Getting the Care You Need
Eligibility, Coverage and Benefits
How do I contact BlueCross BlueShield?
Please refer to our Contact Us page on this Web site for telephone numbers and email links to our customer service departments.
How do I request a new identification card?
You can request an identification card online or by calling our customer service department. Please refer to our Contact Us page on this web site for telephone numbers.
How do I change my address?
You can change your address online or by calling our customer service department. Please refer to our Contact Us page on this web site for telephone numbers.
How can I get a claim form?
Follow this link to print a copy of forms in our online forms center.
Where do I mail my claims or other information?
Excellus BlueCross BlueShield
P.O. Box 22999
Rochester, NY 14692
How do I fill out a medical, dental or vision claim form?
Health care providers who participate with our plan will submit your claim for you. In other instances, please submit an itemized bill for each patient on a separate form. Separate claim forms are required for different calendar years. Please retain a copy for your records.
The itemized bills must include name and address of the provider, patient's full name, type of service, place of service, date and charge for each service, and patient's diagnosis condition. Receipts, canceled checks, money orders, credit card vouchers and personal lists are not acceptable. Please allow up to 30 days for processing.
For prescription drug submissions, you must also include script number, name of drug, number of days supplied, quantity and name of prescribing doctor.
For private duty nursing services, we require the type of nurse (RN, LPN, HHA), license number, shift and hours worked, and statement of medical necessity from prescribing doctor. Receipts, canceled checks, money orders, credit card vouchers and personal lists are not acceptable.
For Durable Medical Equipment (DME) submissions, we require a statement of medical necessity of prescribing doctor which indicates how long it will be used as well as a statement from the supplies showing rental versus purchase price. Receipts, canceled checks, money orders, credit card vouchers and personal lists are not acceptable.
How do I request a duplicate Explanation of Benefits?
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 mean?
Follow this link to view a sample of our EOB. 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.
What is a Primary Care Practitioner or PCP?
A Primary Care Practitioner (PCP) is a physician whose principle medical specialty is in Family Practice, Internal Medicine, 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 and nurse practitioners, to provide your treatment. In an HMO, care is provided or arranged by a participating PCP. If you haven't yet met your PCP, be sure to call his or her office today to make an appointment.
Do I have to choose a PCP?
Health Maintenance Organization (HMO) 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, including diagnosis, treatment, referrals to specialists, hospitalization, and follow-up care. Your PCP is your partner in managing and coordinating your care and will refer you to a specialist, when needed.
What if I don't want to select a PCP?
We offer other types of health coverage that may not require you to select a PCP. If you would like to change to a different policy, call your benefits representative (if you receive coverage through an employer or group) or call us directly (if you purchase coverage directly from us) to ask about your eligibility to switch at this time.
How do I select a PCP?
Here are two ways to select your PCP:
- Select or change your doctor online. If you haven't yet made arrangements with a doctor's office to accept you, be sure to check the box for "Accepting New Patients" as a search option.
- Call Customer Service at the phone number printed on your member ID card or view our Contact Us page for a directory of phone numbers.
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 database includes participating health care professionals' names, addresses and driving directions, specialties, whether or not they are accepting new patients, hospital affiliations, office hours, information about their board certification, and much more.
Almost all of the physicians in the area participate with us, so you have a large network to choose from.
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 provider for covered Ob/Gyn care, including routine yearly exams, prenatal care, or mammograms.
- You can select an Ob/Gyn online. Be sure to narrow your search by selecting "Obstetrics", "Gynecology", or "Obstetrics and Gynecology" as a specialty.
What if I want to change my PCP?
You can change your PCP or Ob/Gyn provider online or by calling Customer Service:
- If you are currently in treatment with your Primary Care Practitioner, we can make the change to your new doctor 30 days from the date of your request. This allows time to notify your current physician of your request and enough notice for him/her to forward any pertinent records to your new physician.
- If you are not currently in treatment with your primary care physician, we can make the change effective the date of your request.
- For our records, we may ask that you give a reason for changing PCP. This information is optional and can be used to track patient access, quality of care and other provider trends.
How does my plan pay health care providers?
Do plan health care providers receive financial incentives for my care? How are plan health care providers paid?
Our plans review health care services to see if they are medically necessary. This process is called utilization management (UM) and is conducted by licensed health care professionals and practitioners. UM decision making is based only on appropriateness of care and service and existence of coverage. We do not specifically reward practitioners or other individuals for issuing denials of coverage or care. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
As the costs and financial arrangements of health care become more complicated, we'd like to let you know how we pay a number of the main providers of your care.
We reimburse hospitals based on a negotiated rate, determined by each individual hospital and BlueCross BlueShield. We also reimburse ancillary providers, such as laboratories and durable medical equipment suppliers, based on a negotiated fee schedule.
For your primary and specialty care, we reimburse physicians based on a negotiated fee schedule set up by their governing body or individual practice association (IPA). Under this fee schedule, each procedure or type of office visit has a predetermined fee. The IPA receives a set or capitated rate each month from us called a per member per month (PMPM) fee. The PMPM is based on the number of HMO patients assigned to all physicians in the IPA. The IPA uses the PMPM funds to pay providers for their services, according to the negotiated fee schedule.
To provide better quality care and to better manage health care costs, many of our primary care specialties (Internal Medicine, Family and General Practice and Pediatrics) have developed a Provider Profiling system that allows physicians incentives for meeting established goals. For example, the Provider Profile may monitor individual provider mammography rates.
Your PCP will consider quality of care, your individual medical situation and cost when making decisions regarding health care services provided to you. If you have questions, please contact us.
How do I obtain care when my doctor's office is closed?
As a member of a Health Maintenance Organization (HMO), you have access to your Primary Care Physician (PCP) for urgent medical care day or night, seven days a week. If you get sick or hurt and need care after regular office hours, you should first call your doctor's office, unless it is an emergency medical condition.
He or she knows your medical history and is the best person to advise you. Your PCP has also made arrangements through an answering service or another doctor who is on-call to ensure you have access to urgent care. If your physician refers you to the emergency room, he or she will generate a referral for you.
Your physician or the physician on-call will determine if you need immediate treatment or if you can wait for regular office hours. If you do need care, your physician may make arrangements to see you at his or her office, or refer you to an immediate care center at a participating facility.
What should I do if it's an emergency?
If, however, 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 HMO 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.
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.
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 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?
This age varies from group to group. If you have coverage through an employer or group, please contact your group benefits representative. If you purchase your coverage directly from us, please call the number listed on your member ID card.
Is my handicapped child covered under my family policy?
All of our family contracts cover dependent children until their 19th birthday. If you are a group subscriber, your group may have purchased a Student or Dependent Rider which extends this age limit, or your handicapped child may be eligible to be covered under your family contract beyond the dependent age limit.
If your group does have one of these riders, the rider would have been issued to you with your identification card. The age limit under these riders does vary. If you are unsure if your group has one of these riders or what the age limit is, contact the health benefits representative at your place of employment.
A handicapped dependent may qualify if he or she is 19 or older, unmarried and unable to work or support himself or herself because of mental illness, developmental disability, mental retardation as defined in the New York State Mental Hygiene Law, or physical handicap. The condition must have happened before the dependent reached the age limit of your contract and he or she must qualify as your dependent under federal income tax support rules.
Please call the number listed on your member ID card for more details. To help us determine if your handicapped child is eligible for continued coverage under your family contract, please complete and submit a handicapped dependent application. The top portion of the application must be completed by the subscriber. The bottom portion must be completed by the child's physician. Once we receive the completed application, we will review it for eligibility and will notify you of our decision.
When am I eligible for senior health insurance plans that complement Medicare?
If you 65 or older, employed, and are enrolled for both Parts A and B of Medicare, you and your spouse may be eligible to change your BlueCross BlueShield group health coverage to Senior Insurance contracts that complement Medicare. Your group must offer Senior Insurance coverage and must have less than 20 employees.
To change your BlueCross BlueShield coverage to Senior Insurance, you must complete an application within 30 days of your Medicare effective dates. The coverage change would be effective on the next dates or on the next date your group's premium is due following your Medicare effective dates.
If you apply to change your coverage more than 30 days after the Medicare effective dates, the coverage changes would become effective on the next date your group's premium is due, following the date we receive the application.
If you are an employee changing to Senior Insurance coverage and you have family enrollment, your spouse may be eligible for individual enrollment or continuous coverage under COBRA through your group. Your spouse must complete and sign and application for individual or COBRA coverage. Your spouse's coverage would become effective on the same date as your Senior Insurance coverage.
Managed care subscribers may elect to purchase Medicare Supplemental contracts. For more information about the types of policies available, please refer to the Health Plan section.
What's the difference between Medicare and Medicaid?
Choosing the best coverage to meet your needs isn't always easy. Here are some points to consider.
Being a U.S. citizen does have its benefits. Federal programs such as Medicare and Medicaid can be a great help with health care costs if you or your loved one is eligible. The following information highlights these programs and their eligibility requirements.
Medicare Part A
Generally, U.S. citizens and permanent residents 65 and older who are eligible for Social Security benefits. Also, some younger people with disabilities and chronic kidney failure. Questions? Call the Social Security Administration at 1-800-772-1213 or contact the U.S. Government Medicare Hotline at 1-800-MEDICAR or online at www.medicare.gov.
How much does it cost?
How do I enroll?
If you're younger than 65 and have received Social Security disability benefits for two years, you'll be enrolled automatically.
If you're almost 65 and aren't getting Social Security benefits, you have to apply for Medicare. You should do this about three months before your 65th birthday. You also have to apply for Medicare coverage if you need dialysis or a kidney transplant.
You can apply for Medicare through any Social Security Administration office. Don't wait too long after you become eligible - you can be penalized.
What does it cover?
Medicare Part A will cover care away from home and specialist care without limiting your choice of doctor. Medicare Part A pays for part of your care in hospitals, nursing facilities, hospices and some home health care. However, it doesn't cover prescription drugs, hearing aids or vision care. You'll have to pay deductibles and copayments.
Medicare Part B
Almost anyone who is eligible for Part A can purchase Part B coverage.
How much does it cost?
Right now, most people pay $45.50 a month. This premium may increase annually. If you didn't enroll in Part B when you became eligible for Medicare, your premium may be higher.
How do I enroll?
If you're automatically enrolled in Part A, you'll be enrolled in Part B at the same time. You'll have to decline Part B coverage if you don't want it.
If you're not automatically enrolled, you have to apply for Medicare Part B through the Social Security Administration.
What does it cover?
Medicare Part B will cover care away from home and specialist care without limiting your choice of doctor. Part B helps pay for doctor visits, outpatient care, some home health services, physical therapy, mental health care, vaccinations and some cancer screening tests. However, it doesn't cover prescription drugs, hearing aids or vision care. Again, there are copayments and deductibles for some services.
Medicare HMOs, Medigap, and Medicare Supplemental
Anyone who has Medicare and wants to buy more insurance to "fill the gaps."
How much do they cost?
These options are sold by private insurance companies, including Excellus BlueCross BlueShield. The costs vary based on the plan you choose.
How do I enroll?
No one is automatically enrolled in these plan options. You need to contact an insurance company to buy it.
What do they cover?
Medicare HMOs, such as Blue Choice Senior, replace your original Medicare benefits by covering the same services as Medicare Parts A and B, plus offer some additional benefits, including ease in claims filing. Medigap and Medicare Supplemental plans work with your Medicare coverage to cover copayments and other eligible services not covered by Medicare, such as prescription drugs. Coverage varies greatly from one plan to the next.
Medicaid is designed for people of any age who can't afford health insurance. You must meet low-income requirements to get Medicaid. For questions, call your county's Department of Social Services of visit the Health Care Financing Administration Web site at cms.hhs.gov.
How much does it cost?
How do I enroll?
You can apply for Medicaid through your State Medicaid Program office.
What does it cover?
Medicaid coverage depends on your income and the rules set by the state you live in. For people enrolled in Medicare, Medicaid may pay part or all of their Part A or Part B deductibles and copayments. It may also pay for additional medical services not covered by Medicare.
What do I do if my benefits are exhausted for mental health or alcohol/substance abuse services?
The following agencies may be able to connect you with resources:
The New York State Office of Alcoholism and Substance Abuse Services (OASAS)
For information or for a referral, New York State residents can call toll-free 1-800-522-5353. For callers outside New York State, contact the Educational Alliance at (212) 982-8130.
SAMHSA - an Agency of the U.S. Department of Health & Human Services
For mental health services, call toll-free 1-800-789-CMHS or visit the Knowledge Exchange Network (KEN) online at www.mentalhealth.org. For substance abuse treatment, call toll-free 1-800-662-HELP for the Referral Help-line for assistance locating substance abuse treatment near you.
NYS Information and Referral for Differently Abled (Voice and TTY)
For people with speech or hearing disabilities, contact 1-800-522-4369.
What treatment is covered for accidental dental injuries?
Members of our HMO plans have limited dental coverage for treatment from an accidental injury. Although this coverage is limited in scope, it can be a real benefit for members when an accident occurs.
Our HMO plans provide limited coverage for the immediate treatment of accidental dental injuries. This includes the initial exam and x-ray as well as treatment to eliminate immediate pain. Benefits are limited to those covered in the dental schedule of allowances and must meet the following conditions:
- The tooth must have been a previously sound and natural tooth that has not had restorative treatment or is not diseased (no fillings, bonding, crowns, root canals, cavities or fractures).
- The benefit is limited to dental treatment rendered within 12 months of the injury.
- Care must be provided by an Excellus BlueCross BlueShield participating dentist.
Often, one or more treatments are available to restore the tooth. We will cover the less expensive option. If the dentist decides that a root canal, extraction or prosthetic care (such as a crown, bridge or partial denture) is needed, we must receive the complete treatment plan from the dentist for review and approval before service is rendered. All claims are subject to review by Excellus BlueCross BlueShield.
What isn't covered
Benefits are limited to immediate treatment rendered within 12 months from the date of the injury. We do not provide coverage for:
- Care provided by a dentist who does not participate with Excellus BlueCross BlueShield.
- Treatment that continues beyond 12 months from the date of injury.
- Additional services or treatment rendered after 12 months from the date of injury.
- Treatment to repair a tooth that has already had restorative work or is diseased.
- Services for implants and/or orthodontics, including any related services.
However, if you have benefits available through a dental plan, you may submit the services to that plan for consideration.
How to obtain benefits
A pretreatment plan is required for any dental treatment, and care must be provided by an Excellus BlueCross BlueShield participating dentist. You can ask your dentist if he or she participates with us, or view our online directory of participating dentists. If you have any question about this coverage, call the number listed on your member ID card.
What are my rights with respect to mastectomy and breast reconstruction services?
Both the New York Insurance Law and the federal Women's Health and Cancer Rights Act (WHCRA) require that we cover specific services in connection with a mastectomy, subject to applicable referral and/or cost-sharing (copayment, deductible, coinsurance) requirements of your health benefits plan. WHCRA, which was enacted after the New York law, added a requirement that we specifically identify prostheses as a covered benefit in connection with mastectomy. Some of our older (pre-WHCRA) contracts/certificates did not specifically mention prostheses as covered. However, we have been covering prostheses, along with the required breast reconstruction and care of physical complications, since the New York mandate was effective. If your member contract/certificate or rider did not specify that prostheses are covered in connection with mastectomy, and you or your provider either did not submit claims or received a claims denial for the prostheses, please contact Customer Service at the phone number on your member ID card for instructions on how to submit or resubmit those claims for payment.
What is a certificate of creditable coverage and how can I obtain one?
Under the federal law commonly known as HIPAA, you are entitled to receive a record of your medical coverage for the past 18 months or less, when your coverage ends. This record, called a “certificate of coverage,” ensures that you will be given credit for you prior health benefits coverage, if you enroll for coverage in the future. If your coverage ends, you can expect to receive more than one certificate. Both your employer and your insurer must provide you with a certificate. The certificate that we provide will identify the coverage that you had with us. Your employer’s certificate should provide your complete insurance history with the employer. To obtain a copy, call Customer Service at the number on your member ID card.
What do 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 orskilled nursing therapy, you may call 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 - 1-888-697-7582
Website - www.nyspltc.org
CMS – State and Local Information
The Centers for Medicare and 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 - 1-800-333-4114
Website - www.hiicap.state.nys.us
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. Look in your local phone directory for specific agency listings.
Website - www.health.state.ny.us
New York State Information and Referral for Differently Abled (Voice and TTY)
This resource provides information for differently abled members of the community.
Phone - 1-800-522-4369