Policies, privacy and legal

Since you have Medicare, you have certain rights to help protect you. This page explains your Medicare rights and protections as a member of Blue Cross NC. We will tell you what you can do if you think you are being treated unfairly or your rights are not being respected. If you want Medicare publications about your rights, you may call and request them at 800-MEDICARE (800-633-4227). TTY users should call 877-486-2048. You can call 24 hours a day, 7 days a week.

Your right to be treated with fairness and respect

You have the right to be treated with dignity, respect, and fairness at all times. We must obey laws against discrimination that protect you from unfair treatment. These laws say that we cannot discriminate against you (treat you unfairly) because of your race or color, age, religion, national origin or any mental or physical disability you may have.

If you think you have been treated unfairly due to your race, color, national origin, disability, age or religion, please let us know. You can also reach the Office for Civil Rights at 800-368-1019 (TTY 800-537-7697), or you can contact the regional Office for Civil Rights in your area.

Southern Regional Office for Civil Rights

States in Region:

North Carolina

Alabama

Florida

Georgia

Kentucky

Mississippi

South Carolina

Tennessee

Contact Information:

Phone number: 800-368-1019

TTY number: 800-537-7697

(For the hearing and speech impaired)

Address:

Office for Civil Rights

U.S. Department of Health and Human Services

Atlanta Federal Center

Suite 16T70

61 Forsyth Street, SW

Atlanta, GA 30303

ATTENTION: if you require language assistance services, these are available to you free of charge. Please use the information listed above to contact Blue Cross NC Customer Service.

Your right to the privacy of your medical records and personal health information

There are Federal and State laws that protect the privacy of your medical records and personal health information. We keep your personal health information private as protected under these laws. Any personal health information that you give us when you enroll in this plan is protected. We will make sure that unauthorized people do not see or change your records. Generally, we must get written permission from you (or from someone you have given legal power to make decisions for you) before we can give your health information to anyone who is not providing your care or paying for your care. There are exceptions allowed or required by law, such as release of health information to government agencies that are checking on quality of care. The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We are required to provide you with a notice that tells about these rights and explains how we protect the privacy of your health information. For example, you have the right to look at your medical records, and to get a copy of the records (there may be a fee charged for making copies). You also have the right to ask us to make additions or corrections to your medical records (if you ask us to do this, we will review your request and determine whether the changes are appropriate). You have the right to know how your health information has been given out and used for non-routine purposes. If you have questions or concerns about the privacy of your personal information and medical records, please use the information listed above to contact Blue Cross NC Customer Service.

Your right to get your prescriptions filled within a reasonable period of time

You should get all of your prescriptions filled from a network pharmacy, that is, from pharmacies that contract with Blue Cross NC. You have the right to go to any network pharmacy in order to get your prescriptions filled at the benefit level. You have the right to timely access to your prescriptions. "Timely access" means that you can get your prescriptions filled within a reasonable amount of time.

Your right to know your treatment choices and participate in decisions about your health care

You have the right to know about the different Medication Management Treatment Programs we offer and in which you may participate. You have the right to be told about any risks involved in your care. You have the right to refuse treatment. This includes the right to stop taking your medication. If you refuse treatment, you accept responsibility for what happens as a result of refusing treatment.

You have the right to get a detailed explanation from us if you believe that a network pharmacy has denied coverage for a drug that you believe you are entitled to get or care you believe you should continue to get.

Your right to make complaints

You have the right to make a complaint if you have concerns or problems related to your coverage or care. "Appeals" and "grievances" are the two different types of complaints you can make. Which one you make depends on your situation.

If you make a complaint, we must treat you fairly (i.e., not discriminate against you). You have the right to get a summary of information about the appeals and grievances that members have filed against us in the past. To get this information, please use the information listed above to contact Blue Cross NC Customer Service.

Your right to get information about your drug coverage and costs

This website tells you what you have to pay for prescription drugs as a member of Blue Cross NC. If you need more information, please use the contact numbers listed above to contact Blue Cross NC Customer Service. You have the right to an explanation from us about any bills you may get for drugs not covered by your plan. We must tell you in writing why we will not pay for a drug, and how you can file an appeal to ask us to change this decision.

Your right to get information about our Plan and our network pharmacies1

You have the right to get information from us about Blue Cross NC and our Blue Medicare Rx Plans. This includes information about our financial condition and about our network pharmacies. To get any of this information, please use the information listed above to contact Blue Cross NC Customer Service.

Your right to disenroll from your plan

You have the right to disenroll from Blue Medicare Rx Plans during certain periods by giving written notice to the Blue Cross NC of your intent to do so. Coverage will end on the last day of the month following the date that Blue Cross NC receives your written request. To end your coverage, you may send written notice to Blue Medicare Rx Plans, P.O. Box 17468, Winston-Salem, NC 27116. You will receive an acknowledgement of your disenrollment from Blue Cross NC.

How to get more information about your rights

If you have questions or concerns about your rights and protections, use the information listed above to contact Blue Cross NC Customer Service. You can also get free help and information from Seniors' Health Insurance Information Program (SHIIP). You can reach SHIIP at 855-408-1212. In addition, the Medicare program has written a booklet called Your Medicare Rights and Protections. To get a free copy, call 800-MEDICARE (800-633-4227). TTY users should call 877-486-2048. You can call 24 hours a day, 7 days a week. Or, you can visit medicare.gov to order this booklet or print it directly from your computer.

What can you do if you think you have been treated unfairly or your rights are not being respected?

For concerns or problems related to your Medicare rights and protections described in this section, please use the information listed above to contact Blue Cross NC Customer Service. You can also get help from SHIIP by calling 855-408-1212.

What are your responsibilities as a member of Blue Cross NC?

Along with the rights you have as a Blue Cross NC member, you also have some responsibilities. Your responsibilities include the following:

• Become familiar with your coverage and the rules you must follow to get care as a member. Use the information available on this website as well as other information we give you to learn about your coverage, what you have to pay, and the rules you need to follow. If you have questions, use the information listed above to contact Blue Cross NC Customer Service.
• Give your health care provider(s) the information they need to care for you, and follow the treatment plans and instructions given to you. Be sure to ask your health care provider(s) if you have any questions.
• Pay your plan premiums and any copayments you may owe for the covered drugs you get.
• Let us know if you have any questions, concerns, problems, or suggestions. If you have questions, use the information listed above to contact Blue Cross NC Customer Service.

For a detailed explanation of the appeals and grievance procedures and timeframes for a response, refer to the Evidence of Coverage for your plan.

To obtain an aggregate number of Medicare Advantage Plan appeals and quality of care grievances, you may call Customer Service at 888-310-4110 (toll-free) for Blue Medicare HMO or 877-494-7647 for Blue Medicare PPO, 888-451-9957 / TTY:711, seven (7) days a week, 8 a.m. to 8 p.m. Eastern Standard Time.

Appeals

An appeal is your opportunity to request a redetermination of an adverse coverage determination.

Standard appeals

You can appeal a Notice of Denial of Medical Coverage decision, a Denial of Payment decision, or you can dispute the Copayment or Coinsurance amount you are being billed. Appeal requests for a Denial of Payment decision must be submitted in writing including why you think the denial should be overturned. You may also appeal a denial of Medical coverage by calling Blue Cross and Blue Shield of North Carolina.

How do I file a standard appeal?

You or your prescriber may file an appeal. An appeal must be filed within sixty (60) calendar days of the date of the denial notice.  If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. 

You or your prescriber may file an appeal. An appeal must be filed within sixty (60) calendar days of the date of the denial notice.  If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal If you cannot file an appeal, you may designate someone, in writing, to file an appeal for you.  An Appointment of Representative (AOR) form (PDF) should be completed and accompany your written appeal.  Your physician can also file an appeal of a Notice of Denial of Medical Coverage decision for you without being your appointed representative.

By phone:

Blue Medicare HMO members should call 888-310-4110, for the hearing and speech impaired call 711

Blue Medicare PPO members should call 877-494-7647, for the hearing and speech impaired call 711

Seven (7) days a week

8 a.m. to 8 p.m. Eastern Standard Time

Mail:

Blue Cross and Blue Shield of North Carolina

Attn: Medicare Provider Appeal Department

P.O. Box 1291

Durham, NC 27702-129

Fax:

888-375-8836

When will I receive a decision on my standard appeal?

We will investigate your concern(s) and respond to you in writing. Our response to a standard appeal of a Notice of Denial of Medical Coverage will be sent within thirty (30) calendar days of the Plan's receipt of the appeal, or within forty-four (44) calendar days if an extension was taken. Our response to an appeal of a Notice of Denial of Payment will be sent within sixty (60) calendar days of the Plan's receipt of the appeal.

Expedited or Fast Appeals

If you or your doctor believes that waiting on a standard appeal decision on a Notice of Denial of Medical Coverage could seriously harm your health or your ability to function, you, your authorized representative or your doctor can ask for an expedited or fast appeal. 

Note: An appeal request for a Notice of Denial of Payment or Copayment or Coinsurance dispute cannot be expedited.

How do I request an expedited or fast appeal?

You or your doctor can request an expedited or fast appeal.

If you cannot file an appeal, you may designate someone, in writing, to file an appeal for you.  An Appointment of Representative (AOR) form (PDF) should be completed and accompany your written appeal.  Your physician can also file an appeal of a Notice of Denial of Medical Coverage decision for you without being your appointed representative.

By phone:

Blue Medicare HMO members should call 888-310-4110, for the hearing and speech impaired call 711

Blue Medicare PPO members should call 877-494-7647, for the hearing and speech impaired call 711

Seven (7) days a week

8 a.m. to 8 p.m. Eastern Standard Time

If calling after business hours, just follow the prompts to file an expedited or fast appeal.

By mail:

Blue Cross and Blue Shield of North Carolina

           Attn: Medicare Provider Appeal Department

           P.O. Box 1291

           Durham, NC 27702-129

By fax:

888-375-8836

When will I receive a decision on my expedited appeal?

We will respond by phone and in writing to an expedited appeal within seventy-two (72) hours of our receipt of the expedited or fast appeal request. If someone other than you or your physician decides to file an expedited or fast appeal for you, an Appointment of Representative (AOR) form (PDF) must be received before the appeal review can begin.

We may extend the timeframe by up to fourteen (14) calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

Appealing an Important Message Notification for Your Hospital Discharge

If you receive an Important Message from Medicare About Your Rights for your inpatient hospital services from the provider and you want your inpatient hospital services to be covered longer, you are entitled to file an appeal with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), rather than Blue Medicare HMO or Blue Medicare PPO. Please follow the instructions contained in the Important Message for the steps to follow to file an appeal with the BFCC-QIO.

Appealing a Notice of Medicare Non-Coverage

If you receive an advance Notice of Medicare Non-Coverage for skilled nursing, home health or comprehensive outpatient rehabilitation services from the provider of the service, you are entitled to file an appeal with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), rather than Blue Medicare HMO or Blue Medicare PPO, regarding the upcoming termination of services. Please follow the instructions contained in the Notice for the steps to follow to file an appeal with the BFCC-QIO.

Grievances

A grievance is an expression of dissatisfaction with any aspect of the operations, activities, or behavior of a plan or its delegated entity in the provision of health care or prescription drug services or benefits, regardless of whether remedial action is requested.

Please see your Evidence of Coverage for a detailed explanation of the grievance procedures and timeframes for a response. 

How do I file a grievance?

The grievance must be filed within sixty (60) days after the event or incident that caused you to be dissatisfied. A specific form is not required for you to file a grievance. 

A Medicare beneficiary may appoint an individual to act as his/her representative in filing a grievance. A representative who is appointed by the court or who is acting in accordance with North Carolina law may also file a grievance. A grievance by a representative is not valid until the Appointment of Representative (AOR) form (PDF) is completed and submitted, or other equivalent form, legal papers or authority are submitted.

You or your appointed representative may file a grievance by phone, mail, fax, or in-person. You can also file a complaint with Medicare here: Medicare Complaint Form

By phone:

Blue Medicare HMO members should call 888-310-4110, for the hearing and speech impaired call 711

Blue Medicare PPO members should call 877-494-7647, for the hearing and speech impaired call 711

Seven (7) days a week

8 a.m. to 8 p.m. Eastern Standard Time

By mail:

Blue Cross and Blue Shield of North Carolina

          Attn: Medicare Provider Appeal Department

          P.O. Box 1291

          Durham, NC 27702-129

By fax:

888-375-8836

Via KERPO

If you are dissatisfied with the quality of care you have received, you may also file your grievance with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). The Beneficiary and Family Centered Care Quality Improvement Organization for North Carolina is KEPRO.

By phone:

888-317-0751 or for the hearing and speech impaired call 855-843-4776 (TTY/TDD)

By mail:

5201 W. Kennedy Blvd.

Suite 900

Tampa, FL 33609

By fax:

833-868-4058

Online: www.keproqio.com

When will I receive a decision on my grievance?

The resolution of a grievance will be made as quickly as your concern requires, but no more than thirty (30) calendar days after we receive the grievance. We may extend the timeframe by up to fourteen (14) calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. If you request a written response to an oral grievance, one will be provided within thirty (30) days after we receive the grievance. A written response will be provided for all written grievances. Our decision on a grievance is final and is not subject to an appeal.

If we have denied your request for an expedited coverage decision or an expedited appeal or if we have taken a fourteen (14) calendar day extension on the time frame for a coverage decision or appeal, and you disagree with those actions, you may file an expedited or fast grievance. Our response will be provided within twenty-four (24) hours after we receive the grievance.

Appeals

An appeal is your opportunity to request a redetermination of an adverse coverage determination, which includes denied exception requests. For example, if we deny your request for an exception to cover a non-formulary drug, then you may file an appeal of the denial. An appeal can only be filed after an exception has been requested and denied by the Plan.

How do I file an appeal?

If you receive a coverage determination denial, you or your appointed representative or your prescriber may file an appeal. An appeal must be filed within sixty (60) calendar days of the date of the denial notice.  If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. 

A specific form is not required for you to file an appeal; however, a form is available for your use by clicking on the link below. Completion of this form may help you with your review request and assist us in the review process.

Part D Appeal Form (PDF)

A Medicare beneficiary may appoint an individual to act as his/her representative in filing an appeal. A representative who is appointed by the court or who is acting in accordance with North Carolina law may also file an appeal. An appeal by a representative is not valid until the Appointment of Representative (AOR) form (PDF) is completed and submitted, or other equivalent form, legal papers or authority are submitted.

You or your appointed representative may file an appeal by phone, mail, fax, email or in-person. You can also file a complaint with Medicare here: Medicare Complaint Form

By phone:

Blue Medicare Rx (PDP) members call 888-247-4142 TTY:711

Seven (7) days a week

8 a.m. to 8 p.m. Eastern Standard Time

By mail:

Blue Cross and Blue Shield of North Carolina

Medicare Provider Appeal Department

P.O. Box 1291

Durham, NC 27702-129

By fax:

888-375-8836

By email:

Send Part D appeal emails to: PartDAppeals@bcbsnc.com 

A Part D appeal by email must include the member's:

• Full name
• Member ID number (see your member ID card)
• Date of birth
• Phone number
• The name of the drug for which the appeal is being requested
• The name and telephone number of the person who prescribed the drug
• The reason you think the drug should be covered

When will I receive a decision on my appeal?

Standard Appeals

We will perform a standard review of your appeal as soon as your health requires but no later than seven (7) calendar days after we receive your appeal. You will receive a written response to your appeal.

Expedited or Fast Appeals

We will review requests for an expedited or fast appeal as soon as possible, but no later than seventy-two (72) hours following our receipt of the request. The decision on an expedited appeal will be provided by phone followed by the written notice.

An individual who was not involved with your original coverage determination will make a decision on your appeal.

If our decision is to deny the appeal, the notice will advise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructions on how to do so. 

If we miss our timeframes for claims adjudication or review of the appeal, we will automatically forward the appeal to the IRE for a decision. 

There may be additional levels of appeal available to you. We will inform you of your additional rights in the notice, or you may refer to your Evidence of Coverage for further details.

Grievances

A grievance is an expression of dissatisfaction with any aspect of the operations, activities, or behavior of a plan or its delegated entity in the provision of health care or prescription drug services or benefits, regardless of whether remedial action is requested.

Please see your Evidence of Coverage for a detailed explanation of the grievance procedures and timeframes for a response. 

How do I file a grievance?

The grievance must be filed within sixty (60) days after the event or incident that caused you to be dissatisfied. A specific form is not required for you to file a grievance. You may file a grievance by phone, mail, fax, or in-person. You can also file a complaint with Medicare here: Medicare Complaint Form

A Medicare beneficiary may appoint an individual to act as his/her representative in filing a grievance. A representative who is appointed by the court or who is acting in accordance with North Carolina law may also file a grievance. A grievance by a representative is not valid until the Appointment of Representative (AOR) form (PDF) is completed and submitted, or other equivalent form, legal papers or authority are submitted.

By phone:

Blue Medicare Rx (PDP) members should call 888-247-4142, for the hearing and speech impaired call 711

Seven (7) days a week

8 a.m. to 8 p.m. Eastern Standard Time

By mail:

          Blue Cross and Blue Shield of North Carolina

          Medicare Provider Appeal Department

          P.O. Box 1291

          Durham, NC 27702-129

By fax:

888-375-8836

Via KERPO

If you are dissatisfied with the quality of care you have received, you may also file your grievance with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). The Beneficiary and Family Centered Care Quality Improvement Organization for North Carolina is KEPRO.

By phone:

888-317-0751 or for the hearing and speech impaired call 855-843-4776 (TTY/TDD)

By mail:

5201 W. Kennedy Blvd.

Suite 900

Tampa, FL 33609

By fax:

833-868-4058

Online: www.keproqio.com

When will I receive a decision on my grievance?

The resolution of a grievance will be made as quickly as your concern requires, but no more than thirty (30) calendar days after we receive the grievance. We may extend the timeframe by up to fourteen (14) calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. If you request a written response to an oral grievance, one will be provided within thirty (30) days after we receive the grievance. A written response will be provided for all written grievances. Our decision on a grievance is final and is not subject to an appeal.

You have the right to an expedited review of a grievance concerning our refusal to grant an expedited coverage determination or expedited appeal. This type of grievance will be responded to within twenty-four (24) hours after we receive the grievance.

When we make an organization determination, we are making a decision about whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are called 'coverage decisions' in your Evidence of Coverage (EOC).

Certain services need prior approval for payment by the plan. Your evidence of coverage (EOC) provides explanation of what services require prior approval.

Prior Approval means we review the information before the service occurs. Information needed for these reviews includes the name of your ordering physician, the name of the provider of service, the type of service(s) needed and any supporting medical information.

How do I request coverage for a service that requires prior approval?

You or your physician may contact the Plan by phone, mail or in-person to request prior approval for a service. You may also appoint an individual to act as your representative in filing a request for prior approval. A representative who is appointed by the court or who is acting in accordance with North Carolina law may also file a request for prior approval for you.

A request by your representative is not valid until the Appointment of Representative (AOR) form (PDF), or other equivalent form, legal papers or authority is submitted to the Plan.

By phone:

Blue Medicare HMO members should call 888-310-4110,

Hearing and speech impaired call 888-451-9957 / 711 (TTY)

Blue Medicare PPO members should call 877-494-7647,

Hearing and speech impaired call 888-451-9957 / 711 (TTY)

Seven (7) days a week

8 a.m. to 8 p.m. Eastern Standard Time

By mail:

Blue Cross Blue Shield of North Carolina

Attn: Care Management

          P.O. Box 1291

          Durham, NC 27702-129

When will I receive a decision on my request for prior plan approval?

The prior approval review will be made as quickly as possible once all of the necessary medical information is received. You will receive a written response when a decision is made.

• The timeframe for a standard request is no more than fourteen (14) calendar days.
• The timeframe for an expedited request is seventy-two (72) hours.
• We may extend the timeframe by up to fourteen (14) calendar days if you request the extension, or if we justify a need for additional information, and the delay is in your best interest.

How do I file an appeal?

Standard Appeals

You can appeal a denied Notice of Denial of Medical Coverage decision, Notice of Denial of Payment decision, or if you are disputing a Copayment or Coinsurance amount you are being billed for, by sending a written, signed request detailing why you think the denial should be overturned. If you cannot file an appeal, you may designate someone, in writing, to file an appeal for you. An Appointment of Representative (AOR) form (PDF) should be completed and accompany your written appeal. Your physician can also file an appeal of a Notice of Denial of Medical Coverage decision for you without being your appointed representative.

An appeal must be filed within sixty (60) calendar days of the denial notice that we sent to you.

You may file your appeal by:

Mail:

Blue Cross Blue Shield of North Carolina

Attn: Medicare Appeals and Grievances Department

          P.O. Box 1291

          Durham, NC 27702-129

Fax:

888-375-8836

We will investigate your concern(s) and respond to you in writing. Our response to a standard appeal of a Notice of Denial of Medical Coverage will be sent within thirty (30) calendar days of the Plan's receipt of the appeal, or within forty-four (44) calendar days if an extension was taken. Our response to an appeal of a Notice of Denial of Payment will be sent within sixty (60) calendar days of the Plan's receipt of the appeal.

Expedited or Fast Appeals

If you or your doctor believes that waiting on a standard appeal decision on a Notice of Denial of Medical Coverage could seriously harm your health or your ability to function, you, your authorized representative or your doctor can ask for an expedited or fast appeal. Note: An appeal request for a Notice of Denial of Payment or Copayment or Coinsurance dispute cannot be expedited.

To file an Expedited or Fast appeal:

By phone:

Blue Medicare HMO members should call 888-310-4110, for the hearing and speech impaired call 888-451-9957 / 711 (TTY)

Blue Medicare PPO members should call 877-494-7647, for the hearing and speech impaired call 888-451-9957 / 711 (TTY)

Seven (7) days a week

8 a.m. to 8 p.m. Eastern Standard Time

If calling after business hours, just follow the prompts to file an expedited or fast appeal.

By mail:

Blue Cross Blue Shield of North Carolina

Attn: Medicare Appeal and Grievance Department

          P.O. Box 1291

          Durham, NC 27702-129

By fax:

888-375-8836

When will I receive a decision on my appeal?

We will respond by phone and in writing to an expedited appeal within seventy-two (72) hours of our receipt of the expedited or fast appeal request. If someone other than you or your physician decides to file an expedited or fast appeal for you, an Appointment of Representative (AOR) form (PDF) must be received before the appeal review can begin.

We may extend the timeframe by up to fourteen (14) calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

Appealing an Important Message Notification for Your Hospital Discharge

If you receive an Important Message from Medicare About Your Rights for your inpatient hospital services from the provider and you want your inpatient hospital services to be covered longer, you are entitled to file an appeal with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), rather than Blue Medicare HMO or Blue Medicare PPO. Please follow the instructions contained in the Important Message for the steps to follow to file an appeal with the BFCC-QIO.

Appealing a Notice of Medicare Non-Coverage

If you receive an advance Notice of Medicare Non-Coverage for skilled nursing, home health or comprehensive outpatient rehabilitation services from the provider of the service, you are entitled to file an appeal with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), rather than Blue Medicare HMO or Blue Medicare PPO, regarding the upcoming termination of services. Please follow the instructions contained in the Notice for the steps to follow to file an appeal with the Beneficiary and Family Centered Care Quality Improvement Organization.

Please see your Evidence of Coverage for a detailed explanation of the appeals and grievance procedures and timeframes for a response. Refer to the Evidence of Coverage for your plan.

To obtain an aggregate number of Medicare Advantage Plan appeals and quality of care grievances, you may call Customer Service at 888-310-4110 (toll-free) for Blue Medicare HMO or 877-494-7647 for Blue Medicare PPO, 888-451-9957 / 711 (TTY), seven (7) days a week, 8 a.m. to 8 p.m. Eastern Standard Time.

Quality Assurance includes the processes and systems put in place to evaluate prescriptions for health and safety issues. They help promote the appropriate use of medications by improving compliance and reducing medication errors and adverse drug interactions.

Quality assurance processes for Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx (PDP) are summarized below:

Concurrent Drug Utilization Review (DUR)

This occurs while a claim is being processed at the pharmacy. Prescriptions are screened for the following safety issues and the pharmacist is sent a message immediately, alerting them of the potential issue.

• Drug Interactions: Instances when the prescribed drug can potentially result in ineffective or unsafe treatment when used in combination with another drug
• Drug-Allergy: Identifies when the prescribed drug may potentially cause problems based on patient's reported allergies.
• Drug-Disease: Instances when the prescribed drug may potentially worsen the patient's reported medical condition(s).
• Drug-Gender Contraindications: Identifies prescription medications being inappropriately filled based on patient gender.
• Drug-Age: Identifies those drugs that are contraindicated for use by older adults.
• Excessive Daily Dosing and Duration of Therapy: Identifies when a prescription claim is being filled for more than the recommended maximum daily dose or duration.
• Refill Too Soon or Too Late: Identifies patients who may not be taking their medication as prescribed by their physician.
• Therapy Duplication: Identifies when the prescription being filled is from the same Therapeutic Class as other medications in the members profile.
• Potential Drug Name Confusion: Identifies prescriptions that sound alike, or when written, look alike.

Retrospective Drug Utilization Review (DUR)

This occurs after the prescription has been dispensed. It is a program that evaluates a members' drug history to identify prescribing issues. Alerts are provided by mail to physicians, addressing prescribing practices and uses that are unsafe, ineffective, or otherwise inconsistent with evidence-based standards of care. Retrospective DUR complements the Concurrent DUR program by identifying physicians who for some reason may be resistant to the messages generated by concurrent monitoring.

The Retrospective DUR health and safety alerts are made up of four key categories:

• Potential Drug-Drug Interactions: Instances when prescribed medications can potentially result in ineffective or unsafe treatment when used in combination with another drug
• Dose Considerations with Pain Medications: Examines the use of certain high dose pain medications
• Drug Age Considerations: Considers the adverse effects of certain drugs or drug classes on the elderly population.
• Therapy Duplication: Identifies the use of two or more drugs in the same therapeutic class that may put the patient at risk of additional unwanted side effects or adverse medical event.

Refill Reminders to Patients

As part of the dispensing process, a refill notice is generated by computer and included with each dispensed mail-order prescription. The email refill reminder program is designed to remind plan members to refill and continue to take important medications, specifically those medications that are for chronic conditions for which there may not always be signs and symptoms of illness.

Blue Cross and Blue Shield of North Carolina (Blue Cross NC), has a contract with the Centers for Medicare & Medicaid Services (CMS) to provide a Medicare Advantage prescription drug plan (MAPD). Blue Cross NC is also a Medicare-approved Part D sponsor. CMS is the government agency that runs Medicare. This contract renews each calendar year. Each year the contract is reviewed, and either Blue Cross NC or CMS can decide to end it. Members will get 90 days advance, written notice if the contract will not be renewed in this situation. It is also possible for our contract to end at some other time. If the contract is going to end, we will generally tell members 90 days in advance. Advance notice may be as little as 30 days or even fewer days if CMS ends our contract in the middle of the year. In this notice, we would provide a written description of alternatives available for obtaining qualified prescription drug coverage in North Carolina. We are also required to notify the general public of a contract termination via local newspapers.

If Blue Cross NC decides to stop offering Blue Medicare HMO, Blue Medicare PPO or Blue Medicare Rx coverage, or change the service area so that it no longer includes the area where you live, membership in Blue Medicare HMO, Blue Medicare PPO or Blue Medicare Rx affected by that change will end for everyone in the affected plan within that service area, and members will have to change to a different Medicare Advantage or Medicare drug plan, return to Original Medicare or select a Medicare Supplement plan, if needed. Blue Medicare HMO, Blue Medicare PPO or Blue Medicare Rx will provide coverage until the contract ends.