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

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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
The amount paid includes the reasonable cash value of any benefts provided in the form of services� Reimbursement and subrogation The Plan maintains both a right of reimbursement and a separate right of subrogation� If you or your dependents, heirs, guardians, executors, or other representatives receive benefts under the Plan arising out of an illness or injury for which a third party is or may be liable, the Plan shall be subrogated to your claims against that third party� If the Plan pays any benefts and you or your dependent(s) later obtain a recovery, you are obligated under the terms of the Plan to reimburse the Plan for the benefts paid� The Plan will be reimbursed frst for 100% of benefts paid by the Plan before you are entitled to keep any amounts, regardless of whether the amounts represent a full or partial recovery by you, or you are made whole, and regardless of whether medical or dental expenses are itemized in a settlement agreement, award, or verdict� As used in this “Reimbursement and subrogation” section, amounts means any recoveries, settlements, judgments, or other amounts that you, your dependents, heirs, guardians, executors, attorneys, or other representatives receive, are awarded, or become entitled to from any plan, person, entity, insurer (frst party or third party), or insurance policy (including no-fault automobile insurance, an uninsured motorist’s plan, a homeowner’s plan, a renter’s plan, or a liability plan) that is or may be liable for (1) the accident, injury, sickness, or condition that resulted in benefts being paid under the Plan; or (2) the medical, dental, and other expenses incurred by you or your dependents for which benefts are paid or will be paid under the Plan� Until the Plan has been reimbursed for the full amount of all benefts paid under the Plan, all amounts that you, your dependents, your attorneys, or other representatives receive shall be held in constructive trust for the Plan, whether such amounts remain with you or with some other person or entity� Duty to cooperate You, your dependents, your attorneys, or other representatives must cooperate to secure enforcement of these subrogation and reimbursement rights� This means you must take no action — including but not limited to settlement of any claim — that prejudices or may prejudice these subrogation or reimbursement rights� As soon as you become aware of any claims or amounts for which the Plan is or may be entitled to assert subrogation and reimbursement rights, you must inform the Plan by providing written notifcation to Anthem BCBS of: • Potential or actual claims that you and your dependents have or may have • The identity of any and all parties who are or may be liable • The date and nature of the accident, injury, sickness, or condition for which the Plan has or will pay benefts and for which it may be entitled to subrogate or be reimbursed You and your dependents must provide this information as soon as possible and, in any event, before the earlier of the date on which you, your dependents, your attorneys, or other representatives (1) agree to any settlement or compromise of such claims; or (2) bring a legal action against any other party� In addition, as part of your duty to cooperate, you and your dependents must complete and sign all forms and papers, including a Reimbursement Agreement, and provide any other information required by the Plan� A violation of the Reimbursement Agreement is considered a violation of the terms of the Plan� The Plan may take such action as may be necessary and appropriate to preserve its rights, including bringing suit in your name or intervening in any lawsuit involving you or your dependent(s) following injury� The Plan may require you to assign your rights of recovery to the extent of benefts provided under the Plan� The Plan may initiate any suit against you or your dependent(s) or your legal representatives to enforce the terms of the Plan� Any proceeds collected, held, or received by you, your dependent, your attorney, or any other party to whom such proceeds may be paid by virtue of a settlement of, or judgment relating to, any claim of yours or your dependent(s) that arises from the same event to which payment by the Plan is related, are constructively held in trust for the beneft of the Plan and for the satisfaction of the Plan’s subrogation and reimbursement claims� Attorneys’ fees The Plan will not be responsible for any attorneys’ fees or costs incurred by you or your dependents in connection with any claim or lawsuit against any party, unless, before incurring such fees or costs, the Plan in the exercise of its sole and complete discretion has agreed in writing to pay all or some portion of fees or costs� The common fund doctrine or attorneys’ fund doctrine shall not govern the allocation of attorneys’ fees incurred by you or your dependent(s) in connection with any claim or lawsuit against any other party� Anthem Blue Cross Blue Shield PPO Plan 43
Page 1: Summary Plan Description Anthem Blu
Page 4 and 5: ii Page intentionally left blank An
Page 6 and 7: 2 Page intentionally left blank Ant
Page 8 and 9: Anthem BCBS, CVS Caremark, and Anth
Page 10 and 11: services described in this SPD� O
Page 12 and 13: • Left ventricular assist devices
Page 14 and 15: Benefts charts This section lists c
Page 16 and 17: Ambulance The Plan covers BlueCard
Page 18 and 19: Chiropractic care The Plan covers C
Page 20 and 21: Not covered: • Accident-related d
Page 22 and 23: Extended skilled nursing care The P
Page 24 and 25: Hospital inpatient The Plan covers
Page 26 and 27: Infertility and fertility The Plan
Page 28 and 29: Medical equipment, prosthetics, and
Page 30 and 31: Organ and bone marrow transplant co
Page 32 and 33: Outpatient surgery and diagnostic a
Page 34 and 35: • Speech therapy that has not bee
Page 36 and 37: Preventive care services The Plan c
Page 38 and 39: Other notes: • For more informati
Page 40 and 41: Skilled nursing facility The Plan c
Page 42 and 43: General exclusions In addition to a
Page 44 and 45: • Services a provider gives to hi
Page 48 and 49: The plan administrator may delegate
Page 50 and 51: Ordering prescriptions Once you hav
Page 52 and 53: What you’ll pay for prescriptions
Page 54 and 55: Some drugs require what’s called
Page 56 and 57: Pre-service claims If the Plan requ
Page 58 and 59: 54 Page intentionally left blank An
Page 60 and 61: Your benefts and costs at a glance
Page 62 and 63: Each case will be reviewed, diagnos
Page 64: © 2011 Wells Fargo Bank, N�A�

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