Claims Payment Policy & Other Information

Listed below are claims payment policies and other information for Qualified Health Plans offered by Blue Cross and Blue Shield of Alabama. A Qualified Health Plan is an insurance plan that has been certified by the Health Insurance Marketplace and provides essential health benefits, follows established limits on cost sharing and meets other requirements under the Affordable Care Act.

Out-of-network liability and balance billing

If you receive services from an out-of-network provider, these services may not be covered at all under the plan. In that case, you will be responsible for all charges billed to you by the out-of-network provider, also referred to as balanced billing. If the out-of-network services are covered, in most cases, you will have to pay significantly more than what you would pay an in-network provider because of lower benefit levels and higher cost sharing. Additionally, out-of-network providers have not contracted with us or any Blue Cross and/or Blue Shield plan for negotiated discounts and can bill you for amounts in excess of the allowed amounts under the plan.

If you receive out-of-network benefits for a medical emergency in the emergency room of a hospital, those services will be paid at the applicable in-network coinsurance amounts for such benefits described in your benefit booklet and subject to the in-network calendar year deductible. The allowed amount for such out-of-network benefits will be determined in accordance with the requirements of the applicable Federal law.

If you receive non-emergency services performed by an out-of-network provider at certain in-network facilities, those services will be paid at the applicable in-network coinsurance and/or copayment amounts for such benefits described in your benefit booklet and subject to the in-network calendar year deductible, provided the out-of-network provider has not satisfied the applicable notice and consent requirements. The allowed amount for such non-emergency services performed by an out-of-network provider at certain participating facilities will be determined in accordance with the requirements of the applicable Federal law.

Find more information about your rights and protections against surprise medical bills and balanced billing here.

Emergency services are not covered out-of-network under our dental plans.

Enrollee claims submission

When you receive services from an in-network provider, your provider will generally file claims for you. If your provider does not file your claim for you, you can call our Customer Service Department at the number on the back of your ID card and ask for a claim form. Tell us the type of service or supply for which you wish to file a claim (for example, hospital, physician, dentist or pharmacy), and we will send you the proper type of form. You can also find our claim forms on our website at:

• Medical Expense Claim
• Dental Expense Claim
• Vision/Hearing Claim
• Pharmacy Claim
• Travel Benefit Claim

Claims must be submitted and received by us within 24 months after the service takes place to be eligible for benefits.

Claims forms with attached itemized bill must be submitted to:
Blue Cross and Blue Shield of Alabama
450 Riverchase Parkway East
Birmingham, Alabama 35244-2858

Grace periods and claims pending policies during the grace period

You are required to pay your premium by the scheduled due date. If you do not do so, your coverage is subject to termination. If you purchased an individual plan through the Health Insurance Marketplace and you are receiving advance payments of tax credits and/or cost sharing reductions in accordance with the Affordable Care Act, each of your monthly periodic payments is due on the first day of the month for that coverage period. There is a grace period of three months for all monthly premium payments after the initial premium payment. A grace period is the time after which the payment is due when your plan will not terminate even though the payment has not yet been made.

All properly submitted claims, received for covered services within the first month of the grace period will be considered for payment. Claims received during months two and three will be placed in a pending status (suspended). When claims are in ‘pending’ or ‘suspended’ status, no payment is made to the provider and the claim is not considered for processing until payment is received or the grace period is exhausted, whichever comes first. If you pay your delinquent premium before the end of month three we will consider all pending claims for payment to providers. If you fail to pay past due monthly payments in-full before the end of the grace period for those coverage periods, your coverage under the plan will be retroactively canceled back to the last day of the first month of the grace period. All claims in a pending status at the time of cancellation will reject and your provider may balance bill you for those services.

Failure to timely pay premium payments is not a special open enrollment event for later coverage under the plan.

Retroactive denials

In certain situations, a claim may be reprocessed and denied retroactively, even after it has been paid. In these cases, you are responsible for payment to the provider. A retroactive denial is the reversal of a previously paid claim. In most cases, you can prevent a retroactive denial by paying your premiums on time and/or by promptly notifying the plan or, if applicable, the marketplace of changes in your eligibility status for the plan.  

Enrollee recoupment of overpayments

If you believe you believe you have overpaid your premium due to our overbilling, please contact us by calling the Customer Service Department number on the back of your ID card.

Medical necessity and prior authorization timeframes and enrollee responsibilities

A precertification (sometimes referred to as a prior authorization) is a requirement of a member’s benefit plan to obtain a medical necessity decision that certain healthcare services, treatment plans, durable medical equipment or prescription drugs are medically necessary before services are received, except for emergency services.

A precertification provides earlier notification of medical necessity decisions for services that require medical review, which ensures the member and provider have all the information available before the services take place. In addition, a precertification reinforces quality to ensure that services are not rendered that are not medically appropriate. With precertification requirements in place, members are less likely to receive unexpected medical bills for these services if a required precertification is not approved.

Below is a list of some services that may require a precertification

• Inpatient Care (including transplants, acute inpatient rehabilitation, long-term acute care facilities and skilled nursing facilities)
• Outpatient Services (including surgeries and diagnostic imaging services such as MRIs, PETs, and CT scans)
• Home Healthcare and Hospice
• Durable Medical Equipment
• Prescription Drugs (including provider-administered drugs)
• Behavioral Health Services

A member’s Summary Plan Description (SPD), benefit booklet, includes precertification requirements and are directed to a precertification webpage that includes a list of some outpatient services that require prior authorization per their contract benefits. Members may also call customer service, utilizing the number on the back of their membership card, to inquire about precertification requirements.

Providers can verify benefits through an online provider portal prior to rendering services and determine if a procedure requires precertification.

It is both the member and provider’s responsibility to know what the precertification requirements are under the member’s benefit plan. It is industry standard for providers to verify eligibility and benefits before each service is rendered; however, a member should always check with their provider to be sure that this step has been completed. Additionally, ensure that there is an approved precertification on file prior to receiving a service that requires a precertification. If precertification is not obtained, no benefits will be payable under the plan for the services.

The Plan provides notice of all review determinations and communicates them in accordance with applicable state, federal, and/or accreditation requirements. The timeframes are national guidelines prescribed for review timeliness by the National Committee for Quality Assurance (NCQA) and are cited below.

• Preservice Non-Urgent – 15 calendar days
• Preservice Urgent Review - We have 24 hours to make our decision for On-exchange plans, all other plans we have 72 hours to make our decision.
• Urgent Concurrent – 24 hours - if we receive the request no later than 24 hours before the end of your preapproved stay or course of treatment. If the request is not received before the 24 hour time frame, we have 72 hours to make our decision.
• Urgent Preservice – 72 hours
• Emergency admissions – 48 hours
• Non-urgent concurrent review – 72 hours
• Post service review – 30 days
• Post service review: Care and services have been provided and the member has discharged from the service, we have 30 days to make a decision.

Drug exceptions timeframes and enrollee responsibilities

If your self-administered pharmacy benefit drug is not covered and you think it should be, you may ask us to make an exception to the drug coverage rules by calling the Customer Service Department number on the back of your ID card. Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception. We will give you a response within 72 hours of receiving all information we need to make a decision for a standard review. If you or your doctor believe there are exigent circumstances that require an expedited review, an expedited exception request can be submitted, and we will give a response within 24 hours. For provider-administered drugs under the medical benefit, we will provide a response within 15 calendar days of receiving all information we need to make a decision for a standard review, and for expedited reviews, a response will be provided within 72 hours. If we deny your request, you may request an internal appeal and an external review by an impartial third party reviewer, known as an Independent Review Organization (IRO). We must follow the IRO’s decision. Additional details about this and other exception review details can be found in the Claims and Appeals section of your benefit booklet.

Information on Explanations of Benefits (EOBs)

Each time Blue Cross processes a claim submitted by you or your healthcare provider, we send you an Explanation of Benefits (EOB). An EOB is not a bill. An EOB is a statement that describes what medical treatments and/or services we paid on your behalf, what our payment was and your financial responsibility under the terms of the plan. 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. It also tells you how much has been credited toward any required deductible and out-of-pocket maximums.

Coordination of Benefits (COB)

Coordination of Benefits (COB) is a provision designed to help manage the cost of healthcare by avoiding duplication of benefits when a person is covered by two or more benefit plans. COB provisions determine which plan is primary and which is secondary. A primary plan is one whose benefits for a person's healthcare coverage must be determined first without taking the existence of any other plan into consideration. A secondary plan is one which takes into consideration the benefits of the primary plan before determining benefits available under its plan.