Personal Comp Member Handbook - CareFirst BlueCross BlueShield

18Claims, Enrollment Changes & PaymentsMedical review is a process that ensures claims areprocessed according to the terms of your policy.Medical review is an important process. It makes certainthat benefits are properly administered, which helpskeep premium rates as low as possible. Claims may bereviewed for a number of reasons. In most cases, claimsare reviewed for medical necessity, contract limitations,or pre-existing medical conditions.If your insurance policy was medically underwritten,certain individuals may have been excluded fromcoverage.The medical review process sometimes requires usto request additional medical information from yourprovider. This may result in a delay in processing yourclaim. If we find that a condition not listed on yourapplication existed prior to the effective date of yourpolicy, we may deny payment on your claim or cancelyour policy.Please be assured that the medical review process isdesigned to provide you with the maximum allowedbenefits from your policy. By following medical reviewguidelines, we can provide a high quality policy at thelowest premium possible.Here are some reasons why a claim may be denied:■ If the claim is for an over-aged dependent who is nolonger covered on your policy■ If a Student Certification was not submitted in atimely manner■ If the wrong diagnosis code is listed■ If pre-existing conditions that are not covered underyour policy are listed on the claimIf you feel a claim was denied as a result of error or ouwould like to appeal the denial, call Member Servicesat the number on your member ID card. For moreinformation on the appeal process, see page 24.You will receive a detailed Explanation of Health CareBenefits Statement (EOHB) whenever we process aclaim (shown on page 19). The EOHB outlines theservices that were paid; the amount that was appliedto your deductible; and your share, if any, of theremaining cost. The name of the patient is listed on eachseparate page.Your membership number and the nameof your Program.The customer service telephone number listed onyour statement is the one you call when you havea question or problem.Each claim number, the name of eachprovider (doctor, hospital, laboratory, etc.) andeach service you had are listed togetherin this column.The date of service is the date you received service.If multiple dates are shown, they are “from” and“to” dates.The billed charge is the amount billed bythe provider.The reduction of billed charges can be oneof two things:a. The difference between the amount yourprovider charged and, if applicable, processingthe amount Medicare approved for the service.b. The portion of the amount you willhave to pay, if you received anon-covered service.If applicable, the amount paid by Medicare. Thisamount will be deducted from your billed charge.The amount eligible for benefits is the portionof the billed charge that will be consideredfor benefits.