Learn some basics about your health plan coverage.
Out-of-network services are from doctors, hospitals, and other healthcare professionals that haven't contracted with your plan. A healthcare professional who is out of your plan network can set a higher cost for a service than professionals who are in your health plan network. Depending on the healthcare professional, the service could cost more or not be paid for at all by your plan. Charging this extra amount is called balance billing. The following services and/or providers will always be covered at the highest in-network benefit level for covered services and supplies, based on the allowable charge:
A claim is a request to an insurance company for payment of healthcare services. As a Premera Blue Cross Blue Shield of Alaska member, you may need to submit a claim yourself, especially if you see a provider or use a pharmacy outside of the network. In most cases, the time limit for a member to submit a claim is 365 days, but this can vary depending on the group. Please contact customer service at 800-508-4722 to determine the specific time limit for submitting your claim.
Get more claims information and forms.
A grace period is a period of time after the premium is due in which you are able to make a premium payment without the coverage ending. A pended claim means a claim is being held until specific conditions are met. For example, pended status can change when you make a premium payment or when previously insufficient information is provided.
If you have a federal government subsidy that helps you to pay your monthly premium (your monthly health plan bill), you have a 3-month grace period to pay your portion of the monthly premium. For the first month of the 3-month grace period, we will continue to process and pay claims for the covered services under this plan. Beginning on the first day of the second month and through the last day of the third month, we will suspend all of your claims. If we have not received all outstanding premium charges by the last day of the third month, we will terminate your coverage as of the last day of the first month of the grace period. We will also deny all pended claims for services you received in the second and third months of the grace period. Providers can seek reimbursement directly from you for those services.
For members whose premiums are not subsidized by the federal government, you have a 30-day grace period to pay subsequent premium charges. If a payment is not received by the end of the grace period, your coverage will terminate as of the last day of the period for which premium charges were paid. Claims for services received after the end date will be denied. Providers can seek reimbursement directly from you for those services.
You have a 10-day grace period to pay subsequent subscription charges. If a payment is not received by the end of the grace period, your coverage will terminate as of the last day of the period for which premium charges were paid. Claims for services received after the end date will be denied. Providers can seek reimbursement directly from you for those services.
Some claims may be retroactively denied, even after the member has obtained services from the provider. A retroactive denial is the reversal of a previously paid claim, through which the member then becomes responsible for payment.
There are ways to prevent this from occurring. You can:
Members may obtain a refund of premium overpayment by notifying HealthCare.gov of changes that could impact eligibility or your premium amount owed and then contacting Premera Blue Cross Blue Shield of Alaska Customer Service at 800-508-4722. Please note that in some situations, changes to eligibility must be received from HealthCare.gov before Premera can refund an overpayment.
Some services may require prior authorization and/or be subject to review for medical necessity.
The time frame for prior authorization requests for urgent pre-service decisions is within 72 hours of receipt of the request. For non-urgent pre-service decisions, it's within 15 calendar days of receipt of the request. Please contact Premera Blue Cross Blue Shield of Alaska customer service at 800-508-4722 with questions about your specific prior authorization.
Get more details about prior authorization, medical necessity, and member responsibilities.
Sometimes our members need access to drugs that aren't listed on the plan's formulary (drug list). These medications are initially reviewed by Premera through the formulary exception review process. The member or provider can submit the request to us by faxing the Pharmacy Formulary Exception Request form. If the drug is denied, you have the right to an external review.
If you feel we have denied the nonformulary request incorrectly, you may ask Premera to submit the case to an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). Premera must follow the IRO's decision.
For standard exception review of medical requests where request was denied, the timeframe for review is 72 hours from when we receive the request. For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we receive the request.
An IRO may be requested by a member, member's representative, or prescribing provider by mailing, calling, or faxing the request to:
Premera Blue Cross Blue Shield of AlaskaAttention: Pharmacy ServicesPO Box 327, MS 432Seattle, WA 98111-0327
Phone: 888-261-1756Fax: 888-260-9836
Find out more about drugs requiring approval.
Learn what an explanation of benefits is and how to read it.
Coordination of benefits, or COB, is when you are covered under one or more other group or individual plans, such as one sponsored by your spouse's employer. An important part of coordinating benefits is determining the order in which the plans provide benefits. One plan is responsible for providing benefits first. This is called the primary plan. The primary plan provides its full benefits as if there were no other plans involved. The other plans then become secondary. Further information about Coordination of Benefits can be found in your benefit booklet.