Member Eligibility and Coverage

  • Eligibility and benefits

    The benefits of each plan vary widely by contract. You can verify a member’s eligibility and benefits in several ways. However, actual payment is subject to the subscriber’s contract and eligibility at the time of service.

  • Our secure provider website offers the quickest way to obtain secure, personalized, easy-to-use information. You can verify member eligibility and benefits (including plan effective dates) basic demographic information, deductible, and benefit limit accumulators. You can also check the status of a claim.

    Our Interactive Voice Response (IVR) provides self-service specific information and is available 24 hours a day, seven days a week. Many Customer Service numbers offer an IVR option. Callers enter the member's ID number, date of birth, and the physician's or other provider's tax ID number to obtain eligibility, general benefit information, and claims information. Information available on the IVR system varies by plan.

    • Key in or say the member's identification number. Enter the member's date of birth as month (two digits), day (two digits), and year (four digits). Do not use slashes or hyphens. Example: 03011972 represents March 1, 1972.
    • Once familiar with the script, you no longer need to listen to the complete prompt before entering a selection.
    • If you request eligibility verification for more than one member at the same time, and you encounter subscriber or birth date errors, note them and wait until you have completed your inquiries before connecting to a customer service representative.
    • If you do not respond to each prompt within five seconds, the system will repeat the prompt. If you do not respond in another five seconds, you will be routed to a customer service representative (during normal Customer Service hours).
    • If you make an error while keying in the member ID number, press the * key and the system will prompt you to re-enter it.

    Contact IVR at 800-722-4714, option 2. (IVR is not available for service pertaining to the Federal Employee Program or BlueCard.)

    Benefit plans typically have exclusions and limitations-services and supplies that plans do not cover.

    Benefits are not provided for services, treatment, surgery, drugs or supplies for any of the following:

    • Conditions arising from acts of war, or service in the military
    • Cosmetic or reconstructive services, except as specifically provided
    • Experimental or investigative services
    • Orthognathic surgery
    • Services determined by us to be not medically necessary
    • Services in excess of specified benefit maximums
    • Services payable by other types of insurance coverage
    • Services received when the member is not covered by the program
    • Sterilization reversal
    • Treatment for work-related conditions for which benefits are provided by Workers' Compensation or similar coverage.

    Note: Plan limitations and exclusions vary widely by contract, and are subject to change. This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force. This manual is not a contract. For full coverage provisions, including a description of waiting periods, limitations and exclusions, please contact Customer Service.

    Sometimes a member wants to receive services from a provider or facility not in his/her network. Depending on the member’s benefits, out-of-network services might be covered at a lower rate or not at all.

    In certain situations, a prior authorization can be requested to pay out-of-network services at the in-network benefit level. A prior authorization should be requested before the service. We might allow out-of-network services at an in-network benefit level if they are determined to be medically necessary. Examples include specialist care, capacity, distance, and unique service. A benefit-level exception is subject to a review process prior to approval or denial. See the Integrated Health Management section for information about Prospective Review.

    Members should call 911 or seek care immediately if they have a medical emergency condition. Our plans cover emergency care 24 hours a day, anywhere in the world.

    A “medical emergency condition” means the sudden and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy. (A “prudent layperson” is someone who has an average knowledge of health and medicine.)

    Medical emergency examples include severe pain, suspected heart attacks, and fractures. Examples of non-emergencies include minor cuts and scrapes. In a medical emergency, members can go to any physician or other provider office, urgent-care center, or hospital emergency room.

    The hospital’s emergency department must perform a medical screening examination for any individual seeking evaluation for treatment for a medical condition. For presenting conditions that are not a medical emergency, the emergency department must have the authorization of the member’s treating physician or other provider to treat past the point of screening and stabilization. In such cases, we expect the treating physician or other provider to respond within 30 minutes of being called, or we will assume there is authorization to treat, and the emergency department will treat the member.

    If a member is treated in the emergency department, the member’s physician or other provider needs to provide any necessary follow-up care (e.g., suture removal).

  • Member appeals

    Members have the right to voice and/or submit their complaints when they have a problem or a concern about claims, quality of care or service, network physicians, and other providers, or other issues relating to their coverage. If your office receives a request for information or records in connection with a patient’s appeal, please expedite the request.

  • We evaluate all the information and make a decision. We send the member written notice of our decision, including a reason, within 30 calendar days of the date we received the appeal. Providers submitting a Level I request on the member’s behalf must provide a signed appeals authorization form from the member. We will not accept Level I requests from providers on the member’s behalf without this authorization. If the member is not satisfied with the outcome from the first review, he/she may request a second review or independent review (Level II Appeal or IRO).

    If a member is not satisfied with the Level I decision, and if their contract provides the option, he/she may request a Level II review. We must receive the request for a second review in writing, from the member, within 60 days of the date they received notice of the Level I appeal decision. Providers submitting a Level II request on the member’s behalf must provide a signed appeals authorization form from the member. We will not accept Level II requests from providers on the member’s behalf without this authorization.

    A different panel is appointed to review the Level II appeal. Anyone involved in the previous review/reviews will not be involved in the Level II appeal. The member and/or his/her representative may meet with the panel in person or via phone. The panel review will occur within 30 calendar days of receiving the request. The panel evaluates all the information submitted with the Level II and all previous information and makes a decision. Written notice of the decision is sent to the member within five business days of the panel review.

    If a member is not satisfied with a Level I or Level II decision, and if his/her contract provides the option, he/she may request an independent review. We must receive the request in writing from the member within 60 days of the date the member received notice of the Level I or Level II appeal decision. Providers submitting a request for independent review on the member’s behalf must provide a signed appeals authorization form from the member. We will not consider the provider’s request for independent review without the signed authorization.

    An independent review organization (IRO) conducts independent reviews. An IRO is an organization of medical and contract experts not associated us that is qualified to review appeals. Premera submits the member’s file to the IRO, and for fully insured groups, pays the costs of the review. The IRO gives the member its decision in writing, and Premera promptly implements the IRO’s determination.

    Expedited appeals are warranted when following the routine appeals process might jeopardize the life or health of the member. The member can hand-deliver, mail, or fax the request to us.

    Level I Expedited Appeal: We evaluate all the information and make a decision. We will notify the member of our decision, and the reasons for it, within 72 hours after we receive the appeal. If a member is not satisfied with the Level I decision, and if his/her contract provides the option, he/she may request a Level II expedited review.

    Level II Expedited Appeal: We must receive the request for a second review from the member in writing. A review panel is appointed to review the Level II appeal. We will notify the member of the panel meeting. The member and/or his/her representative may meet with the panel. We will notify the member of our decision, and reasons for it, within 72 hours of the request for a second review. If the member is not satisfied with the appeal determination and if their contract provides the option, he/she may request an Independent Review.

  • Customer rights and responsibilities

  • Our customers have the right to:

    • Get information about the organization, its services, its practitioners, and providers.
    • Work with their healthcare provider to decide on treatment options needed for their conditions.
    • Talk honestly about what treatment options are right and needed for their conditions, regardless of cost or benefit coverage.
    • Make complaints or appeals about the health plan or the care or service the health plan provides.
    • Recommend changes to the health plan’s member rights and responsibilities policy.
    • Choose their healthcare providers.
    • Have the health plan keep private any information they give the health plan about their health plan claims and other related information.
    • Have their healthcare and healthcare coverage information protected.
    • Review and get copies of their personal information on file.

    Our customers have the responsibility to:

    • Give as much information as they can that the health plan and its providers need in order to provide care.
    • Follow plans and instructions for care that they have agreed to with their providers.
    • Try to understand their health problems.
    • Work as much as possible with their healthcare providers to develop treatment goals they can agree on.
    • Try to keep healthy habits, such as exercising, not smoking, and eating a healthy diet.
    • Disclose relevant information. Members must try to communicate clearly what they want and need.
    • Avoid knowingly spreading disease.
    • Understand their healthcare provider’s obligation to provide care equally and efficiently to other patients and the community.
    • Learn about their health plan coverage and options, including all covered benefits, limitations and exclusions, and rules about the use of information.
    • Understand how to appeal coverage decisions.
    • Show respect for other patients, health workers, and health plan employees.
    • Make a good-faith effort to meet financial obligations.
    • Follow the administrative and operational procedures of their health plan and healthcare providers.
    • Report wrongdoing and fraud.
  • Member responsibilities

  • Members should present their ID cards at each time of service. Depending on the plan, members are responsible for any applicable copayment (copay), coinsurance, or deductible. Members are also responsible for the costs of non-covered services beyond their program's maximum benefits.

    The copay is a predetermined amount a member pays for a specific service (e.g., $20 for an office visit). Typically, copayments are fixed amounts for office visits, prescriptions or hospital services. Copays should be collected at the time of service from the member. If the member is admitted to the hospital from the emergency room, the emergency room copay may be waived.

    The member’s copay is calculated into the Premera Blue Cross payment.

    The deductible is a predetermined amount of eligible expense, designated by the subscriber’s contract that the member must pay each year from his/her own pocket before the plan will make payment for eligible benefits.

    Coinsurance is the portion of covered healthcare costs for which a member is financially responsible, usually according to a fixed percentage of the allowed amounts for services rendered. Coinsurance often applies after first meeting a deductible requirement.

    Copay, coinsurance, and deductible amounts vary by plan. Check the member's ID card or call Customer Service for the specific copay amount. For BlueCard members, call 800-676-2583.

    Members are responsible for the payment of services not covered by their contracts. Noncovered services (services that are not medically necessary or a covered benefit) can vary based on the member’s plan. To verify if a service is covered, use Premera’s online eligibility and benefits tool, or contact Customer Service.

    If a member decides to proceed with a non-covered service, before or following Premera’s determination, the member should sign a consent form agreeing to financial responsibility before the service is provided. The consent form should clearly state the proposed service that will be rendered and the cost of the service. If the consent form is not obtained, services deemed not medically necessary would be the provider’s financial responsibility.

    We offer a language translation line for 140 languages. For more information, please call Customer Service, or the number listed on the back of the member’s ID card.