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 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.
Completed claim forms can be submitted via secure email. Use the Send to Us Electronically link under Submit a 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 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.
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.
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.
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.
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.
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 Member card.
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.
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.
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.
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 card.
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.
Our plans have a process for reviewing health care services to ensure that they are evidence based, medically necessary, and being performed at the right level of care by qualified professionals. This process is called utilization management (UM) and it is conducted by licensed health care professionals and practitioners.
UM decision-making is based solely upon the application of nationally recognized clinical criteria and transparent corporate medical policies. We do not, in any way, encourage or reward UM decision makers for denials of coverage or limits on access to care.
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.
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;
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 Member 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.
Your Mental Health and Chemical Dependency Benefits
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 card.
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.
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.
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 card.
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.
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.
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 card.
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.
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.
non-emergency services rendered to a member by an out-of-network physician at an in-network hospital or ambulatory surgery center when: an in-network physician is unavailable; or an out-of-network physician renders the services without the member's knowledge; or a need for unforeseen medical services arises; or
non-emergency services rendered by an out-of-network provider upon referral from an in-network physician, without the member’s explicit written consent to an out-of-network referral.
Members who receive a surprise bill and who complete an Assignment of Benefits form are only responsible for applicable in-network cost-sharing (copayment, coinsurance or deductible) that would have been incurred, had the physician or other provider been an in-network provider.
Providers are prohibited from billing you after you have completed an AOB form and provided it to us and to the provider.
If you believe you have received a surprise bill, please complete an Assignment of Benefit (“AOB”) form and submit a copy to your provider and to the Health Plan. A completed AOB form directs the provider to seek payment for the service from the Health Plan (your “assignment”). Once you have submitted the AOB form to the Health Plan, no other action is required on your part. The Health Plan will review your inquiry to ensure that the bill in question meets the New York State definition of a surprise bill and will work with your provider regarding the payment.
If the AOB form is for a claim that meets the definition of a surprise bill, the Health Plan will work with the provider to resolve the bill. If we are unable to agree on a payment, we will pay what we deem to be a reasonable amount. An adjustment amount may appear on your next Monthly Health Statement or Explanation of Benefits.
If the provider is not satisfied with our payment, he/she may submit the claim to an independent dispute resolution entity who will determine whether our payment or the provider’s charge is most reasonable. The IDRE’s determination is binding on us and the provider.
If we determine that the AOB form is for a claim that does not meet the definition of a surprise bill, we will notify you of the denial and you will be responsible for any costs not covered under your contract.
Yes. Providers may dispute payments from the plan for a bill through an Independent Dispute Resolution Entity. If that body rules in favor of the provider, the charge for the service could be increased, causing your cost-sharing amount to possibly increase. This occurs most frequently when your cost-share for a particular benefit is a deductible or coinsurance.
Providers can submit disputes to the IDRE by submitting an application through the Department of Financial Services (DFS) portal. Members who do not complete an AOB form can submit a dispute by completing the IDR Patient Application and sending it to NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.