Affordable Care Act (ACA) Plan Information

The following policies and practices apply to Blue Cross Blue Shield of Arizona's (AZ Blue) ACA plans for individuals and families.

It is always a good idea to check if a doctor, hospital, or other facility is part of the AZ Blue network before you see them.

Ways to find a doctor:

Use the find a doctor tool
Or call the number on the back of your member ID card for help locating a doctor or hospital

To keep your healthcare costs down, it’s important to get care from healthcare professionals in the network for your plan. A healthcare professional who is out of your plan network can set a higher cost for a service than professionals who are in your health plan network. Depending on the healthcare professional, the service could cost more or not be paid for at all by your plan. Charging this extra amount is called balance billing. In cases like these, you will be responsible for paying for what your plan does not cover. Balance billing may be waived for emergency services received at an out-of-network facility.

For HMO plans, generally you only have coverage for services from out-of-network providers in emergency situations. You will have to pay the whole bill for most other services that are outside the plan’s network.

Enrollee Claim Submission

A claim is a request to an insurance company for payment of healthcare services. As a member, you may need to submit a claim yourself, especially if you see a provider or use a pharmacy outside of the network. In most cases, the time limit for a member to submit a claim is one year from the date of service.

You can download the claim form or call the Customer Service number on your ID card. AZ Blue may reject claims that are filed without complete information needed for processing. If AZ Blue rejects a submitted claim due to lack of information, AZ Blue will notify you or the Provider who submitted the claim. Lack of complete information may also delay processing. A complete claim includes, at a minimum, the following information:

Billed charges
Date of service(s)
Diagnosis code
Group number
Member ID number
Member name
Name of provider
Patient name
Patient’s birth date
Procedure code
Provider ID number
Area of oral cavity or tooth treated, as applicable (dental claims only)
Description of service (dental claims only)

Even when the claim has all information listed above, we may need to request medical or dental records or coordination of benefits information to make a coverage determination. If we have requested medical records or other information from a third party, we will suspend claim processing while the request is pending. We may deny a claim for lack of timely receipt of requested records.

You may mail your claim form to:

Blue Cross Blue Shield of Arizona
P.O. Box 2924
Phoenix, AZ 85062-2924

If you have questions, please contact Customer Service at 602-864-4465.

Grace Periods and Claims Pending

You are required to pay your premium by the scheduled due date. If you do not do so, your coverage could be canceled. For most AZ Blue individual healthcare plans, if you do not pay your premium on time, you will receive a 31-day grace period. A grace period is a time period when your plan will not terminate even though you did not pay your premium.

If you are enrolled in an individual healthcare plan offered on the Health Insurance Marketplace and you receive an advance premium tax credit, you will get a three-month grace period. AZ Blue will pay all properly submitted claims for covered services received during the first month of the grace period. During the second and third months of that grace period, AZ Blue will pend any claims you incur. If you pay your full outstanding premium before the end of the three-month grace period, AZ Blue will pay properly submitted claims for covered services received in the second and third months of the grace period. If you do not pay all of your outstanding premium by the end of the three-month grace period, your coverage will terminate, and we will not pay for any pended claims submitted for you during the second and third months of the grace period. Your provider may balance bill you for those services.

Retroactive Denials

It is important to pay your premium on time to avoid termination of coverage. In certain circumstances, coverage may be terminated retroactively. This may occur, for example, if you are entitled to a premium grace period but fail to make your premium payment before the end of the grace period. In such event, claims for services rendered during some or all of the grace period will be denied.

Recoupment of Overpayments

If you feel we have made an error on your premium bill, please contact us at 602-864-4847.

Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities

AZ Blue, or AZ Blue’s contracted vendor, in its sole and absolute discretion, decides whether a service is medically necessary. Decisions about medical necessity may differ from your provider’s opinion. A provider may recommend a service that AZ Blue decides is not medically necessary and therefore is not a covered benefit. You and your provider should decide whether to proceed with a service that is not covered. Also, not all medically necessary services are covered benefits under your plan. All benefit plans have exclusions and limitations on what is covered. A service may be medically necessary and still excluded from coverage. Certain services and medications require prior authorization. Prior authorization is the process AZ Blue uses to determine eligibility for benefits. Prior authorization is not a pre-approval or a guarantee of payment and prior authorization made in error by AZ Blue is not a waiver of AZ Blue’s right to deny payment for non-covered services.

Some covered services and prescriptions require approval from AZ Blue before you get them. This is called a prior authorization. You do not need prior authorization for doctor visits, preventative care, urgent care, or emergency care. Each benefit description in your benefit booklet tells you whether prior authorization is required for that benefit. If it is required, your network provider must obtain it on your behalf before rendering services. AZ Blue may change the services that require prior authorization. If the benefit description does not indicate that prior authorization is required, and you or your provider are unsure, go to azblue.com for a listing of medications and services that require prior authorization or call the Customer Service number listed in the front of your benefit book. Refer to your plan's benefit book for more information regarding prior authorization.

If prior authorization is required, but not obtained, the consequences vary by benefit. The benefit description section in your benefit book tells you which consequences will apply to specific benefits. AZ Blue typically decides on requests for prior authorization for medical services within 72 hours of receiving an urgent request or within 15 days for non-urgent requests.

How to Obtain Prior Authorization

Ask your provider to contact AZ Blue for prior authorization before you receive services. Your provider must contact AZ Blue because he or she has the information and medical records we need to make a benefit determination. AZ Blue will rely on information supplied by your provider. If that information is inaccurate or incomplete, it may affect the decision on your claim.

Drug Exception Timeframes and Enrollee Responsibilities

Sometimes our members need access to drugs that are not listed on the plan's formulary (drug list). These medications are often referred to as non-formulary medications. These medications are initially reviewed by AZ Blue through the formulary exception review process. If a member or provider feels there are no suitable formulary alternatives available, he or she may request that an exception be made to allow coverage for a non-formulary medication by filling out the Non-Formulary Exception Request Form. The member or provider can submit the request to us by faxing the Non-Formulary Exception Request Form along with appropriate documentation supporting the review to 602-864-3126. If the drug is denied, you have the right to an external review.

If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case to 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 mailing, calling, or faxing the request:

Pharmacy Management Department A115
Blue Cross Blue Shield of Arizona
P.O. Box 13466
Phoenix, AZ 85002-3466
Fax: 602-864-3126
Phone: 602-864-4028

For standard exception review of medical requests where the request was denied, the timeframe for review is 72 hours from when we receive the request. For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we receive the request. To request an expedited review for an exigent circumstance, select the box labeled “exigent” on the review form and provide a written explanation for the exigency. For questions regarding your Pharmacy Benefits, please contact Pharmacy Member Services at 1-866-325-1794.

Explanations of Benefits (EOBs)

After your claim is processed, AZ Blue and/or any contracted vendors that process claims will send you an EOB. Your EOBs also will be available through the member portal on azblue.com. An EOB shows services billed, whether the services are covered or not covered, the allowed amount, and the application of cost-sharing amounts. Carefully review your EOB for any discrepancies or inconsistencies with the amounts your provider actually collects from you or bills to you. AZ Blue and/or any contracted vendors will also send your network provider the information that appears on your EOB. This information is not sent to out-of-network providers. Most EOBs are consolidated and sent to you in a monthly member health statement rather than as single EOBs.

Here are definitions to terms that were used in the above statement for reference.

Terms	Definition
Amount Billed	A provider’s full billed charge.
Amount Paid	What AZ Blue pays for a claim. The amount paid is based on the allowed amount, the coverage provided by your benefit plan, and any contract between AZ Blue and the provider. If you see a non-contracted provider, AZ Blue sends any payment directly to you, minus your cost share.
Message Code (Msg. code)	Additional information about the way a claim was processed and paid, if needed.
Cost Share	The amount you pay for a covered service. Examples of cost share include copays, deductibles, and coinsurance.
Deductible	A flat amount you must pay before the insurer will make any benefit payments on certain services.
Copay	A specific dollar amount you must pay to the provider for some covered services such as a doctor’s office visit. It is usually paid at the time of services.
Coinsurance	The percentage of the allowed amount that you pay for certain covered services after meeting any applicable deductible.

Example of Acceptable Language:

Each time we process a claim submitted by you or your healthcare provider, we explain how we processed it in the form of an Explanation of Benefits (EOB).

The EOB is not a bill. It simply explains how your benefits were applied to that particular claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you're responsible for paying the provider. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.

Coordination of Benefits (COB)

Coordination of benefits is how insurers determine who pays first when two or more health insurance plans are responsible for paying the same medical claim. If you have more than one health plan for yourself or a family member it is important to tell AZ Blue about that coverage so we can make sure your medical claims are paid correctly. Two ways you may do that are online (sign in to your member account at azblue.com/Member; Click on "Account Profile"; under "Other Insurance Information", click on "Add/Edit other insurance") or by contacting Customer Service at 602-864-4465.