How Your Health Insurance Works
Do you know how your health insurance works? Get your member rights and responsibilities and information essential to being an active partner in maintaining your good health.
As a member of Blue Cross and Blue Shield of North Carolina (Blue Cross NC), you should know your rights, how to track claims, how to appeal a decision and other information essential to being an active partner in maintaining your good health. To help you find that information quickly and easily, we put together this summary1explaining how your health insurance works, with additional information about Blue Cross NC Quality Improvement programs.
Using Your Benefit Booklet
To learn more about your benefits and access to medical services, please log in to Blue Connect for details within your benefit booklet.
Your benefit booklet provides information regarding:
- Benefits and services included in, and excluded from, coverage
- Pharmaceutical management procedures, if they exist
- Copayments and other charges for which members are responsible
- Benefit restrictions that apply to services obtained outside the organization's system or service area
- How to submit a claim for covered services, if applicable
- How to obtain information about practitioners who participate in the provider network
- How to obtain primary care services, including points of access
- How to obtain specialty care and behavioral health care services and hospital services
- How to obtain care after normal office hours
- How to obtain emergency care, including the organization's policy on when to directly access emergency care or use 911 services
- How to obtain care and coverage when subscribers are out of the organization's service area
- How to voice a complaint
- How to appeal a decision that adversely affects coverage, benefits or a member's relationship with the organization
- How the organization evaluates new technology for inclusion as a covered benefit
How to Appeal Payment Decisions
There are two common reasons that an adverse benefit determination2 may be made:
- The service may not be medically necessary
- The service is not covered under your health plan
Your First Step
To find out whether something is covered by your health plan, first carefully review the benefits in your benefit booklet or visit bcbsnc.com/content/services/medical-policy to see our medical policies. If you need more help, a Blue Cross NC Customer Service professional can help you review your benefits. If you disagree with an adverse benefit determination, you have the right to appeal by following the process below. For more information about the appeals process, please refer to your benefit booklet.
Internal and External Appeals Process
Level One — only level required for individual/direct-pay members for noncertifications
At this level, you can appeal an adverse benefit determination, or submit a grievance, by submitting a written request that includes a description of the situation and, if applicable, a full explanation of why you disagree with the initial Blue Cross NC decision. Be sure to supply any documentation that supports your position and Blue Cross NC will review this information. If you disagree with the outcome, in most instances you can proceed to the next level of the appeals process.
Level Two — applicable to employer group health plan members and individual/direct-pay members for grievances
Please refer to your benefit booklet for specific details regarding the Level Two appeals process.
Level Three — external review
For members of fully-insured employer group health plans and individual/direct-pay plans, this level is handled through the North Carolina Department of Insurance (NCDOI). You may request a review through the NCDOI for all medical necessity denials. Generally, you must complete Level One and Level Two appeals before you can appeal to the NCDOI. If your request is accepted by the NCDOI for review, it will be sent to an Independent Review Organization (IRO). Blue Cross NC must follow the decision of the IRO. For members of non-grandfathered self-funded employer group health plans, the external review by an IRO is facilitated by either Blue Cross NC or the employer group. You should contact your Plan Administrator for details.
Notice of Mastectomy Benefits
As required by the Women's Health and Cancer Rights Act of 1998, your health insurance policy provides benefits for mastectomy related services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses and complications resulting from a mastectomy, including lymphedema. This coverage is subject to the same deductibles, copayments, coinsurance or limitations as applied to other medical and surgical benefits provided under your policy. If you have questions, please check your benefit booklet or call the Customer Service number on your ID card for more information.
Continuity of Care
At Blue Cross NC, when you change health plans or your doctor* is no longer part of the Blue Cross NC network, you may be eligible to get continued care from your doctor for a short time. During that time, you and your doctor should look for a new, in-network doctor for your care. Blue Cross NC will help its members who need continued care during a change in coverage. This process is called "continuity of care."
To be eligible for continuity of care, one of these four conditions must apply:
- You have a short-term health problem that is life-threatening and needs continued care from your doctor to prevent a chance of death or permanent harm.
- You have a long-term health problem that is life-threatening, degenerative or disabling and need continued care over a longer time.
- You are in the second or third trimester of pregnancy or completing post-partum care.
- You have a terminal illness, which means a medical prognosis that puts your life expectancy at six months or less.
You must send a request to Blue Cross NC for continuity of care. A Blue Cross NC nurse will review your request. You can call Customer Service at the phone number on the back of your ID card and ask for a continuity of care request form. Your doctor also has to agree to Blue Cross NC's rules for continued care.
If you are new to Blue Cross NC, you must send the form in within 45 days of your effective date.
If you are not a new member and have learned that your doctor is not in the Blue Cross NC network, you must send the form in within 45 days from when you found out your doctor was out of Blue Cross NC's network.
* Doctor may also mean a nurse practitioner, physician assistant or other health care expert that you have seen for health care.
Transitioning from Pediatric to Adult Care
For teenagers and young adults, it can be tough to know when to switch from their childhood doctor to one who specializes adult care. Most choose to make this transition around 18 to 21 years of age. To find an in-network doctor near you who is qualified to care for adults, visit Find a Doctor or call the customer service number on the back of your member ID card.
- Online: Blue Connect
- Access to utilization management review staff:
1-800-672-7897 (toll free)
- Blue Cross NC Customer Service:
1-800-446-8053 (toll free)
8 a.m. – 9 p.m., Monday – Friday
To receive a printed version of any content, please call the Customer Service number listed on your ID card.
- In the event of any inconsistency between information contained in this summary and the member's Benefit Booklet, the Benefit Booklet shall govern.
- The Benefit Booklet defines an adverse benefit determination as follows: A denial, reduction or termination of, or failure to provide full or partial payment for, a benefit, including one that results from the application of any utilization review, or a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate. Rescission of coverage is also included as an adverse benefit determination.
The National Committee for Quality Assurance (NCQA) is an independent, not-for-profit organization that evaluates and reports on the quality of the nation's managed care plans. NCQA maintains and regularly updates quality standards utilized by the health insurance industry to gauge levels of ongoing quality and improvement. The NCQA accreditation program helps employers and consumers compare health plans based on various quality measures.