 Claims
Q: Will you please explain the terms, deductible, co-pay and coinsurance?
A: Co-pay is the amount defined by your employer’s Medical, Prescription Drug, Dental, and Vision Plan that you are responsible for paying each time a medical, dental, or vision expense is rendered.
Coinsurance refers to the amount you and your employer’s Medical, Prescription Drug, Dental, and Vision Plan share on a percentage basis.
Q: What is the difference between calendar year versus plan year?
A: Calendar year is defined as January 1-December 31 of any given year. Plan year is defined as any twelve-month period not beginning in January and ending in December.
Q: How does a wellness/routine benefit differ from medical benefit?
A: Wellness/routine services are received when a patient is in good health. (i.e. for example annual pap smear and or cholesterol screening). The treatment is considered medical in nature when signs and symptoms of an illness or injury are present.
Q: Why are all ”Other Insurance” letters and yearly “OI” letters sent?
A: Your employer’s Medical, Prescription Drug, Dental, Vision and/or Short Term Disability Plan requires Anthem Blue Cross and Blue Shield (Anthem) as the administrator of their Plan to verify if your spouse and/or dependents have any other insurance coverage on an annual basis. The Plan also requires investigation of any possible injuries to determine if a third party, auto insurance carrier, or worker’s compensation insurance carrier is responsible for reimbursing any of your medical expenses.
Q: How do I contact the company that provides me with prescription drugs?
A: Your medical/prescription drug card should have a telephone number for your Pharmacy Benefit Manager. If it does not, contact your Human Resource Department.
Q: What is the difference between pre-certification and pre-authorization and provide a list of services that may require pre-authorization?
A: Please note that these definitions are commonly used interchangeably.
Pre-authorization:
The process of obtaining prior approval for health care coverage based on a plan’s requirements for coverage. Pre-authorization does not guarantee coverage.
Pre-certification:
A review of a proposed hospital or healthcare facility admission or of certain services or procedures prior to receiving them, in order to determine whether the proposed admission or services meets the medical necessity criteria for payment and to receive the maximum benefits available under a healthcare plan.
This is a typical list of services found in a majority of plans that may require pre-certification. Refer to your Summary Plan Description for your plan’s specific requirements:
- Inpatient hospitalization
- Select covered outpatient procedures or surgeries (dermatological procedures,
potentially cosmetic procedures, breast reduction)
- Physical therapy
- Rental or purchase of medical equipment or supplies
- Fertility services
- Obesity treatment programs and surgery
- Home health care services
- Admission to extended care facilities
- Behavioral health services (psychiatric or substance abuse)
- Chiropractic treatment
- Surgical second opinions
- Hospice care
- Purchase of prosthetic devices
- Inpatient maternity services
- Organ/bone marrow transplant services
Q: What does Usual and Customary mean?
A: Usual and customary is the allowable amount for network claims determined by Anthem, the Plan Administrator. When services are rendered by your provider, Anthem will determine the usual and customary allowable based on both the procedures and the geographical area billed by your provider.
Q: How can I get a copy of my Explanation of Benefits (EOB)?
A: You can print off the information contained on your EOB by going to the “Members“ tab on this website. This is available if your employer has authorized this access. Or you can contact your claims analyst to request a copy.
Q: Can you send me some claim forms?
A: You do not need to submit claims on a claim form. Ask your medical provider to forward the claims as indicated on the medical ID card that has been provided to you. Your dental plan may require that you submit a claim form. If so; you can print a dental claim form for submission on this website, or you may request forms from your Anthem Dental Benefit Analyst.
Q: What is meant by a pre-existing condition and/or a pre-ex clause?
A: Please review that section of your Summary Plan Document.
Q: Why were my claims denied when I just received the letter requesting the information?
A: Until Anthem has received the information necessary to process your claims; Anthem is required to make a claim determination on the information available to it at that time.
Q: What is the confirmation letter that the call center specialists send out for confirming the injury information received via phone call?
A: This letter is written verification that you identified via telephone your treatment rendered was not a result of an injury that was the responsibility of a third party, auto insurance carrier, or worker’s compensation insurance carrier.
Q: What is meant by medical necessity?
A: Please see the definition section of your medical plan Summary Plan Description
Q: How do I obtain a new ID card?
A: You can request one from this website (See Tab “Employees “) if your employer has authorized that access, or you can contact your Human Resources Department.
Q: Is a referral needed from my Primary Care Physician? (This is confusing for a participant coming from an HMO Plan).
A: As a general rule, a Primary Care Physician referral for Specialty Care services is a requirement of HMO plans. Your current plan is not an HMO therefore, you will need to review your Summary Plan Description for precertification requirements for Specialty Care.
Q: How do I file a claim?
A: Ask your provider to send the claim to the address on the back of your medical ID Card.
Q: Who should I call if I don’t understand how a claim was processed?
A: Please contact your dedicated Claims Associate as identified on your Explanation of Benefits.
Q: How are claims for pre-existing conditions handled?
A: Please see the pre-existing condition section of your medical Summary Plan Description.
Q: What if I have expenses for an accident or illness that may be payable by worker’s compensation, car insurance or a party I intend to sue?
A: If you have a claim that you believe may be covered by worker’s compensation you should contact your employer immediately. If you have car insurance or other insurance that may cover your medical expenses, forward the claims to Anthem so we make a determination whether the expenses are covered as well. Please notify Anthem’s Subrogation Department if you intend to file a lawsuit against someone regarding injuries or illnesses for which you have submitted medical, dental, or short-term disability claims to Anthem.
Q: Are all prescription drugs covered under health care plans?
A: No. You will need to review the Limitation and Exclusion Section of your medical Summary Plan Description. If you are having prescriptions filled at a pharmacy and you are using a drug card issued by a major pharmacy benefit manager such as Systemed, Restat, or Walgreen’s, your pharmacist should be able to tell you whether your prescription is covered.
Q: Do I need precertification?
A: Please see the Managed Care section of your Summary Plan Description.
Q: Will my health benefit plan claim payment be reduced if I do not precertify?
A: Every health plan may be different. Failure to precertify could result in benefits being reduced. You should read your medical Summary Plan Description carefully and refer to this document to determine how benefits could be affected.
Q: Does pre-admission certification guarantee coverage?
A: No, pre-admission certification does not guarantee payment of benefits. Call your claims administrator for information regarding your coverage.
Q: If my pharmacist has a problem processing my prescription, what should we do?
A: Depending upon the design of your benefit plan, you may receive a separate Identification card for your prescription drug benefits. If so, your pharmacist should contact the telephone number on the back of your Identification card. If you received a single Identification card for both medical and prescription drug services, the information on the back of the Identification card will direct the pharmacist as to where he/she can call for assistance.
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