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Frequently Asked Questions
Frequently Asked Questions

How can I file a claim?

In the majority of cases, your health care providers will file claims to us on your behalf. That is why it is very important for you to have your Excellus BlueCross BlueShield member ID card with you at all times. If you need to file a claim yourself, follow this link to print a claim form in our online forms center.

If I do need to file my own medical, dental or vision claim, what do I need to include with my claim form?

You will need to attach an itemized bill from the provider who rendered services to you. The itemized bill must include the following:

For Medical, Dental, Vision, or Hospital Care

  • Provider's name and address
  • Date(s) of service for each service provided
  • Description of the type of service(s) rendered
  • Where the services were rendered (e.g., in a doctor’s office, in a hospital or at home)
  • Diagnosis code (not applicable to dental claims)
  • Charge for each service rendered

For Prescription Drugs
Your claim for prescription drugs must include:

  • Name and address of the pharmacy
  • Script number
  • Drug name
  • Quantity and dosage of the medication
  • Number of days prescribed
  • Name of the prescribing doctor

For Private Duty Nursing Care
Your claim for private duty nursing care must include:

  • The type of nurse who rendered the care (e.g., RN or LPN)
  • License number
  • Shift and hours worked
  • Statement from the ordering doctor indicating why the nursing services were medically necessary

For Durable Medical Equipment (DME)
Your claim for durable medical equipment must include:

  • Statement from the ordering doctor indicating why the DME was medically necessary
  • How long the DME needs to be used
  • Supplier’s statement indicating rental vs. purchase price

How can I access my claims online, and use the online tools available to me on this website?

In order to take advantage of the convenient tools and information available to you on our website, you need to login or register for a web account.

What is your mailing address?

Follow this link to View our Mailing Address. Be sure to include your ID number on everything you mail to us.

How do I obtain a duplicate Explanation of Benefits or Monthly Health Summary statement showing how my claims have been processed?

Please contact customer services. You'll find phone numbers and email links on our Contact Us page.

What do the fields on my Explanation of Benefits (EOB) mean?

Follow this link to view a sample of our EOB (PDF). It contains an explanation to some of the common fields.

What if I disagree with the denial of my claim?

Excellus BlueCross BlueShield provides a process to follow if you and/or your health care provider disagree with our decision to deny services. If the denial was based on your contract, you may file a grievance. If the denial was based on medical necessity and/or the experimental or investigational nature of the treatment, you and/or your health care provider may request a medical appeal.

Whether it's for a grievance or a medical appeal, the first step in the process is to file your concern with our Customer Service Department.

Call Customer Service at the phone number listed on your Member ID Card, or view our Contact Us page for a listing of phone numbers. You may also submit your grievance or request for appeal in writing. See our Contact Us page for the address of your local office.

If you would like to appoint a representative to act on your behalf, give Customer Service that person's name. At any time, you may also file a complaint with the State Department of Health, (800) 206-8125, or the State Department of Insurance, (800) 342-3736.

How do I obtain care when my doctor's office is closed?

If you have a non-life threatening condition (e.g., sore throat, cold/flu symptoms, or ankle sprain) we encourage you to obtain care at one of the many Urgent Care Centers in your area.

Visit our Find an Urgent Care Center page to find an Urgent Care Center near you.

What should I do if it's an emergency?

If you have an emergency medical condition, you should go directly to the nearest emergency room. An emergency medical condition is defined as a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson possessing an average knowledge of medicine and health could reasonably expect the absence of immediate medical attention to result in placing the health of the person in serious jeopardy, or in the case of behavioral health, placing the health of others in serious jeopardy; or serious impairment to a bodily function; or serious dysfunction of any bodily organ or part; or serious disfigurement. Some examples include severe chest pain, poisoning or unconsciousness.

Most managed care plan members must have a referral from their PCP prior to seeking emergency room care if the condition does not appear to be for an emergency medical condition. If you receive treatment for an emergency medical condition at the emergency room, be sure to notify your PCP within 24 hours to arrange for follow-up visits and continuing care.

Can I fill prescriptions at an out-of-town pharmacy?

If you have our prescription drug coverage and need to fill a prescription while traveling, you can use FLRx, our National Pharmacy Network. There are over 50,000 FLRx pharmacies in the United States who will electronically file your prescription claim. This means less out-of-pocket cost to you, and less hassle because there's no need to fill out paperwork. View our online pharmacy directory to find a FLRx participating pharmacy.

What should I do when I’m away from home?

As our member, there's no need to worry about your coverage if you get sick or injured while traveling. Follow this link to learn more about how our coverage travels with you.

What is a Primary Care Physician (PCP)?

A PCP is a physician whose principal medical specialty is in family practice, internal medicine, OB/GYN, general practice or pediatrics. Your PCP is your partner in managing and coordinating your health care services. He or she works with a team of health care professionals, which may include physician assistants (PAs) and nurse practitioners (NPs), to provide your treatment. In a managed care plan, most care is provided or arranged by a participating PCP.

Do I have to choose a PCP?

Managed care and point of service (POS) plans require you to select a PCP to provide, manage, arrange or authorize almost all the medical care you receive. Your PCP is your partner in managing and coordinating your care and will refer you to a specialist, when needed.

Check your contract or benefit booklet, talk to your employer group representative or contact us if you are unsure whether or not you need to select a PCP.

How do I select a PCP?

Our Find A Doctor online tool is designed to help you connect with any doctor participating in our network, including Primary Care Physicians.

If you would rather speak to us directly, please contact our Customer Service department at the number listed on the back of your ID card.

How do I change a PCP?

If you are currently in treatment with your PCP, we can make the change effective on the date of your request.

For our records, we may ask that you give a reason for changing your PCP. This information is optional and can be used to track patient access, quality of care and other provider trends. Follow this link to Select or Change Your Doctor Now. If you would rather speak to us directly, please contact our Customer Service department at the number listed on the back of your ID card.

Can you help me decide which PCP to select?

We can’t tell you whom to select, but we do offer tools to help you decide which practitioner is right for you.

Our online Find a Doctor feature includes participating health care professionals’ names, addresses and driving directions, specialties, office hours, and much more.

Almost all of the physicians in the area participate with us, so you have a large network from which to choose.

Should women also select an obstetrician/gynecologist (OB/GYN)?

We encourage our female members to select a provider specializing in obstetrics/gynecology as well as a PCP. While a PCP can handle most health care needs, there may be situations where the specialized knowledge of an OB/GYN provider is required.

You won’t need a referral from your PCP to see a participating OB/GYN for covered OB/GYN care, including routine annual exams, prenatal care, or mammograms.

Do I need to get a referral from my PCP before I obtain services from other providers or facilities?

You may or may not need a referral from your PCP in order to obtain services from a specialist or other provider. Check your contract or benefit booklet, talk to your employer group representative or contact us if you are unsure whether or not you need to obtain a referral from your PCP.

How do I request new or additional identification cards?

Follow this link to Order an ID Card Online. You will be prompted to log in.

What policies do you offer for people who don't receive health insurance coverage through an employer?

We offer a variety of direct payment policies (when a member purchases coverage from us directly, not through an employer or group). We have policies for families, children, full-time students, seniors, and for people on low or fixed incomes. Follow this link to learn more about our direct payment plan offerings.

How can I add or remove a dependent from my policy or change my type of coverage?

Contract changes may be made at any time due to a qualifying event such as a birth, death, marriage, divorce or loss of employment. If you have coverage through an employer or group, you may be able to update your policy online (if your employer or group participates in online enrollment). If you are unsure, please contact your group benefits representative. If you purchase your coverage directly from us, please call us at the number listed on your member ID card.

How long are my dependent children covered under my family policy?

The Patient Protection and Affordable Care Act (PPACA) signed into law in March 2010 requires private insurers that offer dependent coverage for children to allow young adults up to age 26 to remain on their parent’s insurance plan.

To learn more about PPACA, visit our Health Care Reform page and click on the “Resources” tab.

What can I do if my benefits are exhausted for physical therapy, occupational therapy, speech therapy or skilled nursing?

New York State Exhausted Benefit Resource Guide
If your benefits have exhausted for physical therapy, occupational therapy, speech therapy or skilled nursing, you may contact one of the agencies below for assistance in obtaining necessary care.

  • New York State Partnership for Long Term Care
    The New York State Partnership for Long Term Care is a unique program that combines private long term care insurance and Medicaid to help New Yorkers prepare financially for the possibility of needing nursing home or home care.
    Phone - 1-866-950-7526
    Website - www.nyspltc.org

  • CMS - State and Local Information
    The Centers for Medicare & Medicaid Services (CMS) provides Medicare and Medicaid information for each state. The website includes Frequently Asked Questions and search capabilities.
    Website - www.cms.gov

  • New York State Office for the Aging - Medicare Links
    Residents of New York state can learn about the eligibility requirements, benefits and services of Medicare plans in the site.
    Phone - 1-800-342-9871
    Website - www.aging.ny.gov

  • New York State Department of Health
    The New York State Department of Health can be a useful source of consumer information. The website includes a Directory of Services and links to New York state government resources. Check your local phone directory for specific agency listings.
    Website - www.health.ny.gov

  • New York State Information and Referral for Differently Abled (Voice and TTY)
    This resource provides information for differently abled members of the community.
    Phone - 1-800-421-1220

Guide to Health Insurers

The New York Consumer Guide to Health Insurers is available from the New York State Insurance Department. The guide provides important consumer information on the performance of health maintenance organizations (HMOs) and other insurers. You can find us in the guide under the name Excellus BlueCross BlueShield.

You can view this report online at http://www.dfs.ny.gov/insurance/hgintro.htm or use the addresses below to request a printed copy:

Email to * : Publicat@ins.state.ny.us

Mail to * :

New York State Insurance Department
Attn. NY Consumer Guide to Health Insurers
Agency Building One, 5th Flr.
Albany, New York 12257
 

* If requesting by email or mail, please provide Your Name, Address, City/State/ZIP.

Member Rights & Responsibilities

As a member of our plan, you have certain rights and responsibilities that are outlined below.

What are my rights?

You have the right to:

  • Receive all the benefits to which you are entitled under your contract;
  • Receive quality health care through your providers in a timely manner and medically appropriate setting;
  • Considerate, courteous and respectful care;
  • Be treated with respect and recognition of your dignity and right to privacy.
  • Information about services, staff, hours of operation and your benefits, including access to routine services as well as after-hours and emergency services, and members' rights and responsibilities;
  • Participate in decision-making with your physician about your health care;
  • Obtain complete, current information concerning a diagnosis, treatment and prognosis from a provider in terms that you can reasonably be expected to understand;
  • Refuse treatment as allowed by law, and be informed by your physician of the medical consequences;
  • Refuse to participate in research;
  • Confidentiality of medical records and information, with the authority to approve or refuse the re-disclosure by us of such information, to the extent protected by law;
  • Receive all information needed to give informed consent for any procedure or treatment;
  • Access to your medical records as permitted by New York State law;
  • Express concerns and complaints about the care and services provided by physicians and other providers, and have us investigate and respond to these concerns and complaints;
  • Candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage;
  • Care and treatment without regard to age, race, color, sex or sexual orientation, religion, marital status, national origin, economic status or source of payment;
  • Voice complaints and recommend changes in benefits and services to staff, administration and/or the New York State Insurance Department or Department of Health, without fear of reprisal;
  • Formulate advance directives regarding your care. To obtain a Health Care Proxy form, contact us;
  • Contact one of our service departments to obtain the names, qualifications and titles of providers who are responsible for your care;
  • All information about your health plan, its services and its providers and procedures.
  • To make recommendations regarding the organization's members' rights and responsibilities.

What are my responsibilities?

You have the responsibility to:

  • Be an active partner in the effort to promote and restore health by:
  • openly sharing information about your symptoms and health history with your physician;
  • listening;
  • asking questions;
  • becoming informed about your diagnosis, recommended treatment and anticipated or possible outcomes;
  • following the plans of care you have agreed to (such as taking medicine and making and keeping appointments);
  • returning for further care, if any problem fails to improve; and
  • accepting responsibility for the outcomes of your decisions.
  • Participate in understanding their health problems ad developing mutually agreed upon treatment goals.
  • Have all care provided, arranged or authorized by your primary care physician (PCP);
  • Inform your PCP if there are changes in your health status;
  • Obtain services authorized by your PCP;
  • Share with your PCP any concerns about the medical care or services that your receive;
  • Permit us to review your medical records in order to comply with federal, state and local government regulations regarding quality assurance, and to verify the nature of services provided;
  • Respect time set aside for your appointments with providers and give as much notice as possible when an appointment must be rescheduled or cancelled;
  • Understand that emergencies arise for your providers and that your appointments may be unavoidably delayed as a result;
  • Respect staff and providers;
  • Follow the instructions and guidelines given by your providers;
  • Show your ID card and pay your visit fees to the provider at the time the service is rendered;
  • Become informed about our policies and procedures, as well as the office policies and procedures of your providers, so that you can make the best use of the services that are available under your contract;
  • Abide by the conditions set forth in your contract.

Information on your Mental Health and Chemical Dependency Benefits

Introduction

Before you begin treatment, it is important for you to understand your mental health and chemical dependency benefits. We hope that by understanding these benefits, you or a family member will be able to take the first step toward seeking treatment.

The intent of this brochure is to provide you with a general understanding of benefits and definitions. Coverage of both mental health and chemical dependency treatment is for medically necessary care. Our goal is to help you to get the treatment you need at a cost you can afford.

For specific details about your benefits, you should check your program information and/or contact Customer Service. The telephone number for your Customer Service department is located on your member identification card.

What are Mental Health benefits?

Mental Health benefits are available under most programs for both inpatient and outpatient mental health treatment. Inpatient mental health is hospital-based treatment. Many programs require that a member, physician or hospital contact the health plan or plan administrator to inform them of an admission. There typically are a limited number of days available for inpatient treatment in a calendar year.

Outpatient mental health benefits are for counseling for mental health problems. Some programs do not have coverage for outpatient mental health treatment. Those that do provide coverage often have a limit on the number of sessions.

Your health programs may require a primary care physician referral. Whether or not your program requires a referral, it is a good idea to discuss your concerns with your primary care physician who may be able to assist in selecting a mental health specialist.

What are Chemical Dependency benefits?

Chemical Dependency benefits are for the treatment of drug and/or alcohol problems. Most often these services are provided in facilities that are licensed by the Office of Alcohol and Substance Abuse and provide individual, group and family counseling. Programs that provide this benefit often have a limited number of sessions.

Some health programs provide a limited number of inpatient chemical dependency rehabilitation days. This is when you or a family member requires medically necessary treatment in a facility that provides 24-hour care.

Out of Area Coverage

Some plans require you to obtain treatment from participating providers in your area. Other plans may not have this requirement, but you may need to get a referral or pay a higher copay for out of area treatment. Your plan will have information on this and the type of coverage you have. If you still have questions, you should contact the Customer Service department at the telephone number on your member identification card.

How will my care be approved?

Prior to your care, you or your provider should contact Customer Service to see what the benefits and prior authorization requirements are for your coverage. If it is an emergency situation, there is no referral required before seeking care.

What if I disagree with a decision?

If you disagree with a decision made by us to deny a requested service, you may contact Customer Service and a representative will be glad to assist you.

How will my privacy be protected?

All information regarding your care and treatment is confidential and protected by law. You will be asked by your provider to sign a release of information. This will allow your Mental Health or Chemical Dependency specialist to share information with your Primary Care Physician concerning your treatment plan and medical condition.

What is my responsibility?

  1. Contact your physician before you enter treatment, unless it is an emergency. Your physician may want to meet with you to evaluate and discuss the appropriate care for you.
  2. Select a participating mental health or chemical dependency specialist, with the help of your physician.
  3. Check your coverage information or call Customer Services to see what benefits are available to you and if prior authorization is required.
  4. Pay all co-payments required under your program.
  5. Keep scheduled appointments. Providers have the right to charge you for a missed appointment if that is their standard office policy.

What is not covered?

We will not provide benefits for any service or treatment that does not meet the guidelines for the diagnosis of your condition. If you need additional information, please contact Customer Service at the telephone number listed on your member identification card.

What do I do if my benefits are exhausted for mental health or alcohol/substance abuse services?

New York State - Mental Health and Chemical Dependency Resources

If your mental health or chemical dependency benefits have exhausted, you may call one of the agencies below for assistance in obtaining necessary care.

NYS Information and Referral for Differently Abled (Voice and TTY) 1-800-522- 4369
This resource provides information for differently abled members of the community.

New York State Office of Alcoholism and Substance Abuse Services (OASAS) 
The following links are designed to assist you finding information or a referral: Call the toll-free information and referral line 1-800-522-5353 or go on-line to http://www.oasas.ny.gov/. The staff are skilled in providing information and referral services for all New Yorkers.

SAMHSA - an Agency of the U.S. Department of Health & Human Services
Their number is 1-877-726-4727 or you can visit them on-line at: http://www.samhsa.gov/. They maintain a toll-free Treatment Referral Line for locating substance abuse treatment in your area at 1-800-662-HELP (4357).

Note: This information is not intended to provide medical advice or to take the place of medical care, nor can we guarantee that all requests for authorization will be granted. Coverage is limited to the terms of your health care program. Any questions you have should be brought to the attention of your physician.

Who besides me can gain access to my claims, benefits and other Protected Health Information (PHI)?

Under the federal Health Insurance Portability and Accountability Act (known by its acronym, HIPAA), we are required to protect any and all information that could lead anyone to identify you by your past, present and/or future medical or mental health treatment or conditions. This is also known as your protected health information (PHI).

Because of HIPAA, we cannot release any information regarding your policy, claims or benefits without your express permission.

The law does allow us to discuss your PHI with your health care providers, but only within the scope of services that they themselves are providing to you.

Follow this link to enter or update your PHI authorizations online or to read our Privacy Policy.

If my life or my dependent’s life is in jeopardy, are you allowed by law to give PHI to anyone else?

If not releasing the information would put your health in danger, we are allowed to release it to those who need to know it. In these cases, we will not release more information than necessary.

Will the privacy laws prohibit me from getting member-specific information for my dependent who is over 18, my elderly parents or even my spouse’s claims if I’m also on the policy?

Yes, these regulations require that any protected health information about members or their dependents age 18 or older cannot be released, even to family members, without the member’s authorization.

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