2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 7. Filing a Claim for Covered Services
Page 116
 
If we need an extension because we have not received necessary information (e.g., medical records) from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

Prescription drug claims

Preferred Retail Pharmacies – When you use Preferred retail pharmacies, show your ID card. To find a Preferred retail pharmacy, visit www.fepblue.org/provider. If you use a Preferred retail pharmacy that offers online ordering, have your ID card ready to complete your purchase. Preferred retail pharmacies file your claims for you. We reimburse them for your covered drugs and supplies. You pay the applicable coinsurance or copayment.

Note: Even if you use Preferred retail pharmacies, you will have to file a paper claim form to obtain reimbursement if:

 
  • You do not have a valid ID card;
     
  • You do not use your valid ID card at the time of purchase; or
     
  • You did not obtain prior approval when required (see page 22).

See the following paragraphs for claim filing instructions.

Non-Preferred Retail Pharmacies: There are no benefits for drugs or supplies purchased at Non-preferred retail pharmacies. Note: For overseas pharmacy, see page 110.

Specialty Drug Pharmacy Program

If your physician prescribes a specialty drug that appears on our FEP Blue Focus Specialty Drug List, your physician may order the initial prescription by calling our Specialty Drug Pharmacy Program at 888-346-3731, TTY: 877-853-9549, or you may send your prescription to: Specialty Drug Pharmacy Program, AllianceRx Walgreens Prime, P.O. Box 692169, Orlando, FL 32869. You will be billed later for the copayment. The Specialty Drug Pharmacy Program will work with you to arrange a delivery time and location that is most convenient for you. To order refills, call the same telephone number to arrange your delivery. You may either charge your copayment to your credit card or have it billed to you later.

Note: For the most up-to-date listing of covered specialty drugs, call the Specialty Drug Pharmacy Program at 888-346-3731, TTY: 877-853-9549, or visit our website, www.fepblue.org.

Records
Keep a separate record of the medical expenses of each covered family member, because deductibles and benefit maximums (such as those for outpatient physical therapy) apply separately to each person. Save copies of all medical bills, including those you accumulate to satisfy a deductible. In most instances they will serve as evidence of your claim. We will not provide duplicate or year-end statements.

Deadline for filing your claim
Send us your claim and appropriate documentation as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided you submitted the claim as soon as reasonably possible. If we return a claim or part of a claim for additional information (e.g., diagnosis codes, dates of service, etc.), you must resubmit it within 90 days, or before the timely filing period expires, whichever is later.

Note: Timely filing for overseas pharmacy claims is limited to one year from the prescription fill date.

Note: Once we pay benefits, there is a five-year limitation on the re-issuance of uncashed checks.

Overseas claims
Please refer to the claims filing information on page 110 of this brochure.

When we need more information
Please reply promptly when we ask for additional information. We may delay processing or deny benefits for your claim if you do not respond. Our deadline for responding to your claim is stayed while we await all of the additional information needed to process your claim.