tax penalty on your federal income tax return.

premium

The amount you pay to your health insurance company each month. 


Preventive services

Health care services that focus on the prevention of disease and health maintenance.

rehab SERVICES

Services and devices to help you recover if you are injured or have surgery. This includes physical, occupational and speech therapy.

special enrollment period

The time after the Open Enrollment Period when you can still purchase health insurance only if you have a qualifying life event (losing other health coverage, having a baby, getting married, moving).

specialist

A physician who has a majority of his or her practice in fields other than internal or general medicine, obstetrics/gynecology, pediatrics or family practice.