HomeTransparency in Coverage

Transparency in Coverage

An Open Look at Important BlueCross BlueShield of Tennessee Health Plan Information

Health insurance plans are available to the general public through the Marketplace, sometimes called the Health Insurance Marketplace, the Federally Facilitated Marketplace or the Exchange. Below you’ll find information that may be useful to you as you shop for a Marketplace plan that’s right for you.

Marketplace Plans

Out of Network and Balance Billing
Out-of-Network Liability and Balance Billing
As a valued member it is important to understand what your financial responsibility will be for out-of-network services.
When you use out-of-network providers, you will be responsible for the total cost of services provided.
By using network providers, you maximize your benefits and avoid paying for the total charge billed by an out-of-network provider. This amount can be substantial.
Knowing that certain situations can be unexpected, there are exceptions to out-ofnetwork liability, such as emergency services. Emergency care services provided by an out-of-network provider are based on the following criteria:
Medically necessary and medically appropriate health care services and supplies provided in a hospital emergency department that are required to determine, evaluate, and/or treat an emergency until such condition is stabilized, as directed or ordered by the practitioner or hospital protocol.
You or your dependent(s) are responsible for all deductible, co-pay, and/or coinsurance amounts. Cost-sharing for applicable out-of-network emergency care services will be the same as cost-sharing for emergency care services received in-network. However you and your dependent(s) are also responsible for any disallowed amounts that are over the maximum allowable charge for each procedure.
An emergency is defined as a sudden and unexpected medical condition that manifests itself by symptoms of sufficient severity, including severe pain,that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect to result in:
a. Serious impairment of bodily functions; or
b. Serious dysfunction of any bodily organ or part; or
c. Placing the prudent layperson’s health in serious jeopardy.
Examples of emergency conditions include: (1) severe chest pain; (2) uncontrollable bleeding or (3) unconsciousness
Enrollee Claims Submission
Submitting a Claim
Most of the time, providers in your network submit claims for you or others on your plan. But sometimes you may need to submit a claim yourself. You can download a claim form here. If you need help filing a claim or need us to send you one, call us at the number on the back of your Member ID card (TTY: 1-800-848-0298 or 711).
Please mail your completed claim form and any attachments to:
BCBST Claims Service Center
1 Cameron Hill Circle, Suite 0002
Chattanooga, TN 37402-0002
There’s a time limit to submit a claim — within 15 months from the date of care.
Grace Periods and Claims Pending
Grace Periods and Claims Pending Policies During the Grace Period
A grace period is a specific time after your premium is due during which you can pay your premium without a lapse in coverage.
Your initial premium is your first premium payment. Initial premiums must be paid 30 days from your coverage effective date in most cases.
If you get an Advanced Premium Tax Credit (APTC) to help pay your premiums, you have a three-month grace period (three consecutive months) to pay all outstanding premiums once you’ve paid your initial premium.
During this grace period, we'll process claims for covered services from the first month of the grace period and your coverage will continue. We'll pend any claims submitted for you during that grace period. This means we won't make any payment to the provider until your delinquent premium is paid in full. We may suspend payments to providers rendering services to you and your covered dependents during the second and third months of the grace period.
If you pay the premium in full during the grace period, your coverage will continue and we'll honor claims for covered services incurred during the grace period.
If you don’t pay the premium in full by the end of the three-month grace period, your coverage will terminate the last day of the first month of the three-month grace period and you'll have to pay any charges for care you got during the second and third months of the three-month grace period. We’ll keep any premium payments made toward the first month of your coverage, and return all other premium amounts applied to the second or third months. Also, if you apply for another Marketplace policy in the future, you may have to pay anything you owe for your old plan and the first month’s premium for your new plan before your new coverage starts.
If you don’t get an APTC, you’ll have a 31-day grace period to pay your premiums. If you don’t pay the premium in full during the grace period, your coverage will terminate retroactive to the premium due date. You’ll have to pay for any charges for care you got during this 31-day grace period.
Retroactive Denials
As a valued member it is important to understand that sometimes a claim that was paid may later be denied. A retroactive denial is the reversal of a previously paid claim, through which you then become responsible for payment.
For example, a retroactive denial may occur if payment for services is made after termination of coverage. If you or your covered dependent(s) receive, and we pay for, covered services after the termination of your coverage, we may recover the amount paid for such covered services from you.
You can prevent a retroactive denial by making sure we receive your premium payment by the first of each month. To allow time for processing and prevent an interruption in your benefits, we recommend you mail your premium payment five to seven business days before the end of each month.
Recoupment of Overpayments
Enrollee Recoupment of Overpayments
Overpayment of premium resulting from the cancellation or termination of your policy will be refunded to you automatically. Overpayment of premium resulting from changes in your policy or any other reason will be applied to future premiums due unless a refund is requested. You can call Member Service at the number on the back of your Member ID card to request a refund of a premium overpayment.
Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibility
Medical Necessity, Prior Authorization Time Frames and Enrollee Responsibilities
BlueCross BlueShield of Tennessee provides services to help manage your care including performing prior authorization of certain services to ensure they are medically necessary, concurrent review of hospitalization, discharge planning, low-risk condition management, care coordination, complex and chronic care management, and specialty care programs such as transplant case management. BlueCross also provides medical policies.
BlueCross does not make medical treatment decisions under any circumstances. You may always elect to receive services that do not comply with BlueCross’s care management requirements or medical policy, but doing so may affect the coverage of such services.
Prior Authorization
Some covered services must be authorized by BlueCross in advance in order to be paid at the maximum allowable charge without penalty. Obtaining prior authorization is not a guarantee of coverage. All provisions of the policy must be satisfied before coverage for services will be provided.
Services that require prior authorization include, but are not limited to:
Inpatient hospital stays (except maternity admissions);
Skilled nursing facility and rehabilitation facility admissions;
Certain outpatient surgeries and/or procedures;
Certain specialty drugs;
Certain prescription drugs;
Advanced radiological imaging services;
Certain durable medical equipment (DME);
Certain prosthetics;
Certain orthotics;
Certain genetic testing;
Non-emergency Air Ambulance transport;
Certain musculoskeletal procedures (including, but not limited to, spinal surgeries, spinal injections, and hip, knee and shoulder surgeries);
Other services not listed at the time of publication may be added to the list of services that require prior authorization. Visit bcbst.com or call Member Service at the number on the back of your Member ID card to find out which services require prior authorization. Network providers in Tennessee will get prior authorization for you. Network providers outside of Tennessee are responsible for obtaining prior authorization for any inpatient hospital (facility only) stays requiring prior authorization. In these situations, the member is not responsible for any penalty or reduced benefit when prior authorization is not obtained.
You are responsible for obtaining prior authorization when using network providers outside Tennessee for physician and outpatient services, or payments may be reduced or services denied.
If prior authorization is required and not obtained, and services are medically necessary, benefits may be reduced for network providers outside Tennessee. If the reduction results in liability to you greater than $2,500 above what you would have paid had prior authorization been obtained, then you may contact our consumer advisors to have the claim reviewed and adjusted and the reduction will be limited to $2,500. Services that are not determined to be medically necessary are not covered.
Prior Authorization Request Time Frames
Scheduled admissions/services must be authorized at least 24 hours prior to admission. Emergency inpatient admissions/services must be authorized within 2 business days of an admission. We typically decide on requests for prior authorization for medical services within 72 hours of receiving an urgent request or within 15 days for non-urgent requests.

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Drug Exception Timeframes and Enrollee Responsibility
Drug Exceptions, Time Frames and Enrollee Responsibilities
Standard exception request: If a clinically appropriate prescription drug is not included in our drug formulary, you may contact us by phone, electronically, or in writing to request coverage of that specific prescription drug or specialty drug. A standard exception request may be initiated by you, your designee, or the prescribing practitioner by calling Member Service at the number on the back of your Member ID card or visiting bcbst.com. We will respond to a standard exception request no later than seventy-two (72) hours after the receipt date of the request. As part of the standard exception request, the prescribing practitioner should include an oral or written statement that provides justification to support the need for the prescription drug not included in our drug formulary to treat the member’s condition, including a statement that all covered prescription drugs in your drug formulary on any tier:
i. Will be or have been ineffective;
ii. Would not be as effective as the prescription drug not included in our drug formulary; or
iii. Would have adverse effects.
If we grant a standard exception request for coverage of a prescription drug that is not in our drug formulary, we will include approval details, including dates, in written correspondence. Any applicable cost-sharing paid by the member (such as copayment or coinsurance) for the prescription will apply toward the out-of-pocket maximum. If we deny a standard exception request, you have the right to an independent review of our decision, as described below.
Expedited exception request: If a clinically appropriate prescription drug is not included in our drug formulary, an expedited exception request based on exigent circumstances may be initiated by you, your designee, or your prescribing practitioner by calling Member Service at the number on the back of your Member ID card or visiting bcbst.com. We will respond to an expedited exception request within twentyfour (24) hours of receipt of the request. An exigent circumstance exists when a member is:
i. Suffering from a health condition that may seriously jeopardize their life, health, or ability to regain maximum function; or
ii. Undergoing a current course of treatment using a prescription drugnot included in our drug formulary.
As part of the expedited review request, the prescribing practitioner should include an oral or written statement that provides:
i. A description of the exigent circumstance that exists and an explanation of the harm that could reasonably be expected to the member if the requested prescription drug is not provided within the timeframes of the standard exception request process, as outlined above; and
ii. A justification supporting the need for the prescription drug not included in our drug formulary to treat the member’s condition, including a statement that:
1. All covered prescription drugs in our drug formulary on any tier will be or have been ineffective;
2. Would not be as effective as the prescription drug not includedin our drug formulary; or
3. Would have adverse effects.
If we grant an expedited exception based on exigent circumstances for coverage of the prescription drug that is not in our drug formulary, we will provide access to the prescription drug:
i. Without unreasonable delay; and
ii. For the approval duration listed in the written correspondence.
Any applicable cost-sharing paid by the member (such as copayment or coinsurance) for the prescription will apply toward the out-of-pocket maximum. If we deny an expedited exception request, you have the right to an independent review of our decision.
External exception request: If we deny a request for a standard exception or an expedited exception, you, your designee, or the prescribing practitioner may initiate an external exception request for the original exception request by calling Member Services at the number on the back of your Member ID card or visiting bcbst.com. The denial of that request will be reviewed by an independent review panel. The independent review panel’s decision to either uphold or reverse the denial of the original exception request will be provided orally or in writing to you, your designee, or the prescribing practitioner no later than:
i. Twenty-four (24) hours after receipt of an external exception review request, if the original exception request was expedited; or
ii. Seventy-two (72) hours after receipt of an external exception review request, if the original exception request was standard.

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Explanation of Benefits
Information on Explanations of Benefits (EOBs)
Each time we process a claim you or your health care provider submit, we explain how we processed it on an EOB. An EOB, or claim summary, is a statement we send to you explaining:
How much a provider charged for your care or service
How much of that charge we paid
How much of that charge you’re responsible for paying
Why we denied a claim, in some cases
Each time you receive an EOB, please review it closely and compare it to the receipt or statement from the provider. You can find your EOBs/claim summaries in your bcbst.com account or by calling us at the Member Service number on the back of your Member ID card.
Example of an EOB

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Coordination of Benefits
Coordination of Benefits (COB)
Individual policies are not subject to state requirements for coordination of benefits. If you or your covered dependents have other coverage, whether group or individual, an individual policy will always pay secondary. Other coverage means other comprehensive medical coverage including, but not limited to, commercial major medical coverage, and does not include Medicaid, TennCare or limited benefit coverage. Benefits will be calculated as the difference between the amount paid by the other coverage and the greater of our maximum allowable charge or the amount such other coverage considers allowable expense.
If such other coverage also states that it will always pay secondary, benefits under this policy will be calculated as 50 percent of our maximum allowable charge.
In any event, our liability shall be limited to the amount we would have paid in the absence of other insurance coverage.

Transparency in Coverage

Marketplace Plans

Out of Network and Balance Billing

Enrollee Claims Submission

Grace Periods and Claims Pending

Retroactive Denials

Recoupment of Overpayments

Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibility

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Drug Exception Timeframes and Enrollee Responsibility

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Explanation of Benefits

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Coordination of Benefits

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Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibility

Drug Exception Timeframes and Enrollee Responsibility

Explanation of Benefits

Coordination of Benefits

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