Q2: How do I receive the highest level of benefits for my medical claims?
A2: Before you receive health care services, you should be sure that your health care provider is a network provider. Although you may have received a directory listing of the network providers in your area, there may have been changes since printing. It is your responsibility to check your provider’s network status, each visit, to ensure that you will receive the highest benefits your contract allows. Go to Find A Doctor to view the most up-to-date provider listing for your network.
Q4: What if my doctor refers me to another provider that is not in the network?
A4: It is your responsibility to check your provider’s network status, each visit, to ensure that you will receive the highest benefits your contract allows. You can ask your doctor to refer you to another participating physician.
Q5: What if I require emergency care?
A5: If you require emergency care for a life- or limb-threatening emergency, seek care immediately at the nearest facility. The service 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 breathing. There is a copayment, in addition to your coinsurance, 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.
Q6: What if I become ill while away from home traveling in the United States or abroad?
A6: 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.
Q7: Other than the benefit level, are there any differences in the plan if I use non-network providers?
A7: Non-network health care providers can bill you for any difference between actual charges and the approved amount plus and 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 more information about your benefit plan.
Q9: Who do I contact to make changes concerning the members covered under my policy and how much time am I given to make these changes?
A9: Membership questions are handled by your HR Department. You may contact them at the Metro Government Benefit Board, 1-615-862-6640.
Q10: Why did I receive a coordination of benefits letter in the mail?
A10: Each year you may receive a coordination of benefits letter to verify if you or your dependents have obtained or will obtain other medical insurance coverage. This coordination of benefits investigation procedure is a cost containment feature to prevent two insurance companies from making duplicate payments on the same charges, which in turn makes the cost of your insurance premium lower. It is important to keep your COB information current to avoid a delay in claims processing. When you receive a COB letter, fill it out and return it immediately, or you can update your COB information over the phone by calling our member service line at 1-800-367-7790.
Q11: What do I do if I disagree with the payment that was made on my claim?
A11: You can call the member service line at 1-800-367-7790. The Consumer Advisor will assist you in explaining the way your claim was handled and, if necessary, can send your claim for further review.
Q12: If my child is about to turn 24, whom can I contact about extending their coverage?
A12: Contact the Metro Benefit Board at 1-615-862-6640 to continue your dependent’s coverage under COBRA or if you are interested in an individual policy through BCBST you can contact us at 1-800-380-0803 (Individual Sales).
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;
Q14: What does the term “investigational” mean?
A14: 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.
Q15: What if I am not sure if a service is covered?
A15: 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 1-800-367-7790 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, 1 Cameron Hill Circle, Chattanooga, TN 37402. BlueCross BlueShield of Tennessee will respond to confirm or deny benefits within three weeks.
Q16: Where should I file a paper claim?
A16: 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.
Q17: I have heard of a BlueCross BlueShield of Tennessee program called BluePerks® . As a Metro Government member, am I eligible to participate in this program?
A17: Yes. BluePerks® is a program that features discounts on alternative medicine and wellness services not covered by a medical plan. For locations and phone numbers or to view an updated list of alternative medicine practitioners visit http://www.bcbst.com/learn/blueperks/ or call the BlueCross BlueShield of Tennessee BluePerks Discount Program CAM Service Center at (1-800-227-5911). There is also a paper listing available for those members who do not have Internet access.
Q18: What about prior authorization? Who is responsible for this outside the BlueCrossBlue Shield of Tennessee network?
A18: Please remember that certain services must have prior authorization. Most providers will handle this for you. However, outside the BCBST 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 1-800-367-7790 to verify prior authorization.
Q19: How are these claims filed?
A19: 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.