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Anthem Blue Cross : Anthem Blue Cross HMO - California Care

Anthem Blue Cross HMO - California Care

PW_A120256

Frequently Asked Questions About Anthem Blue Cross HMO 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

Claims

Grievances and Appeals

General Information

 
Customer Service
Q1. How do I get additional information about my plan or benefits?
A1.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 online 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 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. 
Q2. How and when can I contact the health plan?
A2.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. 
Q3. How do I change my name or address?
A3. 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. 
Q4. What are your customer service hours?
A4.Customer Service is available Monday through Friday from 8:00 a.m. to 12:00 Midnight, Pacific time. Our automated, interactive voice response (IVR) system is available 24 hours a day/7 days a week. 
Q5. How do I get a provider directory?
A5.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.

Q6. How do I get a list of preferred drugs (drug list information)?
A6.If you have questions about whether a drug is on the prescription drug list or needs to be approved, please call us at (800) 700-2541. 
Enrollment
Q7. How can I cover my newborn from birth?
A7.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. 
Q8. How do I obtain coverage for my newly adopted child?
A8.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. 
Q9. How do I add or delete family members?
A9.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. 
Q10. Can I cover a dependent who lives out-of-state or my child away at school?
A10.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. 
Q11. How often can I change benefit plans?
A11.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. 
Q12. How long can my children remain covered?
A12.Your children remain covered if they are unmarried, under 19 years old, or under 25 years old if they are full-time students at an accredited school. Please see your Evidence of Coverage booklet for more details. 
Q13. How long can my child be covered if he or she has disabilities?
A13.If your child has a physical handicap or mental retardation and reaches the age limits (19 years, 25 years if in college), your child can continue coverage 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. 
Q14. Can I choose a different Primary Care Physician (PCP) than my spouse?
A14.Every member of your family can choose a different Medical Group, Individual Practice Association (IPA), or PCP within that Medical Group or IPA. 
ID Cards
Q15. How do I order additional ID Cards?
A15.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. 
Q16. Do I need to carry my ID Card with me at all times?
A16.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
Q17.How do I find a network provider?
A17.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 HMO Directory. 

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

Q18.What is a primary care physician?
A18.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. 
Q19.What are the advantages of using network providers?
A19.Under the HMO plan, you are only covered for services through a network provider, unless you need emergency services or urgent care. 
Q20.What happens if my current physician is not a network provider?
A20.You may be able to nominate him or her. Call our Customer Service number on the back of your ID Card. 
Q21.How do I change my primary care physician?
A21.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. 
Q22.Can I change my PCP any time I want?
A22.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.  
Q23.What if a primary care physician cannot see me right away? 
A23. Talk with the Anthem Blue Cross HMO coordinator at your medical group. 
Q24.What if a network provider isn't available to treat my condition?
A24.You primary care doctor 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. 
Q25.Can I go to a non-network provider?
A25.Under the HMO plan, you are only covered for services through a network provider, unless you need emergency services or urgent care. If you go to a non-network provider, you will have to pay for it yourself. 
Q26.Do I need a referral to see my OB-GYN?
A26.You can get OB-GYN services from a doctor who specializes in caring for women (OB-GYN) or family practice doctor who does OB-GYN and works with your medical group. You can get these services without an OK from your primary doctor. Ask your HMO coordinator for the list of OB-GYN health care providers you must choose from. 
Q27.Can I self refer to any provider for my Well Woman exam (PAP/mammogram)?
A27.Under our Well Woman benefit, women may visit an OB-GYN within their medical group/IPA without a referral or authorization from their primary care physician.  
Q28.What do I do if my PMG/IPA does not have a particular specialist I need to see within their network?
A28.Your primary care physician will refer your to a Anthem Blue Cross HMO contracting specialist which is associated with your medical group. Your medical group is required to assure that you have access to the types of specialists you need. If necessary you may be referred to any HMO contracting specialist or any specialist that has the expertise to provide the care you need for your condition or disease. 
Q29.What happens if my Primary Care Physician (PCP) or Medical Group leaves the Anthem Blue Cross HMO network?
A29.If your PCP or Medical Group will no longer be affiliated with the Anthem Blue Cross HMO network, in an effort to make this transition as smooth as possible and avoid disruption of care, Anthem Blue Cross will reassign you to another medical group. Your enrollment with the Anthem Blue Cross HMO will not otherwise be affected in any way. A new ID Card reflecting this change will be mailed to you shortly. If this choice of PCP or Medical Group does not meet your needs and you would prefer to make a different selection, please feel free to contact our Member Services department using the Customer Service telephone number listed on your current ID Card. They will assist you with your request. 
Approvals and Referrals
Q30. What services require prior approval or referral? 
A30.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. 
Q31. How do I get prior approval or referral?
A31.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.

Q32. What if I don't get prior approval or referral?
A32.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). 
Q33. When do I need a referral from my PCP?
A33.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.  
Emergency Care 
Q34. What do I do in case of an emergency? 
A34.Call 911 or seek immediate treatment in the nearest facility. If you are admitted to a hospital, ask for the Anthem Blue Cross HMO to be contacted. Review your Evidence of Coverage booklet for more details. 
Q35.Do you cover emergency care?
A35.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. A copay is a set amount you must pay for services. We cover the rest. 
Q36. What is Urgent Care?
A36.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
Q37. What do I do if I need care while traveling? 
A37.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. 
Q38. What routine coverage do I have while I am traveling?
A38.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. 
Q39. What emergency coverage do I have while I am traveling?
A39.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.  
 
Claims
Q40. How do I file a claim?
A40.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 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. 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. 
Q41. How long do I have to file a claim?
A41.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. 
Q42. A provider has billed me, how do I know how much of the bill to pay?
A42.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 receive a bill for HMO authorized services from another provider, 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. 
Q43. How can I check the status of my claim?
A43.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. 
Q44. What are co-payments?
A44.Co-payment is the member's share of the cost of a unit of service or unit of time. This is sometimes a percentage of the charges but may also be a dollar amount for specified services. 
Q45. How does my co-pay limit work?
A45.Co-pay limit is the most you will have to pay in one calendar year in co-pays. Once you reach your co-pay limit, you won't need to pay any more co-pays for the rest of the year. 
Q46. What is Coordination of Benefits (COB)?
A46.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 be coordinated between two contracts at the same Blue Plan, different Blue Plans or between a Blue Plan and a commercial carrier. 
Q47. Why did I receive a Coordination of Benefit Questionnaire and do I have to return it?
A47.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. 
Q48. What do I do with a foreign medical bill for care I received outside of the USA?
A48.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.

Q49. How is a substance abuse claim paid through my coverage? Do I need a referral?
A49.Services for substance abuse/chemical dependency may be received directly, without referral from your primary care physician, from a participating provider. Coverage is paid for acute alcoholism and drug abuse inpatient care, in acute phase only. Please refer to your Evidence of Coverage booklet or call for details as coverage varies. 
 
Grievances & Appeals
Q50. What is the procedure for lodging a compliant against a provider? 
A50.Talk to your Anthem Blue Cross HMO coordinator at your medical group or IPA first. If you have questions about your services, call your Anthem Blue Cross HMO coordinator. He or she may be able to help you right away. You may also call the toll free 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 HMO 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. 
Q51.How do I appeal a disputed health care service pertaining to medical necessity or appropriateness of service?
A51.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 resolved within 30 days, or 3 days if your case involves an imminent threat to your health and should be expedited. 
Q52. 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?
A52.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 dissatsified with the resolution through the formal grievance process, you may submit your grievance to the California Department of Managed Health Care(DMHC)for review. 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 for review. You may be eligible for an independent medical review which is handled through the DMHC 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. 
Q53. What if waiting for you to decide on my appeal would harm my health?
A53.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. 
Q54. My Explanation of Benefits says I received services that I did not have. What should I do?
A54.Please call the Customer Service number on the back of your ID Card for assistance. 
Q55. If I feel I need a second opinion, how do I go about obtaining one?
A55.Your medical group is responsible for arranging second opinions and specialty care with health care providers who are part of or who are affiliated with your Anthem Blue Cross HMO medical group. 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
Q56. How do my HMO benefits work? 
A56.When you enroll, you should choose a primary care physician. Your primary care physician (PCP) will be the first doctor you see for all your health care needs. If you need special kinds of care, this doctor will refer you to other health care providers or specialists. Your primary care physician will be part of a Anthem Blue Cross HMO contracting medical group. 
Q57. What happens to my coverage if I move out of the area?
A57.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. 
Q58. What happens to my coverage if I quit my job or I'm laid off or fired?
A58.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. 
Q59. What happens to my coverage if I turn 65?
A59.If you are age 65 or over and eligible for Medicare, you will get the benefits of this plan without taking into account Medicare unless you've chosen Medicare as your primary plan. If you've chosen Medicare as your primary health plan, you won't be able to get any benefits under this plan. Please see your Evidence of Coverage booklet for more details. 
Q60. What happens to my coverage if I retire?
A60.You may be able to continue your coverage for a limited time. See answer number 63 above.  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. 
Q61. What if I become disabled?
A61.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. 
Q62. What if my spouse and I divorce?
A62.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. 
Q63. Is my child covered while in college?
A63.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. 
Q64. Do I have coverage for pre-existing conditions?
A64.All pre-existing conditions are covered under our HMO 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.