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Transparency in Coverage

Learn some basics about your health plan coverage.

Protection from surprise costs

You have Federal rights and protections against surprise medical bills or balance billing.

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

Get more information about your rights and protections from surprise billing

Member claims submission

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

Grace periods and claims pending policies during the grace period

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.

For plans purchased through HealthCare.gov

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.

For plans purchased directly from Premera

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.

Retroactive denials

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:

  • Notify HealthCare.gov promptly of changes that could impact your eligibility or your premium amount owed.
  • Submit requested documentation to HealthCare.gov and/or Premera Blue Cross Blue Shield of Alaska promptly or within time constraints.
  • Pay your monthly premiums on time.

Member recoupment of overpayments

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.

Medical necessity and prior authorization timeframes and member responsibilities

Some services may require prior authorization and/or be subject to review for medical necessity. If your doctor provides a service that requires prior authorization and has not requested it, you may have to pay part or all of the cost, above your usual cost shares.

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.

Drug exception timeframes 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  (PDF document). 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 Alaska
Attention: Pharmacy Services
PO Box 327, MS 432
Seattle, WA 98111-0327

Phone: 888-261-1756
Fax: 888-260-9836

Find out more about drugs requiring approval

Explanations of Benefits (EOBs)

Each time you visit a healthcare provider and file a claim, you receive an Explanation of Benefits (EOB), which explains how your claim was processed. 

An EOB is not a bill. It simply explains how your plan benefits apply to that particular claim. It includes:

  • Date you received the service
  • Amount billed
  • Amount covered
  • Amount Premera paid
  • Any balance you're responsible for
  • How much has been credited toward your deductible

You will receive a separate bill from your healthcare provider for any payment owed. We recommend comparing that bill with your EOB, and then paying the healthcare provider directly.

Coordination of Benefits (COB)

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.