The information on this page applies to members with an Affordable Care Act (ACA) plan.

Out-of-Network Liability and Balance Billing
Enrollee Claims Submission
Grace Periods and Claims Pending Policies During the Grace Period (Individual and Family coverage only)
Retroactive Denials
Enrollee Recoupment of Overpayments (Individual and Family coverage only)
Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities
Drug Exceptions Timeframes and Enrollee Responsibilities
Information on Explanation of Benefits
Coordination of Benefits

A. Out-of-Network Liability and Balance Billing

• If you have an emergency medical condition and are treated in an emergency room at an out-of-network hospital, we will provide benefits at the in-network coinsurance amount. The allowed amount we pay for emergency services by an out-of-network provider will be the greater of: A) the median amount if such emergency services were rendered by an in-network provider participating in the Individual and Family plan network; or B) the amount for those emergency services calculated using Medicare allowances, which is the method BlueCross BlueShield of South Carolina generally uses to determine payment to an out-of-network provider.
• An enrollee may be balance billed by an out-of-network provider. An out-of-network provider can balance bill you for the difference between the allowed amount we pay and his or her actual charge. Balance billing is the process when a provider bills you for the difference between the provider’s billed charge and the allowed amount we pay or for the penalties for not getting preauthorization. For example, if the provider’s billed charge is $100 and the allowed amount we pay is $70, the provider may bill you for the remaining $30. An in-network provider may not balance bill you for covered services, except as noted in the Preauthorization Section.

B. Enrollee Claims Submission

• If you receive health care services or supplies from an in-network provider, the provider will file your claims for you. If an out-of-network provider is authorized to provide services, an enrollee may be required to pay up front for the services and submit a member claim form for reimbursement. Enrollees can contact Member Services if they have any questions or need to file a claim.
• All claims must be submitted within 180 days after the date services were rendered. A member claim form is available here.
• Complete the front of each claim form and attach the itemized bills from the provider to it. Before you submit your claims, we suggest you make copies of all claim forms and itemized bills for your records since we cannot return them to you. Completed forms should be mailed to:

BlueCross BlueShield of South Carolina
Group & Individual Claims, AX-F25
P.O. Box 100300
Columbia, SC 29202
or
FAX: 1-803-264-0172
 

C. Grace Periods and Claims Pending Policies During the Grace Period (Individual and Family coverage only)

• This policy has a grace period for premium payments. This means if an enrollee’s premium is not paid on or before the date it is due, it may be paid during the grace period. If the premium has not been paid by 12:01 a.m. of the day following the end of the grace period, the coverage will automatically terminate without further notice. Any claims paid after the last premium paid date do not extend this coverage.
• “Pending claims” is the withholding of claims payments to the provider or enrollee during a grace period.
• Grace Period for Coverage with an Advance Premium Tax Credit (APTC) – If an enrollee paid at least one month’s premium and received the advanced premium tax credit, the grace period is three months. During the first month of this grace period, any claims submitted will be processed according to the enrollee’s coverage. Claims will be pended for services provided during the second and third month of the grace period until the full premium due is paid. If premiums are fully paid during the grace period, pended claims will then be paid.
• Grace Period for Coverage without an Advance Premium Tax Credit – If an enrollee did not receive an advanced premium tax credit, the grace period is 31 days during which benefit payments will be pended until all premiums are paid.

D. Retroactive Denials

• Claims may be denied retroactively even after services are received
• To prevent retroactive denials
  • Pay premiums on time
  • Do not use your ID card after the policy has terminated
  • Inform your provider if your policy has terminated

E. Enrollee Recoupment of Overpayments (Individual and Family coverage only)

• Enrollee recoupment of overpayments is the refund of a premium overpayment by the enrollee due to over-billing by the issuer, or some other reason the enrollee has paid more than is required.
• An enrollee may obtain a refund of premium overpayments by contacting Member Services.

F. Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities

Preauthorization must be received for certain categories of benefits. A failure to get preauthorization may result in benefits being denied. We will make our final benefit determination when we process your claims. Even when a service is preauthorized, we review each claim to make sure:

• The patient is a member under the policy at the time service is provided.
• The service is a covered service. Policy limitations or exclusions may apply.
• The service provided was medically necessary as defined by your policy.

In-network providers in South Carolina will be familiar with the requirement to get preauthorization and will get the necessary approvals. If an in-network provider in South Carolina does not get preauthorization, it cannot bill you for the penalty (see chart).

To use the BlueCross preauthorization process, call the numbers listed to reach the appropriate medical services personnel. All preauthorization requests will be completed within two business days after receipt of the request, with the exception of emergency inpatient admissions and all continued stay reviews.  These requests will be completed within 24 hours after receipt of the request.

Here is the list of services that must be preauthorized.

NIA is an independent company that preauthorizes certain radiological procedures on behalf of BlueCross.

CBA is a separate company that preauthorizes mental health and substance use disorder services on behalf of BlueCross.

Avalon Health Services, LLC is an independent company that preauthorizes certain laboratory services and procedures on behalf of BlueCross.

Prior Authorization for Pharmacy (PA): If your drug needs preauthorization, your doctor will have to get approval before we will cover your drug. There are different reasons a drug might require preauthorization. One is to make sure it’s being used for the condition(s) it was approved for by the United States Food and Drug Administration (FDA). Another is because there are covered drugs that usually work just as well, but cost less.

Preauthorization/Prior Authorization Contact Information:

G. Drug Exceptions Timeframes and Enrollee Responsibilities

• Sometimes our members need access to drugs that are not listed on the plan's formulary.
• These medications are initially reviewed by BlueCross through the formulary exception review process. The member or provider can submit the request to us by faxing the Pharmacy Formulary Exception Request form. If the drug is denied, you have the right to an external drug exception review. 
• If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case for an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). We must follow the IRO's decision. 

An IRO review may be requested by a member, member's representative, or prescribing provider by contacting:

OptumRx*
Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 844-403-1029

For standard exception reviews where the request was denied, the timeframe for review is 72 hours from when we receive the request. 

For expedited exception reviews where the request was denied, the timeframe for review is 24 hours from when we receive the request. 

To request an expedited review for exigent circumstance, select the “Request for Expedited Review” option in the Request Form. 

*OptumRx® is an independent company that offers a pharmacy network on behalf of BlueCross BlueShield of South Carolina.

H. Information on Explanation of Benefits

Individual Explanation of Benefits (EOB): Your EOB is a form that gives you details about your claim status. An individual EOB is available for each claim filed.

• Each EOB features important information about health care services you received, how much your health plan covered, how much you may owe your provider and much more. You can find most of the quick details you're looking for in a convenient Summary Information box. The details about your claims are in column format, so you can easily track information about each service you received. You'll also find helpful definitions. You can view your individual EOBs by logging in to My Health Toolkit.
• View a convenient guide that walks you through a typical EOB.

Summary EOB: Summary EOBs offer a convenient way to organize information about your medical bills. Summary EOBs give the status of all of your health insurance claims filed during a certain time period. Each Summary EOB gives information for claims we processed for all individuals under your member ID during the 21-day period. If you had claims filed or processed during that time period, your health plan will mail the Summary EOB to your home. If no claims are filed or processed, you won't receive a Summary EOB for that period.

• The Summary EOB provides all the information you need about your health insurance claims — and it's easy to read and understand. The summary section outlines the costs your health plan covered and the amounts you owe specific providers. It also shows other insurance or Medicare payment amounts, if applicable. You'll also find definitions of some terms and an explanation of your appeal rights. The claims detail section gives more information about each claim, such as charges, allowed amounts and coinsurance. It also explains where you stand on deductible and out-of-pocket amounts.
• If you receive Summary EOBs but would like to view an individual EOB for a particular claim, just log in to My Health Toolkit and click "Health Claims Summary." Then choose the "View EOB" link below the claim.
• View a guide that walks you through a typical Summary EOB line-by-line to make understanding your benefits easier.

I. Coordination of Benefits

A person may be covered for benefits under more than one health plan. In this case, BlueCross may coordinate benefits with the other plans to prevent duplicate payments and overpayments. Individual and Family policies do not coordinate benefits with other plans except when a member has Medicare coverage.