Claims Payment Policy & Other Information

Listed below are claims payment policies and other information for Qualified Health Plans offered by Blue Cross and Blue Shield of Alabama. A Qualified Health Plan is an insurance plan that has been certified by the Health Insurance Marketplace and provides essential health benefits, follows established limits on cost sharing and meets other requirements under the Affordable Care Act.

Out-of-network liability and balance billing

If you receive services from an out-of-network provider, these services may not be covered at all under the plan. In that case, you will be responsible for all charges billed to you by the out-of-network provider, also referred to as balanced billing. If the out-of-network services are covered, in most cases, you will have to pay significantly more than what you would pay an in-network provider because of lower benefit levels and higher cost sharing. Additionally, out-of-network providers have not contracted with us or any Blue Cross and/or Blue Shield plan for negotiated discounts and can bill you for amounts in excess of the allowed amounts under the plan.

If you receive out-of-network benefits for a medical emergency in the emergency room of a hospital, those services will be paid at the applicable in-network coinsurance amounts for such benefits described in your benefit booklet and subject to the in-network calendar year deductible. The allowed amount for such out-of-network benefits will be determined in accordance with the requirements of the applicable Federal law.

If you receive non-emergency services performed by an out-of-network provider at certain in-network facilities, those services will be paid at the applicable in-network coinsurance and/or copayment amounts for such benefits described in your benefit booklet and subject to the in-network calendar year deductible, provided the out-of-network provider has not satisfied the applicable notice and consent requirements. The allowed amount for such non-emergency services performed by an out-of-network provider at certain participating facilities will be determined in accordance with the requirements of the applicable Federal law.

Find more information about your rights and protections against surprise medical bills and balanced billing here.

Emergency services are not covered out-of-network under our dental plans.

Enrollee claims submission

When you receive services from an in-network provider, your provider will generally file claims for you. If your provider does not file your claim for you, you can call our Customer Service Department at the number on the back of your ID card and ask for a claim form. Tell us the type of service or supply for which you wish to file a claim (for example, hospital, physician, dentist or pharmacy), and we will send you the proper type of form. You can also find our claim forms on our website at:

• Medical Expense Claim
• Dental Expense Claim
• Vision/Hearing Claim
• Pharmacy Claim
• Travel Benefit Claim

Claims must be submitted and received by us within 24 months after the service takes place to be eligible for benefits.

Claims forms with attached itemized bill must be submitted to:
Blue Cross and Blue Shield of Alabama
450 Riverchase Parkway East
Birmingham, Alabama 35244-2858

Grace periods and claims pending policies during the grace period

You are required to pay your premium by the scheduled due date. If you do not do so, your coverage is subject to termination. If you purchased an individual plan through the Health Insurance Marketplace and you are receiving advance payments of tax credits and/or cost sharing reductions in accordance with the Affordable Care Act, each of your monthly periodic payments is due on the first day of the month for that coverage period. There is a grace period of three months for all monthly premium payments after the initial premium payment. A grace period is the time after which the payment is due when your plan will not terminate even though the payment has not yet been made.

All properly submitted claims, received for covered services within the first month of the grace period will be considered for payment. Claims received during months two and three will be placed in a pending status (suspended). When claims are in ‘pending’ or ‘suspended’ status, no payment is made to the provider and the claim is not considered for processing until payment is received or the grace period is exhausted, whichever comes first. If you pay your delinquent premium before the end of month three we will consider all pending claims for payment to providers. If you fail to pay past due monthly payments in-full before the end of the grace period for those coverage periods, your coverage under the plan will be retroactively canceled back to the last day of the first month of the grace period. All claims in a pending status at the time of cancellation will reject and your provider may balance bill you for those services.

Failure to timely pay premium payments is not a special open enrollment event for later coverage under the plan.

Retroactive denials

In certain situations, a claim may be reprocessed and denied retroactively, even after it has been paid. In these cases, you are responsible for payment to the provider. A retroactive denial is the reversal of a previously paid claim. In most cases, you can prevent a retroactive denial by paying your premiums on time and/or by promptly notifying the plan or, if applicable, the marketplace of changes in your eligibility status for the plan.  

Enrollee recoupment of overpayments

If you believe you believe you have overpaid your premium due to our overbilling, please contact us by calling the Customer Service Department number on the back of your ID card.

Medical necessity and prior authorization timeframes and enrollee responsibilities

A precertification (sometimes referred to as a prior authorization) is a requirement of a member’s benefit plan to obtain a medical necessity decision that certain healthcare services, treatment plans, durable medical equipment or prescription drugs are medically necessary before services are received, except for emergency services.

A precertification provides earlier notification of medical necessity decisions for services that require medical review, which ensures the member and provider have all the information available before the services take place. In addition, a precertification reinforces quality to ensure that services are not rendered that are not medically appropriate. With precertification requirements in place, members are less likely to receive unexpected medical bills for these services if a required precertification is not approved.

Below is a list of some services that may require a precertification

• Inpatient Care (including transplants, acute inpatient rehabilitation, long-term acute care facilities and skilled nursing facilities)
• Outpatient Services (including surgeries and diagnostic imaging services such as MRIs, PETs, and CT scans)
• Home Healthcare and Hospice
• Durable Medical Equipment
• Prescription Drugs (including provider-administered drugs)
• Behavioral Health Services

A member’s Summary Plan Description (SPD), benefit booklet, includes precertification requirements and are directed to a precertification webpage that includes a list of some outpatient services that require prior auth per their contract benefits. Members may also call customer service, utilizing the number on the back of their membership card, to inquire about precertification requirements.

Providers can verify benefits through an online provider portal prior to rendering services and determine if a procedure requires precertification.

It is both the member and provider’s responsibility to know what the precertification requirements are under the member’s benefit plan. It is industry standard for providers to verify eligibility and benefits before each service is rendered; however, a member should always check with their provider to be sure that this step has been completed. Additionally, ensure that there is an approved precertification on file prior to receiving a service that requires a precertification. If precertification is not obtained, no benefits will be payable under the plan for the services.

The Plan provides notice of all review determinations and communicates them in accordance with applicable state, federal, and/or accreditation requirements. The timeframes are national guidelines prescribed for review timeliness by the National Committee for Quality Assurance (NCQA) and are cited below.

Coordination of Benefits (COB)

• Preservice Non-Urgent – 15 calendar days
• Preservice Urgent Review - We have 24 hours to make our decision for On-exchange plans, all other plans we have 72 hours to make our decision.
• Urgent Concurrent – 24 hours - if we receive the request no later than 24 hours before the end of your preapproved stay or course of treatment. If the request is not received before the 24 hour time frame, we have 72 hours to make our decision.
• Urgent Preservice – 72 hours
• Emergency admissions – 48 hours
• Non-urgent concurrent review – 72 hours
• Post service review – 30 days