Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...

If you receive services from an out-of-network provider,
you are responsible for ensuring that the claim is
fled correctly and on time even if the out-of-network
provider ofers to fle the claim on your behalf�
Late fling by an out-of-network provider is not a
circumstance allowing for submission beyond the
stated 12-month time frame�
You must complete the appropriate claim form and
provide an itemized original bill* from your provider
that includes the following:
• Patient name, date of birth, and diagnosis
• Date(s) of service
• Procedure code(s) and descriptions of service(s)
rendered
• Charge for each service rendered
• Service provider’s name, address, and tax
identifcation number
* Monthly statements or balance due bills are not acceptable� Photocopies
are only acceptable if you’re covered by two plans and you sent your
primary payer the original bill�
Claims for separate family members should be
submitted separately� If another insurance company
pays your benefts frst, submit a claim to that company
frst� After you receive your beneft payment, submit a
claim to Anthem BCBS and attach the other company’s
Explanation of Benefts statements along with your
claim� It is important to keep copies of all submissions�
Call Anthem BCBS Customer Service at
1-866-418-7749 to obtain the correct address to fle
your out-of-network claim�
Complete information on fling claims can be found in
the Benefts Book, “Appendix A: Claims and appeals�”
Claims payment
When a claimant uses providers who have signed a
BlueCard PPO service agreement with the local Blue
Cross Blue Shield organizations, the Plan pays the
provider� When a claimant uses an out-of-network
provider, the Plan pays the claimant� A claimant may not
assign his or her benefts to an out-of-network provider,
except when the claimant is a dependent whose parents
are divorced� In that case, the custodial parent may
request, in writing, that the Plan pay an out-of-network
provider for covered services for a child� When the Plan
pays the provider at the request of the custodial parent,
the Plan has satisfed its payment obligation�
Claims questions, denied coverage, and appeals
If you have a question or concern about a beneft
determination, you may contact member services
before fling an appeal� For more information, see the
“Contacts” section on page 1�
42
You may also fle an appeal with Anthem BCBS without
frst contacting the member service department� An
appeal must be fled within 180 days of the date of the
adverse determination of your initial claim regardless
of any verbal discussions that have occurred regarding
your claim� Once you exhaust the internal appeals
procedures, you are entitled to an external review of
your claim�
Complete information on appeals is provided in the
Benefts Book, “Appendix A: Claims and appeals�”
Coordination with other coverage
When you or your dependents have other group
medical insurance (through your spouse’s or domestic
partner’s employer, or Medicare, for example), the
Wells Fargo health plan and the other plan may both
pay a portion of covered expenses� One plan is primary,
the other plan is secondary� This is called coordination
of benefts (COB)� Please note the following:
• There is no COB between Wells Fargo health plans;
only one Wells Fargo health plan will provide
coverage for eligible expenses�
• Wells Fargo health plans do not coordinate
prescription drug benefts� For example, if you are
covered under a Wells Fargo health plan and the other
plan is primary, there is no secondary prescription
drug beneft under the Wells Fargo health plan�
If the Wells Fargo health plan is secondary, it pays
only the diference between the other plan’s beneft, if
lower, and the normal Wells Fargo health plan beneft�
When the primary plan pays a beneft that equals or
exceeds the normal Wells Fargo health plan beneft, the
Wells Fargo health plan pays nothing�
If you receive benefts from more than one group health
plan (or a government-supported program other than
Medicaid), the primary payer must process your claim
before you can submit it to the secondary payer�
For detailed information regarding coordination
of coverage, refer to the “Coordination with other
coverage” section in “Chapter 1: An introduction to
your benefts” of your Benefts Book�
Right of recovery
If the Plan pays more than it should have paid based
on the terms of the Plan, the Plan may recover the
overpayments from any of the following:
• The persons the Plan paid or for whom the Plan
has paid
• Insurance companies
• Other organizations
Anthem Blue Cross Blue Shield PPO Plan