State of Tennessee - FAQs
- How do I contact Member Service?
- What do I do if I need EAP, mental health, or substance abuse care?
- What if I require emergency care?
- What if I become ill while away from home traveling for business or pleasure?
- Other than the benefit level, are there any differences in the plan if I use non-network providers?
- What do the terms “medically necessary” or “medical necessity” mean?
- What does the term “investigational” mean?
- What if I am not sure if a service is covered?
- Where should I file a paper claim?
- What if I need medical treatment while traveling outside the State of Tennessee?
- What about prior authorization? Who is responsible for this outside the State of Tennessee provider network?
- How are these claims filed?
- Should I be prepared to pay money at the time of service?
Q1: How do I contact Member Service?
A1: Member Service can be reached at 1-800-558-6213 between 8 a.m. – 5 p.m. EST, Monday through Friday. Or, you may contact us online.
Q2: What do I do if I need EAP, mental health, or substance abuse care?
A2: Magellan Health Services can supply information concerning the mental health and substance abuse benefit structure and details concerning available providers for this type care. You should refer to the Magellan Health Services printed materials, or call them at 1 (800) 308-4934 or visit MagellanHealth.com. 
Q3: What if I require emergency care?
A3: If you require emergency care for a life- or limb-threatening emergency, seek care immediately at the nearest facility. The services you require will be covered at the highest benefit level of your plan. These situations include such conditions as serious burns, poisoning, convulsions, or severe difficulty in breathing. There is a copayment for emergency room treatment unless you are admitted to the hospital. You should contact your doctor within 24 hours, or the next working day. This helps to ensure that your doctor is fully aware of all medical episodes and can monitor you following the emergency situation.
Q4: What if I become ill while away from home traveling for business or pleasure?
A4: The highest level of benefits will be provided if you are away from home and require treatment for a life-threatening emergency. If your situation is urgent, yet not life-threatening, you should utilize the BlueCard Program to locate a provider in your area of travel. Refer to your member handbook for further information on the BlueCard Program or contact 1-800-810-Blue to locate a BlueCard Program provider.
Q5: Other than the benefit level, are there any differences in the plan if I use non-network providers?
A5: Non-network health care providers can bill you for any difference between actual charges and the approved amount plus any charges for services deemed not medically necessary or not authorized by BlueCross BlueShield of Tennessee. For these reasons, it is very important to select a network provider whenever possible and to show your identification card to your doctor or hospital before you are admitted. The card contains information about the certification requirements and also provides a toll-free number that providers may call for information about your benefit plan.
Q6: What do the terms “medically necessary” or “medical necessity” mean?
A6: Medical services received must be medically necessary to be covered by the plan. The services must be of proven value for use in the general population and must meet the following criteria;
- have final approval from the appropriate government regulatory bodies;
- have scientific evidence permitting conclusions concerning the beneficial effect of the service on health outcomes;
- improve the net health outcome;
- be as beneficial as any established alternative;
- demonstrate the improvement outside the investigational setting; and not be an experimental or investigational service.
Q7: What does the term “investigational” mean?
A7: Investigational is defined as medical, surgical, diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies, treatments, procedure, drug therapies or devices that are not approved by the appropriate regulatory agency as appropriate for the proposed use. Items or services classified as investigational are not covered by the insurance plan.
Q8: What if I am not sure if a service is covered?
A8: If you are unsure about whether a procedure, type of facility, equipment, or any other expense is covered by your medical plan, contact Member Service at 1-800-558-6213 or ask your physician to submit a pre-determination request form describing the condition and treatment. The physician should send it to BlueCross BlueShield of Tennessee, Attention: Provider Service Center 2 West, 801 Pine Street, Chattanooga, TN 37402. BlueCross BlueShield of Tennessee will respond to confirm or deny benefits within three weeks.
Q9: Where should I file a paper claim?
A9: Most claims are filed electronically by your physician or hospital facility. When receiving services outside Tennessee, use the BlueCard Program to search for a participating provider. BlueCard providers agree to file the claim for you as well and accept contract rates and discounts. However, should you need to file a claim yourself, claims should be submitted to BlueCross BlueShield of Tennessee, Attn: Member Benefits Administration, P.O. Box 180150, Chattanooga, TN 37401.
Q10: What if I need medical treatment while traveling outside the State of Tennessee?
A10: If you need medical services while traveling outside the State of Tennessee, use the BlueCard PPO program . With the BlueCard PPO program, your standard network benefit structure is available nationwide. Your ID card contains a “PPO in a suitcase” logo which identifies you as a member of the BlueCard PPO program. The program links together PPO network providers from Blue Plans across the United States. Call 1-800-810-BLUE (2583) for participating providers or visit bluecard.com . If you require medical services outside the United States, use BlueCard WorldWide participating providers . To locate one of these providers, call the BlueCard Worldwide® Service Center at 1-800-810-BLUE (2583) or collect at 1-804-673-1177 if you are unable to find a suitable provider. You may also visit bluecares.com to locate a participating provider.
Q11: What about prior authorization? Who is responsible for this outside the State of Tennessee provider network?
A11: Please remember that certain services must have prior authorization. Most providers will handle this for you. However, outside the State of Tennessee provider network, you should either call to initiate the process or follow up to make sure that it is done. There is no mechanism outside of Tennessee for this plan to require the provider to write off benefit reductions or denials that occur as a result of failure to comply with prior authorization requirements. This means you will be responsible for any such reductions or denials. For prior authorization, providers may call the number listed on the back of your ID card. Members should contact member service at 1-800-558-6213 to verify prior authorization.
Q12: How are these claims filed?
A12: As long as you use a BlueCard PPO network provider the provider will be responsible for filing the claim. This claim will be filed to the local BlueCross BlueShield Plan where the provider has a network agreement. You should always make sure that your provider has your most current ID card and that they file the claim with the 3-digit alpha prefix.
Q13: Should I be prepared to pay money at the time of service?
A13: Network providers have the right to collect any deductible, copay, or coinsurance amounts on the date of service.
