7 Claims and Payment - Premera Blue Cross

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Premera Dental Reference Manual Premera Blue Cross Blue Shield of Alaska from the first-party carrier showing where they paid out their limits, we will process all related claims accordingly and under the terms of our subscriber’s contract. If the IQ states that there is no first-party coverage available, but there is a third-party liability available, we will process all related claims until all parties are ready to negotiate a settlement for possible reimbursement. Workers’ Compensation Workers’ Compensation will pay when the member’s employer is liable to pay medical bills resulting from illness or injury arising out of, or in, the scope of employment. All Premera contracts exclude coverage for care covered under the Workers’ Compensation Act. Claims submitted with a diagnosis that indicates possible Workers’ Compensation injuries are investigated. We send the member a questionnaire requesting information to determine if benefits are available. If we do not receive a response within the specified period, the claim is denied pending further information. If the information received indicates an onthe-job illness or injury, both the member and physician/provider will receive a denial that states the Premera contract excludes work-related conditions. Closed Workers’ Comp Claims: The member has seven years from the date of first closure to reopen their claim if needed, and can do so multiple times. Denied Workers’ Comp Claims: Subrogation will review all Workers’ Comp denials; if the denial is valid, Subro will update to process claims based on members contract benefits If an invalid denial is received, Subro will contact the members to advise them. Examples of invalid denials: Timely filing No authorization Workers’ comp carrier did not receive information requested to make their decision Claims and Payment Chapter 7 Page 26
Premera Dental Reference Manual Premera Blue Cross Blue Shield of Alaska Section 15: Provider Appeals Complaint and Appeal Process Dentists have the right to appeal certain Premera actions. Our provider appeals process ensures that we address a complaint or an appeal in a fair and timely manner. Our process meets or exceeds the requirements set by the Alaska Division of Insurance. The provider appeal process applies to dental providers contracted with Premera Blue Cross Blue Shield of Alaska. Important: An office has the option to start the claims issue resolution process at the complaint or Level I Appeal stage; however, either stage must take place within 365 days of the Premera action that prompted the dispute. Complaint Occurs when an office communicates an issue (verbally or in writing) to a Premera associate regarding a Premera action. An office has 365 calendar days to submit a complaint following the Premera action that prompted the complaint. If we receive the complaint before the 365-day deadline, it is reviewed and a decision is issued within 30 calendar days via telephone or letter. You also receive information about how to submit a Level I Appeal should you disagree with the decision. A complaint can be made verbally or in writing to Customer Service. You can reach Customer Service by calling 800-722-4714, option 2. The plan mailing addresses are located in Chapter 1, Section 2 in Contact Information. Level I Appeal A Level I Appeal is used to: Dispute a Premera action, or Appeal a decision on a previously submitted complaint. Note: If you already filed a complaint and are appealing its outcome, the Level I Appeal must be submitted within the same 365-day time period of the Premera action that prompted the dispute. Only appeals received within this time period will be accepted for review. Modifications we make to your contract or to our policy or procedures are not subject to appeal unless we made it in violation of your contract or the law. Level I Appeal, continued A Level I Appeal is used for both billing and non-billing issues. A billing issue is classified as a provider appeal because the issue directly impacts your write-off or payment amount. A non-billing issue is classified as a member appeal because the financial liability is that of the member, not the provider (please refer to Chapter 6, Section 4; Member Appeals). Here are examples: Billing Example Non-Billing Example Bundling or Inclusive Procedures Service not a benefit of subscriber’s contract A Level I Appeal must be submitted with complete supporting documentation that includes all of the following: A detailed description of the disputed issue Your position on the disputed issue All evidence offered by you in support of your position including medical/dental records A description of the resolution you are requesting Claims and Payment Chapter 7 Page 27
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7 Claims and Payment - Premera Blue Cross

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