FREQUENTLY ASKED QUESTIONS

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In-network doctors are medical professionals who have agreed to provide services to our members. When you receive care from an in-network doctor, you pay a small copay and don’t need to file a claim.

Out-of-network doctors do not have a working agreement with us to provide services to our members. If you have an out-of-network benefit, you can seek care from out-of-network doctors or hospitals. You will have a higher out-of-pocket expense.

We offer a variety of health and wellness programs throughout the community. Program topics range from lifestyle issues, such as exercise, nutrition, weight management, and smoking cessation as well as health management issues, such as diabetes and asthma management. For more information, call us at number on the back of your member ID card.

Prior authorization is the process of obtaining approval from your health insurance company for a service or medication. Without a prior authorization, the service or medication is not covered. Your physician is responsible for obtaining a prior authorization when required. In addition to medical services, certain medications are subject to pre-approval to be eligible for coverage under your pharmacy benefit. We review medical information provided by physicians to determine if clinical guidelines have been met and that the medication is being used appropriately. In addition to those drugs noted on the drug list as requiring prior authorization, most injectable products are subject to prior authorization.

If you receive care from a non-participating doctor, you may be asked to pay for services when you receive them or you may receive a bill. Submit any bills or receipts to:

Claims Department

P.O. Box 80

Buffalo, NY 14240-0080

Be sure that your itemized receipt or bill includes the patient's name, ID number, a description of the service, date of service, diagnosis, dollar amount, doctor's name and address and your signature.

You may also submit a claim electronically through our secure member website.

  • Go to bcbswny.com/member.
  • Login using your username and password. First time? Click Register Now.
  • Click Manage My Account.
  • Scroll down and click Claims Submission.

A health care proxy is a legal document that allows you to appoint someone you trust, such as a family member or close friend, as your health care agent, to make health-related decisions for you if you lose the ability to make decisions for yourself.

Appointing a health care proxy ensures that your health care wishes are followed. You may give the person you select as your health care proxy as little or as much authority as you want. With a health care proxy in place, important decisions about medical treatment, such as nourishment and water by feeding tubes, as well as instructions like requesting or stopping treatment will be carried out as you have requested.

For more information, call us at number on the back of your member ID card.

 

Health Advocate is a personal health care coaching and patient advocacy service you can call any time you need help navigating the health care system.

Health Advocate can help you:

  • find the best doctors and hospitals for complex needs
  • make appointments with hard-to-reach specialists
  • locate and research treatments for a medical condition
  • provide unbiased information
  • assist with administrative, billing, and claims issues
  • help with eldercare issues

Call Health Advocate toll-free at 1-800-359-5465.

 

Yes. We offer a mail order option that provides convenient home delivery of your prescription drugs, and may also save you money.
For more information, call us at number on the back of your member ID card.

We support doctors and hospitals in several ways, including sharing with them information about health care treatments, helping them to coordinate quality care, and reimbursing them for the care they provide. We have many different ways to pay doctors and hospitals for the care they provide.

  • The resource-based relative value scale (RBRVS) – The RBRVS considers the time a doctor spends on a procedure, how much it costs to run a medical practice, and the cost of medical malpractice insurance. RBRVS also adjusts reimbursement based on how costs vary among different geographic locations. The federal government uses this method to pay doctors across the nation.
  • Fee for service – This is the traditional health care payment method under which doctors and hospitals receive a payment that does not exceed their billed charge for each service they provide. This method of payment can also be used in conjunction with an established fee schedule for our managed care and indemnity plans of coverage.
  • BlueCard® Program(ITS) – The BlueCross BlueShield Association, a national association of independent Blue plans, of which our company is a member, developed this program to help pay your claims when you receive care from an out-of-area doctor or hospital who participates with his or her local BlueCross and BlueShield Plan. The BlueCard Program processes your claims using the payment agreement the physician has with his or her local plan. The local plan pays the doctor directly for the services you received.
  • Agreed-upon amount – This is a negotiated rate agreed to by our company and a medical facility.
  • Capitation – Capitation means we pay doctors a fixed dollar amount in advance, regardless of the number of services they provide to a member. We establish this payment on a per-month basis.

Diagnosis-related grouping (DRG) – A method of reimbursing hospitals for providing inpatient hospital care. It takes into account both your diagnosis and the length of time a patient usually stays in the hospital for that particular diagnosis.

 

 

 

 

Yes. We offer a mail order option that provides convenient home delivery of your prescription drugs, and may also save you money.
For more information, call us at number on the back of your member ID card.

Managed Care

A primary care physician is usually a doctor in general practice, family practice, internal medicine, or pediatrics. Your PCP is your personal doctor, and can coordinate all of your care for you. If you haven't seen your PCP, set up an appointment for a routine physical. This will allow you and your doctor to get to know each other. Be sure to tell your doctor all of your relevant medical history so that he or she can manage your care appropriately. 

To select a PCP who participlates in our network, please refer to your provider directory or call us at the number on the back of your member ID card.

Our BlueCard® Program covers you for urgent care when you are away from home. Urgent care must be coordinated by your PCP before you obtain services. If your PCP recommends treatment, call 1-800-810-2583 to locate a participating Blue doctor.

If you (or a covered dependent) will be temporarily residing outside the Western New York area, in a participating location, for at least 90 days, you may be eligible to become a Guest Member at a BlueCross and BlueShield Association-affiliated HMO. Under the Away From Home Care® program's Guest Membership benefit you retain your coverage under BlueCross BlueShield.

With our Away From Home Care® program's Guest Membership benefit, you can join another HMO and receive the full range of benefits offered by the HMO in that area.

Guest memberships can be used for students away at school, extended business trips, families living apart or long-term travel. Residency eligibility requirements must be met for any long-term traveler requesting Guest Membership for one year or more.

When you return to the BlueCross BlueShield of Western New York service area, you will use your PCP and receive your BlueCross BlueShield of Western New York benefits. For more information and to verify that this benefit is available to you, contact customer service.

Medical problems that require prompt attention, but are not life threatening (i.e., earache, rash, etc.) are considered urgent or non-emergent. These conditions may include:

  • Cold or flu
  • Sore throat
  • Earache
  • Burning/frequency of urination
  • Skin rash
  • Pink eye
  • Body lice/worms

If you have any of these conditions, call your PCP. Your PCP is accessible 24 hours a day, seven days a week. If your doctor is not available, another physician will be covering and can help you

A referral is the recommendation by a physician and/or health plan for a member to receive care from a different physician or facility. Most members do not need a referral from a PCP to see a specialist. If you and your PCP agree that you need to see a specialist, you can select one from our network. You will then be responsible only for your specialist copay. 

Child Health Plus, Healthy New York, Family Health Plus, and Medicaid HMO members require a referral. The word “Referral” is also indicated on your member ID card if appropriate. If you are not sure if you need a referral, call us at number on the back of your member ID card.

Referrals for mental health or chemical dependency services must be arranged by calling 1-877-837-0814. You or your PCP may place this call.

In most cases, your specialist must contact your PCP to request a referral to another specialist. We recommend that you confirm with your PCP that he or she will request the referral. 

Only if we have determined that there is not a participating network doctor or hospital that can treat your illness or condition. Your PCP must request prior approval for this type of out-of-network referral and needs to provide medical information to explain why the services of a non-participating doctor or hospital are necessary to treat your illness or condition. If prior approval is granted, services will be paid at the in-network benefit level.

Timothy's Law requires health policies to include coverage for the diagnosis and treatment of mental, nervous, or emotional disorders for up to 30 days of inpatient care and 20 days of outpatient care in a calendar year. Any deductible, copayments, or coinsurance applied to the Timothy's Law benefits can be no greater than those applied to other benefits under your contract. Most members' contracts already include coverage for 30 days inpatient/20 days outpatient care; the change you may notice is in your out-of-pocket cost for these benefits, which may change to comply with the law.

Based on whether your employer is a large group or small group will determine whether your benefits also include coverage for the treatment of biologically-based conditions, such as schizophrenia/psychotic disorder, major depression, bipolar disorder, delusional disorders, panic disorder, obsessive compulsive disorder, bulimia, and anorexia.

If you are covered under a policy or contract issued to a large employer group (the employer has more than 50 employees eligible for health coverage), the group must provide these benefits. If your employer is a small group employer (50 or fewer eligible employees), your employer may choose to provide these benefits.

Timothy's Law applies to most health insurance policies provided through employer groups. Excluded from this mandate are: Medicare Advantage, Healthy New York, Family Health Plus, Child Health Plus, Medicaid, direct pay, dental, and administrative services only (ASO) accounts.

Prior authorization means that certain services or medications are subject to preapproval by «BlueCross BlueShield»«BlueShield» to be eligible for coverage under your health plan. We review medical information provided by your doctor to determine if clinical guidelines have been met and that the service or medication is being used appropriately. Prescription drugs which require prior authorization are noted on our Medication Guide as such, and most injectable products require prior authorization.

Prior authorization is the process of obtaining coverage approval from BlueCross BlueShield for a service or medication. Without prior authorization, the service or medication is not covered under your health plan benefits. Your doctor is responsible for obtaining the prior authorization when required. A referral is the recommendation by a doctor or a health plan for a member to receive care from a different doctor or facility.

Your doctor needs to complete and fax a Prior Authorization Request form to us. We have provided copies of this form to our doctors’ offices, or you can call us at number on the back of your member ID card.

Your doctor needs to complete and fax a Prior Authorization Request form to us. We have provided copies of this form to our doctors’ offices, or you can call us at number on the back of your member ID card.

Decisions on requests are typically made within 1-3 business days and communicated to your doctor within three business days of the date your doctor submits the prior authorization request. If, however, additional medical information is required from the doctor in order to make a decision, it may take additional time for us to respond to your doctor’s request.

When a request is denied, alternative treatment options which are covered under the benefit plan are suggested to the doctor. Each request is reviewed individually and decisions are made based on medically sound clinical criteria developed and/or approved by one of our physician committees.

If the prior authorization request for a specific medication is denied, the drug is considered a non-covered benefit. It is not available as a third-tier medication. You have the right to appeal denials and your appeal rights will be contained in the denial letter that you and your doctor will receive.

Protecting Yourself - Surprise Bills

If you have coverage through a fully insured commercial, Article 47 ASO group, Medicaid, or Child Health Plus:

New York State has established a new process to resolve disputes on surprise bills. Health plans, doctors, facilities, and patients have the right to request an independent review from New York State if they do not believe a bill or its payment was reasonable.

What is a surprise bill?

When you receive services from a non-participating doctor at a participating hospital or ambulatory surgical center, the bill you receive for those services will be a surprise bill if: 

  • A participating doctor was not available; or
  • A non-participating doctor provided services without your knowledge; or
  • Unexpected medical circumstances occurred at the time the health care services were provides.

It will not be a surprise bill if you chose to receive services from a non-participating doctor instead of from an available participating doctor.

When you are referred by your participating doctor to a non-participating doctor, the bill you receive for those services will be a surprise bill if you did not sign a written consent form stating that you knew the services would be out-of-network and would result in costs not covered by your health plan. 

A referral to a non-participating provider occurs when:

  • During a visit with your participating doctor, a non-participating doctor treats you; or
  • Your participating doctor takes a specimen from you in the office (for example, blood) and sends it to a non-participating laboratory or pathologist; or
  • A referral is required under your plan for any other health care services.

Protect yourself from a surprise bill. 

You can protect yourself from receiving a surprise bill and only be responsible for your in-network copay, coinsurance, or deductible if you:

  • Call the customer service number on the back of your member ID card and ask for an Assignment of Benefits (AOB) form to fill out; and
  • Send the form and a copy of the bill(s) you do not think you should pay to both your doctor and us.

If you don’t complete an AOB, you can also submit your disputed bill directly to New York State’s Independent Dispute Resolution Entity (IDRE) for review. For more information on submitting a dispute for review, visit the New York State Department of Financial Services website at dfs.ny.gov, call 1-800-342-3736, or e-mail IDRquestions@dfs.ny.gov.

We use several nationally accepted methods to pay doctors, hospitals, and urgent care centers both in- and out-of-network.

Agreed-upon amount

This is a negotiated rate between BlueCross BlueShield of Western New York and a doctor, hospital, or urgent care center.

BlueCard program

This program was developed by the BlueCross BlueShield Association, a national organization of independent BlueCross and/or BlueShield plans, to make paying claims easy when you visit a doctor, hospital, or urgent care center outside of your coverage area. You pay your normal copay, deductible, or coinsurance, and the local Blue plan pays the rest.

Resource-based relative value scale

This scale was created by the federal government to help insurers determine pricing for medical procedures. This scale uses information such as the length of the procedure, general costs of running a practice, and geographic location to determine how much each medical procedure should cost.

Out-of-network reimbursement compared to Usual, Customary and Reasonable (UCR) cost

Our general out-of-network reimbursement to doctors for services received using out-of-network benefits is approximately 71 percent of UCR. UCR is the amount providers typically charge for a service.  

Need help figuring out your treatment costs?

 

Visit fairhealthconsumer.org

 

Fair Health® is a free website that can help you estimate the cost of health care services in your area. You can get estimates for both medical and dental procedures and coverage costs when you visit out-of-network doctors, hospitals, or urgent care centers.

New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form

 

Out-of Network Reimbursement Examples of Group Coverage