Anthem Blue Cross : Anthem Blue Cross POS - Point of Service Plan

Anthem Blue Cross POS - Point of Service Plan

PW_A120258

Frequently Asked Questions About Anthem Blue Cross POS Plans

Click on a section below to view applicable questions or scroll down to view all Questions: 

Customer Service

Enrollment

ID Cards

Physicians and Other Providers

Approvals and Referrals

Emergency Care

Travel Coverage

Pharmacy

Claims

Grievances and Appeals

General Information

 
Customer Service
1. How do I get additional information about my plan or benefits?
Connect to Customer Service via our interactive Member Services feature. The Member Service pages link you to the details of your health care plan, including dependent information and claim status, and serve to electronically connect you to Customer Service for ID Card replacement or benefit issues. To safeguard your personal information, you must receive a personal identification number (PIN) before you can access Member Services. You can request a PIN number on-line at the Member Services page, or by calling the toll free Customer Service number printed on the back of your ID Card and the Customer Service Representatives will assist you. You will also find detailed information about your plan or benefits by reviewing your Evidence of Coverage booklet. If you should have any questions regarding the information, call our Customer Service number on your ID Card or speak with your Benefits Administrator at your place of employment. 
2. How and when can I contact the health plan?
Connect to Customer Service via our interactive Member Services feature 24 hours a day, 7 days a week. The Member Service pages link you to the details of your health care plan, including dependent information and claim status, and serve to electronically connect you to Customer Service for ID Card replacement or benefit issues. To safeguard your personal information, you must receive a personal identification number (PIN) before you can access Member Services. You can request a PIN number on-line at the Member Services page, or by calling the toll free Customer Service number printed on the back of your ID Card and the Customer Service Representatives will assist you. 
3. How do I change my name or address?
Please call Customer Service number printed on the back of your ID Card and request that your file be updated with your new name and address. Written verification by mail or fax will be required. If you move more than 30 miles from your Medical Group or IPA, call Customer Service to select a new Medical Group or IPA. 
4. What are your customer service hours?
Customer Service is available Monday through Friday from 8:00 a.m. to 8:00 p.m., Pacific time. Our automated, interactive voice response (IVR) system is  
available 24 hours a day/7 days a week. 
5. How do I get a provider directory?
You can get a directory of Anthem Blue Cross HMO providers as follows:  
If you are a new member, a directory is included in your enrollment kit.  
If you are already a member, your renewal kit includes a brochure with instructions for finding a Anthem Blue Cross HMO provider using our internet web site to link to Provider Finder. The renewal kit also includes a postcard for you to mail to us if you would rather get a copy of the directory.  
You can also call our toll free Customer Service number shown on your Member ID card and ask us to send you a directory.  
6. How do I get a list of preferred drugs (formulary information)?
If you have questions about whether a drug is on the prescription drug formulary or needs to be approved, please call us at (800) 700-2541. 
Enrollment
7. How can I cover my newborn from birth?
Please contact your Human Resources administrator IMMEDIATELY. You have 31 days from the date of birth, date of marriage or adoption to add your new dependents without having to wait until your plan's re-enrollment period. 
8. How do I obtain coverage for my newly adopted child?
Please contact your Human Resources administrator IMMEDIATELY. You have 31 days from the date of adoption to add your new dependents without having to wait until your plan's re-enrollment period. 
9. How do I add or delete family members?
Please contact your Human Resources administrator and call us at the Customer Service number on the back of your ID Card. You will need to fill out a Membership Change form. 
10. Can I cover a dependent who lives out-of-state or my child away at school?
You can cover your enrolled dependents, including students and family members, who temporarily live outside of California through Guest Membership. Guest Membership offers temporary HMO services from a "host" Anthem Blue Cross Blue Shield affiliated HMO. To qualify, you or your enrolled family members, must live outside California for 90-180 consecutive days. Ask your benefits administrator or your Human Resources department representative for a Guest Membership application, or call the Anthem Blue Cross Customer Service number on your ID Card. 
11. How often can I change benefit plans?
You may only change benefit plans during your company's open enrollment period, unless you have a change in family status either through marriage, or the birth or adoption of a child. Changes in family status allow persons to enroll who were not previously enrolled. 
12. How long can my children remain covered?
Your children remain covered until age 26. Please see your Evidence of Coverage booklet for more details.  
13. How long can my child be covered if he or she has disabilities?
If your child has a physical handicap or mental retardation and reaches the age limit of 26, your child can still quality if he or she is: covered under this plan, still dependent on you or your spouse, not able to get a job to self-support him or herself because of the handicap or mental retardation. Please see your Evidence of Coverage booklet for more details.  
ID Cards
14. How do I order additional ID Cards?
Please use the Member Services feature to order ID Cards. Or, call the toll free Customer Service number on the back of your ID Card to order new ID Cards. Customer Service is available from 8:00 a.m. to Midnight, Monday through Friday, Pacific time. 
15. Do I need to carry my ID Card with me at all times?
We recommend that you carry your ID Card at all times. You may need it during an emergency. You will need to present your ID Card at your doctor's office or at a hospital. 
Physicians and Other Providers
16. How do I find a network provider?
You have three options:  

Go to our Provider Finder and follow the prompts to retrieve your health plan's network providers. If you want directions to a specific provider, simply click on the provider's name and you are linked to an area map that shows various routes to the provider's location. 

Look in the printed Anthem Blue Cross PPO Directory. 

Call the toll free Customer Service number on your ID Card. 

 
17. What is a primary care physician?
Primary care physician is a doctor who is a member of the medical group you have chosen to give you health care. Primary care physicians include general and family practitioners, internists and pediatricians. Certain specialists as we may approve may also be designated primary care physicians. 
18. What are the advantages of using network providers?
By using a network provider, you can reduce your out-of-pocket costs. 
19. What happens if my current physician is not a network provider?
You may ask your physician to contact us if he or she is interested in joining our network. 
20. How do I change my primary care physician?
You can ask your employer for a Membership Change form. Fill out the form, sign it and return it to your employer. You can also call our Customer Service number on your Member ID Card. We will need to know why you want to change your medical group. Try to call Customer Service by the 15th of the month so that your change can become effective on the first day of the following month. Changes are not allowed if you are in a course of a medical treatment. You may also connect to Customer Service via our interactive Member Services feature. 
21. Can I change my PCP any time I want?
There are three ways you can change your medical group/PCP:  

At your company's next open enrollment period, you may choose any medical group within the enrollment area, in which you live or work.

If you change your permanent residence or employment location and your new residence or employment location is not within the enrollment area of your current medical group, you must request a transfer to another medical group by calling the Customer Service number on the back of your ID Card or by filing a Membership Change form within 31 days of your move.

Under special circumstances, you can request a transfer by calling the Customer Service number on the back of your ID Card or by filing a Membership Change form. You must include the reasons for your request. We must approve your request for the transfer to become effective.

 
22. What if a primary care physician cannot see me right away?
Talk with the Anthem Blue Cross POS coordinator at your medical group. 
23. What if a network provider isn't available to treat my condition?
You primary care physician will be the first doctor you see for all your health care needs. He or she may refer you to another doctor if you need special care. 
24. Can I go to a non-network provider?
You may go to a non-network provider, but your out-of-pocket cost could be substantially greater than if you went to a participating network provider. 
Approvals and Referrals
25. What services require prior approval or referral?
Members must obtain referrals from their primary care physicians. Referrals are made when the primary care physician (PCP) and the medical group deem services of a specialist medically appropriate. The PCP arranges for the referral and gives the member a completed referral form that authorizes specific treatment or services. 
26. How do I get prior approval or referral?
Your PCP may refer you to another doctor if you need special care. Your primary care physician must OK all the care you get except when you have an emergency. Your PCP's medical group has to agree that the service or care you will be getting from the other health care provider is medically necessary. Otherwise it won't be covered.  
You will need to make the appointment at the other doctor's office.   
Your primary care doctor will give you a referral form to take with you to your appointment. This form gives you the OK to get this care. If you don't get this form, ask for it or talk to your Anthem Blue Cross HMO coordinator at the doctor's office.  
27. What if I don't get prior approval or referral?
Your primary care physician must OK all the care you get except when you have an emergency. Your PCP's medical group has to agree that the service or care you will be getting from the other health care provider is medically necessary. Otherwise it won't be covered. We only pay for the number of visits and the type of special care that your primary care physician OK's. Call your physician if you need more care. If your care isn't approved ahead of time, you will have to pay for it (except for emergencies). 
28. When do I need a referral from my PCP?
Under the HMO benefits, your doctor may refer you to another doctor if you need special care. Your primary care physician must OK all the care you get except when you have an emergency. 
Emergency Care
29. What do I do in case of an emergency?
Call 911 or seek immediate treatment in the nearest facility. If you are admitted to the hospital directly from the emergency room, you will not be charged the emergency room copay. If admitted, please have someone contact your Medical Group or Anthem Blue Cross Customer Service within 48 hours of your admission. For the first 48 hours or until stabilized, emergencies are covered under HMO benefits for emergency outpatient services and supplies, whether or not you receive services from a Anthem Blue Cross HMO facility. Please review your Evidence of Coverage booklet for more details. 
30. Do you cover emergency care?
An Emergency is a sudden, serious, and unexpected illness, injury, or health problem (including sudden and unexpected severe pain). This includes any illness, injury or problem you reasonably believe could endanger your health if you don't get medical care right away. Some examples of an emergency condition are:  

Severe shortness of breath 

Uncontrolled or severe bleeding 

Loss of consciousness 

Suspected heart attack or heart attack 

Fractures 

Poisoning 

Severe burns 

 
We won't cover services that don't fit what we mean by emergency services. You may need to pay a copay for emergency room services. 
31. What is Urgent Care?
Urgent care is a service you receive for a sudden, serious, or unexpected illness, injury or condition to keep your health from getting worse. Although not an emergency condition, care is needed right away to relieve pain, find out what's wrong, or treat the problem. Some examples of an urgent care condition are:   

Colds and Flu 

Sprains and strains 

Vomiting 

Cramps 

Cuts and bruises 

Earaches 

Rashes 

Diarrhea or stomach pains 

Fever

 
Travel Coverage
32. What do I do if I need care while traveling?
You can get urgent care if you are more than 20 miles away from your medical group.  
Within California
For urgent care, if care can't wait until you get back to make an appointment with your primary care physician, get the medical care you need right away. You must call us within 48 hours if you are admitted to a hospital.  
Outside of California
If you are traveling outside California, and need health care because of a sudden non-emergency illness or injury, call the BlueCard Access 800 number on the back of your member ID Card. The BlueCard Access Call Center will tell you if there are doctors or hospitals in the area that can give you care. They will give you the names and phone numbers of nearby doctors and hospitals that you can go to or call for an appointment.  
Outside of California for more than 90 days
If you or your family members will be away from home for more than 90 days, you may be able to get a guest membership in a medical group in the city you are visiting. Before you leave home, call the Anthem Blue Cross HMO Customer Service number on your member ID Card. Ask for the Guest Membership Coordinator. We will send you forms to fill out. If there is a medical group taking part in the national network in the city you will be visiting, you'll be a guest member while you're away from home. The benefits you get may not be the same as the benefits you would get at home.  
Out of the Country
If you need care while traveling out of the country, the BlueCard Worldwide program covers inpatient and emergency care services from many international providers. To access benefits, simply present your Anthem Blue Cross member ID Card when you receive services from a participating provider. BlueCard Worldwide providers will not require a payment from you at the time of your treatment and they will bill us directly for their services. The Anthem Blue Cross Blue Shield Association is in the process of expanding their international network of providers. For updated information, visit their Web site at http://www.bluecares.com/healthtravel/finder.html. You can also get information on Worldwide providers by calling BlueCard Provider Access toll-free at 1-800-810-BLUE. Coverage for services from international providers may be limited. For complete information, please refer to your Evidence of Coverage booklet. If you are unable to access a participating international provider and you require care for an emergency or urgent condition, go to the nearest provider and get treated. Please notify Anthem Blue Cross as soon as possible if you are admitted into a hospital. Ask for your claims and medical records to be provided to you in English, if possible, and mail them to us for processing. 
33. What routine coverage do I have while I am traveling?
Under HMO benefits, routine care is not covered while traveling. It may be covered if you are traveling outside California for more than 90 days. See applicable section of previous question. 
34. What emergency coverage do I have while I am traveling?
You can get emergency services if you are more than 20 miles away from your medical group. Call 911 or seek immediate treatment in the nearest facility. If you are admitted to a hospital, you must call us within 48 hours. Review your Evidence of Coverage booklet for more details.  
Pharmacy
35. How do I use my prescription benefits?
Your health plan’s pharmacy services and network is administered by Express Scripts, one of the nation’s largest pharmacy benefit managers. The combined experience and commitment to the member services of Anthem and Express Scripts will help promote better health and value for millions of members. 
If your coverage includes a pharmacy benefit, your health benefit plan ID card is also your prescription drug card. Simply present your ID card and prescription at a participating retail pharmacy of your choice. The pharmacist will use your prescription and member information to determine your co-payment or co-insurance. Most plans allow you to receive up to a 30-day supply of covered medications at a retail pharmacy. Depending on your benefit, you may also be able to order medications using the Express Scripts Home Delivery pharmacy (home delivery). Consult the terms of your policy and any related riders or Schedule of Benefits for full details about your prescription drug benefits, if they apply. 
36. How do I access my retail pharmacy network?
We offer access to a broad retail pharmacy network that includes thousands of pharmacies throughout the United States. That means you have convenient access to your prescriptions wherever you are — at home, work or even on vacation. For a list of participating pharmacies, access the Express Scripts website in the “My Pharmacy” section. No additional login is required. Then, select “Find a Pharmacy” in the “My Prescription Plan” section. 
  
You’ll get the most from your benefits by using a participating pharmacy. Choosing a non-network pharmacy means you’ll pay the full cost of the prescription up front. Then you must submit a claim form to your health plan for reimbursement.
 
37. How do I order medications using home delivery?
If your coverage includes a pharmacy benefit and you take maintenance medications, you can typically get a 90-day supply of your medication for the same price as two 30-day prescriptions filled at a retail pharmacy. Check your policy terms for details. Home delivery is a service for members who take maintenance medications such as for hormone replacement, asthma, diabetes, high blood pressure, arthritis, and any other conditions that require you to take a drug on an ongoing basis. It offers the convenience of having prescriptions filled using home delivery. Simply pick up the phone or submit your order online, and your medications are delivered directly to your home, office or anywhere in the United States. To order refills of your medications online if you have home delivery, log in to the Express Scripts website in the “My Pharmacy” section. No additional login is required. Then, select “Order Refills” in the “My Prescriptions” section. 
38. What is a Drug list?
Your health plan uses what is called a “Preferred Formulary” that we also refer to as the “drug list” or just the “formulary.” This drug list contains brand-name and generic medications approved by the Food & Drug Administration (FDA) that have been reviewed and recommended by our Pharmacy and Therapeutics (P&T) Committee. Our P&T Committee is an independent group of practicing doctors, pharmacists, and other health care professionals responsible for the research and decisions surrounding our drug list. This group meets regularly to review new and existing drugs and chooses the medications for our drug list — based on various factors, including their safety, effectiveness and value.  
If your doctor prescribes a drug that is not listed on the drug list, you may be subject to extra out-of-pocket costs. Because the medications on the drug list are subject to periodic review, call the Customer Service number on the back of your ID card to determine which medications are included. To obtain a copy, you can also get this information online by logging in to your health plan’s website. 
39. How much will I pay for my prescriptions?
In most cases when you use a participating pharmacy, you will be required to pay a fixed co-payment. (Depending on your policy, coinsurance may apply). In general, you will pay the least amount for generic medications and the highest amount for non-preferred/non-formulary medications. However, there may be exceptions based on our drug list tiers. Having your doctor prescribe generic drugs or drugs listed on your plan’s drug list can help reduce your total prescription out-of-pocket costs. 
40. What is a tiered drug list?
A tiered drug list assigns medications to specific levels, such as Tier 1, 2 or 3, based on various factors. Generic medications have the most affordable copay; brand-name medications, both preferred and non-preferred, usually cost more. Each of these medications is placed on tiers based on certain factors. These include, but are not limited to, the absolute cost of the drug, the cost of the drug relative to other drugs in the same therapeutic class, the availability of over-the-counter alternatives, and other clinical and cost-effectiveness factors. 
41. What if my medication is not on the drug list?
If a drug your doctor prescribes is not on our drug list, we offer an “open drug list” that allows you and your physician to choose a prescription medication that is not on the drug list, as long as it is approved by the FDA. But it’s important to note that choosing medications that are not on our drug list will increase your out-of-pocket costs. Please talk with your doctor about prescribing a medication that is on the drug list when appropriate. If a medication is selected that is not on your drug list, you will be responsible for the applicable non-formulary cost share amount. 
You or your physician may submit a request to add a drug to the drug list either in writing or on our web site. Requests are taken into consideration by the P&T Committee during the drug list review process.  
Inclusion of a medication on the drug list is not a guarantee of coverage. Some drugs, such as those used for cosmetic purposes, may be excluded from your benefits. Please refer to your Certificate or Evidence of Coverage for coverage limitations and exclusions. 
42. What is a prior authorization and step therapy?
Certain prescription drugs (or the prescribed quantity of a drug) may require “prior authorization” before you can fill the prescription. Some drugs require prior authorization because they may not be appropriate for every patient or may cause side effects. Your doctor should have a current list of drugs requiring prior authorization. However, your doctor may call our referral number for authorization and information regarding these requirements. Prior authorization helps promote appropriate utilization and enforcement guidelines for prescription drug benefit coverage.  
In addition, “step therapy” involves medication that is prescribed only after you try a "first-line" drug. With step therapy, our P&T Committee recommends certain drugs as the first ones to try when starting or changing medication treatment. In instances in which one of these medications isn’t effective and/or appropriate for a particular member, the step therapy requirements allow the physician to then prescribe a different medication.  
The drug rider to your policy contains additional detail regarding prior authorization and step therapy, and lists the drugs that are subject to these requirements. For additional information, call the telephone number listed on the back of your ID card. 
At the time you fill a prescription, your pharmacist is informed of the prior authorization or step therapy requirement through the pharmacy's computer system and is instructed to contact your health plan. The health plan will review the request and communicate the approval criteria to the requestor. If additional information is needed, the pharmacist may contact your prescribing physician.  
 
Your doctor may also request an exception to the prior authorization/step therapy requirements, such as in instances in which you have an allergic or adverse reaction to the medication, or another documented reason that prevents you from following the prior authorization and/or step therapy requirements.  
 
43. What do I need to do if one of my prescriptions requires a prior authorization or step therapy?
Your doctor should have a current list of drugs requiring prior authorization or step therapy. The drug rider to your policy that explains your drug benefit also lists these drugs. When you fill your prescription at a retail pharmacy, your pharmacist will be notified that your medication requires prior authorization and will take the necessary steps to request it. If you use home delivery, your doctor must obtain prior authorization or follow the step therapy requirements before you can fill your prescription.  
44. What is dose optimization?
When clinically appropriate, dose optimization typically involves changing from twice-daily dosing to a once-daily dosing schedule. For example, a 10mg dose taken twice per day would be changed to a 20mg dose taken only once per day.  
For a few specific drugs, it is common practice for doctors to initially prescribe a lower strength of medication and then gradually move to higher strengths over a period of time. In these cases, the goal of dose optimization is to help ensure that as higher dosages are prescribed, the member takes a single dose at the higher strength. 
If a member submits a prescription that exceeds the dosing limits set by the dose optimization program, the pharmacy’s computer will receive an electronic message that the prescription claim is being rejected due to Drug Utilization Review (DUR). The pharmacist may contact the doctor to determine if a different dose consistent with dose optimization guidelines is appropriate. If so, the drug is prescribed and filled at the new dosage. Or if there are medical reasons for the drug dosing schedule as originally prescribed, the doctor can request prior authorization review.
 
45. What are medication quantity limits?
Taking too much medication or using it too often isn’t safe and may even drive up your health care costs. Quantity limits regulate the amount of medication covered by your plan for a certain length of time. Most plans cover a 30-day retail pharmacy supply or up to a 90-day supply using home delivery. Quantity limits follow U.S. Food and Drug Administration (FDA) guidelines, as well as manufacturer recommendations. 
If you refill a prescription too soon or your doctor prescribes an amount higher than recommended guidelines, our pharmacy system will reject your claim. When this happens, the pharmacist receives an electronic “Invalid/Excessive Quantity” message. If your doctor believes your situation requires an exception, he or she may request prior authorization review. To avoid disrupting your treatment, you’ll be covered for the approved amount while review takes place. 
46. When I submit a prescription, and my pharmacist receives an age or gender edit, what does that mean?
Certain drugs approved by the FDA or other prescribing guidelines include provisions that they are not appropriate for use based on a person’s age or sex. 
If you submit a prescription that is impacted by these requirements, the pharmacy computer will receive an electronic message of “Indication Not FDA Approved” (gender edit) or “Non-Covered Prescription Item” (age edit). This lets the pharmacist know that your prescription drug plan will not cover the medication as prescribed. However, the prescribing physician may determine that important medical reasons exist for prescribing this medication as written. If this is the case, the physician may request prior authorization review. 
47. What is the difference between generics and brands and how does it affect my benefits?

Brand-name Drug: A brand-name drug is usually available from only one manufacturer and may have patent protection.

Generic Drug: A generic drug is required by law to have the same active ingredients as its brand-name counterpart but is normally only available after the patent expires on a brand-name drug. You can typically save money by using generic medications.

Be sure to check your Schedule of Benefits to see how the use of generic versus brand-name drugs may affect your benefits and out of pocket costs. You may save money by using generic medications.  
48. Are generic medications as safe and effective as brand-name drugs?
Yes. Generic medications are regulated by the FDA. In order to pass FDA review and be A-rated, the generic drug is required to be therapeutically equivalent to its counterpart brand-name medication in that it must have the same active ingredients, and the same dosage and strength.  
49. Why are generic medications less expensive?
Normally, a generic drug can be introduced to the market only after the patent has expired on its brand-name counterpart and can be offered by more than one manufacturer. Generic drug manufacturers generally price their products below the cost of the brand-name versions.  
50. Why are generic drugs important?
Depending on your benefit design, you can help control the amount you pay for your prescriptions by requesting that your doctor prescribe generic medications whenever appropriate.  
  
51. How can I request a generic medication?
Your physician and pharmacist are the best sources of information about generic medications. Simply ask one of them if your prescription can be filled with an equivalent generic medication. You may be subject to higher cost sharing for brand drugs. 
  
52. Can I request a brand-name drug?
Depending on the terms of your drug coverage, you may request that your doctor prescribe the brand-name drug even when a generic version is available. However, if a generic is available, you may have to pay the difference in cost between the generic and brand-name drug plus the generic co-payment.  
53. Can I have my prescription switched to a drug with a lower co-payment?
If your current prescription medication is not a generic, call your doctor and ask if it's appropriate for you to switch to a lower cost generic drug. The decision is up to you and your doctor.  
You can also select the “Save on My Prescriptions” link on Express Scripts’ website where you manage your current prescriptions. You’ll get information to discuss with your doctor and the tools to get started. To access Express Scripts’ website, visit the “My Pharmacy” section of your health plan website. No further login is required. On the Express Scripts site, select “Save on my Prescriptions” in the “My Prescriptions” section. 
54. Can I get reimbursed for drugs I got from a pharmacy that is not in the network?
If your benefits include out-of-network coverage, you can get reimbursed for prescriptions filled at a non-network pharmacy, but it may cost you more. Be sure to take a claim form with you to the out-of-network pharmacy, complete it and mail the completed form to the address listed on the form. You can download a claim form by accessing the Express Scripts website in the “My Pharmacy” section. No additional login is required. Then, select the Claim Reimbursement Form” in the “Printable Forms” section. You can also call the phone number on the back of your health plan ID card. 
55. If I am going to be out of town for an extended time, how do I get an extra supply of drugs to cover me through that period?
If you are going to be out of town for an extended period and need medication, call the customer service number on the back of your member ID card to find a nearby participating national pharmacy. If you are planning to go out of the country, go to your local network pharmacy prior to your trip. Pay for the extra supply and send us a claim form. If you need to purchase drugs while out of the country, pay for the drug and send us a letter indicating your prescription, along with a receipt and a claim form.   
If your coverage includes home delivery service, you can typically obtain up to a 90-day supply of your prescription maintenance drugs with your doctor’s prescription. 
56. Why did I only receive part of my order through home delivery?
You may receive a partial order if a medication within your order cannot be filled right away while the other prescription is shipped separately to help avoid delay. The Prescription History page on Express Scripts’ website where you manage, and order and fill your prescriptions enables you to see when orders are partially shipped or if we need more information from you. 
Claims 
57. How do I file a claim? 
HMO providers' capitation covers the services they provide and the services of specialists they authorize the member to use thus eliminates the need for claim submission. However, claims need to be submitted for authorized inpatient care, emergency services and for outpatient prescription drugs purchased from a non-participating pharmacy under the Prescription Drug Program.HMO/PPO providers and hospitals participating under our standard business contracts will submit claims on the member's behalf. Other providers may require members to submit their own claims.If you receive services from Non-PPO providers, you will likely need to submit a claim to Anthem Blue Cross. You can get a claim form from your employer, by downloading the claim Forms from our Web site, or by calling the Customer Service number on your ID Card. Be sure to use a separate claim form for each patient and service provider. 
58. How long do I have to file a claim?
Claim forms submitted by the member or a provider must be received by us within 90 days of the date the expense is incurred in order to be eligible for benefits. If it is not reasonably possible to submit the claim within that time frame, an extension of up to twelve months will be allowed. We are not liable for the benefits of the plan if claims are not filed within this time period. 
59. A provider has billed me, how do I know how much of the bill to pay?
Under the HMO plan, your provider will bill us directly. If you should receive a bill, please call us at the number on the back of your ID Card and we will answer your questions and ask you to forward the bill to us.If you are referred to a specialist who does not belong to the Anthem Blue Cross HMO network, or if you receive ambulance services, those providers might generate a bill and send it to you in error. If you receive a bill for HMO authorized services, do not ignore it. As quickly as possible, send a copy to your PCP or medical group, then call the service provider and tell them you forwarded the bill to your PCP or medical group. If you have questions regarding a bill for services received from a PPO provider or out-of-network provider, please call us at the toll free number on your ID Card. 
60. How can I check the status of my claim?
Connect to Customer Service via our interactive Member Services feature. The Member Services pages link you to the details of your health care plan, including dependent information and claim status, and serve to electronically connect you to Customer Service for ID Card replacement or benefit issues. To safeguard your personal information, you must receive a personal identification number (PIN) before you can access Member Services. You can request a PIN number on-line at the Member Services page, or by calling the toll free Customer Service number printed on the back of your ID Card and the Customer Service Representatives will assist you. 
61. What is the difference between deductibles and co-payments?
Co-payment is a type of member cost sharing that requires a flat amount per unit of service or unit of time. This is usually a percentage of the charges but may also be a dollar amount for specified services. The most common percentage co-payment is 20%. In HMOs, a common co-pay is $5 per visit. Under the Anthem Blue Cross drug plan, it is $5-$10-$15 per prescription.Deductible is an amount the insured person must pay before insurance payments for covered services begin. The deductible is usually a set amount or a percentage determined by the member's contract, and is calculated based on the lower of the hospital/provider actual charges or the payment benefit. For example, an insurance plan might require the insured to pay the first $250 of covered expenses during a calendar year.  
62. How does my out-of-pocket maximum work?
Out-of-pocket maximum refers to the most you pay for covered expenses during the year before the plan begins paying 100% of covered expenses for the rest of the year. It is a sum of deductible and coinsurance amounts. Only covered expenses count toward the maximum. For example, any charges above the limited fee schedule for out-of-network doctor's services do not count. 
63. What is Coordination of Benefits (COB)?
Coordination of Benefits (COB) is the anti-duplication provision to limit benefits for multiple group health insurance in a particular case to 100% of the covered charges and to designate the order in which the multiple carriers are to pay benefits. Under a COB provision, one Plan is determined to be primary and its benefits are applied to the claim. The unpaid balance is usually paid by the secondary Plan to the limit of its liability. Benefits may becoordinated between two contracts at the same Blue Plan, different Blue Plans or between a Blue Plan and another commercial carrier. 
64. Why did I receive a Coordination of Benefit Questionnaire and do I have to return it?
The Coordination of Benefit questionnaire is used to determine if you are covered by more than one group health insurance carrier. Please fill it out and return to us so that we may process your claims correctly. 
65. What do I do with a foreign medical bill for care I received outside of the USA?
When receiving services in a foreign country, the member should ask for the claim to be written in English and: Submit the itemized bill with the policyholder's identification number clearly displayed. A claim form may also be submitted with the itemized bill if it is available, but it is not required.Use a separate form for each enrolled family member and each provider of service. Submit the form to the Customer Service address printed on the member's ID Card. Anthem Blue Cross is not able to pay benefits in the local currency of the claims submission site. The claims amounts are converted into dollars using the Wall Street Journal exchange rate on the day the claims are paid. 
Grievances & Appeals
66. What is the procedure for lodging a compliant against a provider?
Under the HMO benefits, if you have questions about your services, call your Anthem Blue Cross POS coordinator at your medical group. He or she may be able to help you right away. You may also call the Customer Service number on your member ID Card. If you are still unhappy and wish to file a complaint, you should fill out a "Member Issue Form". You can get this form from your Anthem Blue Cross POS coordinator or from us. You may also call us at the Customer Service number on your member ID Card and ask one of our Customer Service Representatives to fill out the Member Issue Form for you.Under the POS benefits, please call the Customer Service telephone number listed on your ID Card. 
67. How do I appeal a disputed health care service pertaining to medical necessity or appropriateness of service?
You may ask for a review from Anthem Blue Cross. Call us at the Customer Service number shown on your Member ID Card or write to us at the following address:
 
Anthem Blue Cross
Grievance and Appeal Management
P.O. Box 4310
Woodland Hills, CA 91367 

Tell us about your complaint and enclose any bills or records. Your issue may then become part of our formal grievance process and your issue will be resolvd within 30 days, or 3 days if your case involves an imminent threat to your health and should be expedited. 
68. How do I appeal a claim payment or denial?If I am dissatisfied with the resolution through the formal grievance process, what are my remaining options?
You may file an appeal with Anthem Blue Cross. Call us at the Customer Service number shown on your Member ID Card. Your issue may then become part of our formal grievance process and will be resolved accordingly. If you are dissatisfied with the resolution through the formal grievance process, you may have additional rights under the California Department of Managed Health Care(DMHC)or California Department of Insurance (DOI) depending on whether one of those regulatory agencies governs your plan. If your case involves an imminent threat to your health including, but not limited to, the potential loss of life, limb or major bodily function, you may not be required to complete the Anthem Blue Cross appeal process or to wait at least 30 days, but may immediately submit your grievance to the DMHC or DOI for review. You may be eligible for an independent medical review which is handled through the DMHCor DOI and a contracted independent medical review organization. In addition, you may at any time pursue other dispute remedies which may include Small Claims Court or Binding Arbitration. 
69. What if waiting for you to decide on my appeal would harm my health?
If your case involves a sudden threat to your health, such as the loss of life or limb or major bodily function, we'll expedite the review and resolve your complaint within three days. 
70. My Explanation of Benefits says I received services that I did not have. What should I do?
Please call the Customer Service number on the back of your ID Card for assistance. 
If your primary care physician referred you to a specialist and you want a second opinion, you have the right to a second opinion by an appropriately qualified health care professional who is part of the Anthem Blue Cross HMO provider network. To ask for a second opinion about recommendations by your primary care physician, call your primary care physician or your Anthem Blue Cross HMO coordinator at your medical group. To ask for a second opinion from a specialist outside your medical group, please call the Customer Service number shown on your ID Card.  
General Information
71. How do my POS benefits work?
Under the HMO portion of coverage, you must obtain a referral from your primary care physician (PCP) to see a specialist. You must see the specialist to whom your PCP refers you to obtain HMO benefits. As long as your PCP refers you for medically necessary, covered services incurred while coverage is in force, the medical group would be liable for the payment of claims for professional services. If you elect to "opt-out", or use the Prudent Buyer portion of coverage, you are free to select a provider of your choosing. Current Prudent Buyer benefits are paid at the appropriate participating percentage of the negotiated rate for a Prudent Buyer provider after satisfaction of your calendar year deductible for medically necessary covered services furnished, for the most part, to treat an illness or injury. Benefits for a non-Prudent Buyer provider are paid at the non-participating provider percent of the allowable amount after satisfaction of the same calendar year deductible is met. A non-Prudent Buyer provider is under no obligation to reduce a fee to our allowance, if it exceeds the allowance. 
72. What happens to my coverage if I move out of the area?
Please call Customer Service and request that your file be updated with your new address. If you move more than 30 miles from your Medical Group or IPA, call Customer Service to select a new Medical Group or IPA. 
73. What happens to my coverage if I quit my job or I'm laid off or fired?
When your job ends, usually for any reason other than gross misconduct, you can pay to continue, for a limited time, exactly the same benefits you have while employed, through a federal law called COBRA.  Your employer must provide you with detailed information regarding the terms, cost and duration of COBRA benefits upon termination of your employment. 
74. What happens to my coverage if I turn 65?
Members eligible for Medicare will receive the full benefits of this plan except those who are receiving treatment for end-state renal disease or those who are entitled to Medicare benefits as disabled persons. Please see your Evidence of Coverage booklet for more details. 
75. What happens to my coverage if I retire?
If your employer employs 20 or more people, you may be able to keep on being covered when, as a retiree, your benefits are canceled. This is called COBRA. Ask your employer for more information. Your employer will let you know that you have a right to keep your health plan under COBRA. You should know that you might have to pay the whole cost of staying on the health plan. 
76. What if I become disabled?
If you are a totally disabled subscriber or a totally disabled family member and under the treatment of a physician on the date of discontinuance of the Group Benefit Agreement issued by us to the group, your benefits will be continued for treatment of the totally disabling condition. Please refer to your Evidence of Coverage booklet for more details. 
77. What if my spouse and I divorce?
Your family members can continue coverage for a limited time, through COBRA, if you are divorced or legally separated.  Ask your employer for more information. 
78. Is my child covered while in college?
You and your family members do not have to enroll in the same medical group. For your college age student, you may choose a medical group close to the college.You can cover your enrolled dependents, including students and family members, who temporarily live outside of California through Guest Membership. Guest Membership offers temporary HMO services from a "host" Anthem Blue Cross Blue Shield affiliated HMO. To qualify, you or your enrolled family members, must live outside California for 90-180 consecutive days. Ask your benefits administrator or your Human Resources Department representative for a Guest Membership application, or call Anthem Blue Cross Customer Service. 
79. Do I have coverage for pre-existing conditions?
All pre-existing conditions are covered under our POS plan.  

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.