Out-of-Network Liability and Balance Billing

BlueSelect PPO Network

Where a Participant obtains Health Care Services from a Health Care Provider that has elected not to become part of the BlueSelect PPO Network, that Health Care Provider can set a higher cost for a service than a Provider who is in the BlueSelect PPO Network. Depending on the Health Care Provider, the service could cost more and bill the Participant for the total charges reflected in the Health Care Provider’s billing statement to the Participant. Charging this extra amount is called balance billing. In cases like this, Blue Cross Blue Shield of Wyoming will reimburse the Maximum Allowable Amount for the Covered Services directly to the Participant. It will be the Participant’s responsibility to pay this Maximum Allowable Amount to the Health Care Provider. However, in addition to any Cost-Sharing Amounts and charges for Non-Covered Services that are Participant’s responsibility, Participant will also be responsible for paying the Health Care Provider for the difference between the full amount of charges reflected in the Health Care Provider’s billing statement and the Maximum Allowable Amount Blue Cross Blue Shield of Wyoming reimbursed the Participant for the Covered Services. The difference may be a considerable amount of money.

Exceptions

When an out-of-network provider is used for a medical emergency, the above process applies, however, your cost share will accumulate to your in-network amounts.

A medical emergency is defined as a medical Condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

• Placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or
• Serious impairment to bodily functions, or
• Serious dysfunction of any bodily organ or part, or
• With respect to a pregnant woman who is having contractions if there is inadequate time to affect a safe transfer to another hospital before delivery, or if transfer may pose a threat to the health or safety of the woman or the unborn child.

Enrollee Claims Submission

Written Claim For Benefits

A Claim for Benefits must be furnished to Blue Cross Blue Shield of Wyoming at its office at 4000 House Avenue, PO Box 2266, Cheyenne, Wyoming 82003-2266.

Blue Cross Blue Shield of Wyoming will not be liable unless a proper Claim for Benefits is furnished to Blue Cross Blue Shield of Wyoming demonstrating that Covered Services have been rendered to a Participant. The Claim for Benefits must be given within ninety (90) days after completion of the Covered Service. The Claim for Benefits must include all of the information necessary for Blue Cross Blue Shield of Wyoming to determine whether or not the Healthcare Service was a Covered Service and the Maximum Allowable Amount of the benefit.

Failure to submit a Claim for Benefits to Blue Cross Blue Shield of Wyoming within the time specified above will not invalidate nor reduce any Claim for Benefits if it is shown it was not reasonably possible to submit the Claim for Benefits within the time specified above and that the Claim for Benefits was submitted as soon as it was reasonably possible, and in no event, except in the absence of legal capacity, later than one year from the date the Claim for Benefits was first due.

Claim Forms

Blue Cross Blue Shield of Wyoming shall furnish to the person making a claim (claimant) the forms it usually furnishes for filing Claims for Benefits. If such forms are not furnished within fifteen (15) days of the filing of a notice of claim, the claimant shall be deemed to have complied with the requirements as to Claims for Benefits upon submitting, within the time fixed for filing Claims for Benefits, written proof regarding the date(s) Healthcare Services were rendered, and the character and extent of Healthcare Services for which a claim is made.

You can access medical, dental, and prescription drug claim forms online by clicking the following:

• Medical
• Dental
• Prescription Drug
• Vision

You can contact our Member Services with any questions, or if you need a paper form mailed to you.

Member Services Phone Number: 800-442-2376

Grace Periods and Claims Pending Policies During the Grace Period

Grace periods are only applicable for members who enrolled in individual or family coverage on the Health Insurance Marketplace. It is not applicable for members receiving group coverage through their employer.

Grace Periods Where Applicant Receives An Advance Premium Tax Credit (APTC)

Where Applicant has qualified to receive an APTC and has made at least the initial enrollment Premium payment under their current plan, the Applicant shall be entitled, if needed, to a late payment grace period in which to pay the delinquent Premium. The grace period shall be no longer than three (3) months and will begin on the first day of the month following the last month in which Applicant’s portion of the Premium was timely paid in full. During the first month of the grace period, Claims for Benefits will be paid. However, Claims for Benefits will be pended and not paid during the remainder of the grace period. If the full Premium amounts owed by the Applicant are received prior to the end of the grace period, any pended Claims for Benefits will be processed for payment and the grace period will end. If the full Premium amounts owed by the Applicant are not received by the end of the three (3) months following the beginning of the grace period, coverage will be terminated as of the last day of the first month of the grace period. Any Benefits paid by Blue Cross Blue Shield of Wyoming to or on behalf of the Participant for Covered Services received during the second or third months of the grace period will be the legal responsibility of the Applicant/Participant and must be reimbursed to Blue Cross Blue Shield of Wyoming. This grace period does not apply to the Applicant’s payment of the initial Premium, which must be paid in full on or before the Effective Date or to Applicants who are not eligible for the APTC.

Non-APTC Grace Period

If payment is not made by the due date indicated in the billing statement, the Applicant will be granted a late payment grace period ending on the last day of the month in which the Premium payment was due.  During this grace period, coverage shall remain in force and Benefits will be paid so long as payment of the Premium is received by Blue Cross Blue Shield of Wyoming on or before the last day of the grace period.  However, if the Premium is not received by the end of the grace period, coverage will be terminated as of the last day of the month that the last Premium was timely paid in full. Where coverage is terminated, any Benefits paid by Blue Cross Blue Shield of Wyoming to or on behalf of a Participant for Covered Services received during the grace period will be the legal responsibility of the Applicant/Participant and must be reimbursed to Blue Cross Blue Shield of Wyoming. This grace period does not apply to the Applicant’s payment of the initial Premium upon enrollment in this Plan, or to Applicants receiving Advance Premium Tax Credits.

Retroactive Denials

Payment In Error

If Blue Cross Blue Shield of Wyoming makes a payment in error, it may require the Health Care Provider, the Participant, or the ineligible person to refund the amount paid in error. Blue Cross Blue Shield of Wyoming reserves the right to correct payments made in error by deducting against subsequent claims or by taking legal action, if necessary.

Termination Of Coverage

Any Claims for Benefits paid by Blue Cross Blue Shield of Wyoming with a date of service after the termination date will be the legal responsibility of the Applicant and/or Dependent and must be reimbursed to Blue Cross Blue Shield of Wyoming.

Ways To Prevent Retroactive Denials

To avoid termination, be sure to pay your premiums on time. Misrepresentations, fraud, omissions, concealment of facts and incorrect or incomplete statements are also ways your coverage could be terminated.
Enrollee Recoupment of Overpayments

Overpayments

If Blue Cross Blue Shield of Wyoming receives overpayment, it will provide a credit towards payments of premium for future months. If the member would like a refund of future billed months, they can contact our Member Services department to put in that request. If a member is terminated, a refund will automatically be sent to the member.

Please contact our Member Services for any requests to refund overpayment.

Member Services Phone Number: 800-442-2376

Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities

Pre-Admission Review (Prior Authorization)

Pre-Admission Review (sometimes referred to as Prior Authorization in Blue Cross Blue Shield of Wyoming documentation) is required prior to obtaining non-maternity and non-emergency Inpatient Hospitalization Services. Participant must contact Blue Cross Blue Shield of Wyoming at (800) 251-1814 to obtain Pre-admission Review. Request for Prior Authorization for medical services is typically done within 72 hours of receiving an urgent request or within 5 days for non-urgent requests. If the authorization is not obtained, participant may have to pay the full amount. Additional information on obtaining pre-admission review can be found at https://www.bcbswy.com/providers/preadmin/preadmin.

Pre-Certification (Prospective Request)

Certain Covered Services require Pre-certification by Blue Cross Blue Shield of Wyoming (sometimes referred to as a Prospective Request in Blue Cross Blue Shield of Wyoming documentation). A Participant must contact Blue Cross Blue Shield of Wyoming at (800) 442-2376 to obtain Pre-certification before receiving these Health Care Services. Pre-certification may include the required use of designated Health Care Providers who have demonstrated high quality, cost efficient care. The failure to obtain Pre-certification may result in a denial or reduction in coverage for the Health Care Service. A list of Covered Services requiring Pre-Certification can be found at https://www.bcbswy.com/providers/preadmin/precert.

Medically Necessary Services Or Supplies

No Benefits will be provided for services or supplies that are not Medically Necessary.

1. Medical necessity is defined as a medical service, procedure or supply provided for the purpose of preventing, diagnosing or treating an illness, injury, disease or symptom and is a service, procedure or supply that:
   1. Is medically appropriate for the symptoms, diagnosis or treatment of the condition, illness, disease or injury;
   2. Provides for the diagnosis, direct care and treatment of the Participant’s condition, illness, disease or injury;
   3. Is in accordance with professional, evidence based medicine and recognized standards of good medical practice and care;
   4. Is not primarily for the convenience of the Participant, Physician or other Health Care Provider; and
2. A medical service, procedure or supply shall not be excluded from being a Medical Necessity solely because the service, procedure or supply is not in common use if the safety and effectiveness of the service, procedure or supply is supported by:
   1. Peer reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health’s Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus (EMBASE); or
   2. Medical journals recognized by the Secretary of Health and Human Services under Section 1861(t) (2) of the federal Social Security Act.

Drug Exceptions Timeframes and Enrollee Responsibilities

Prescription Drug Exception Request

Internal Exception Request

Unless excluded, the Participant may request access to clinically appropriate drugs not otherwise covered by Blue Cross Blue Shield of Wyoming through a request for exception. The Participant and/or the Participant’s legal representative have up to one-hundred eighty (180) days to request an internal Prescription Drug exception. For a standard exception request, Blue Cross Blue Shield of Wyoming will notify the Participant, the prescribing physician, and/or the facility of its coverage determination no later than seventy-two (72) hours following receipt of the request.

If exigent circumstances exist, the Participant may request an expedited review. The need for expedited review must be certified by the prescribing physician and their signature must accompany the request. For information about sending this request, please visit the Prior Authorization Service Request. In these cases, Blue Cross Blue Shield of Wyoming will notify the Participant, the prescribing physician and/or the facility of its coverage determination no later than twenty-four (24) hours following receipt of the request. Exigent circumstances exist when:

The Participant is suffering from a health condition that may seriously jeopardize the Participant’s life, health, or ability to regain maximum function; or
The Participant is undergoing a current course of treatment using a non-formulary drug.

External Exception Request

If Blue Cross Blue Shield of Wyoming denies either a standard or an expedited exception request, the Participant, the Participant’s designee, the prescribing physician and/or the facility may request, within one-hundred twenty (120) days, that the original exception request and subsequent denial of such request be reviewed by an independent review organization. Blue Cross Blue Shield of Wyoming will make its coverage determination on the external exception request and notify the Participant, the Participant’s designee, the prescribing physician and/or the facility no later than seventy-two (72) hours following its receipt of a standard request, or twenty-four (24) hours following an expedited request.

Note: If there are no drugs within a specific drug class included within the formulary list, the entire class is considered excluded for the purpose of the Prescription Drug coverage exception request.

Information on Explanation of Benefits (EOBs)

Explanation Of Benefits

Blue Cross Blue Shield of Wyoming will provide an Explanation of Benefits (EOB) document to Participant after a Claim for Benefits has been processed. The EOB will include the Participant’s name, claim number, type of Health Care Services received, the identity of the Health Care Provider rendering the Health Care Services, the Covered Services and the Health Care Services not covered, the amount of the Health Care Provider’s charges, the Maximum Allowable Amount paid, and the Participant’s Cost-Sharing Amounts. Participants should carefully review each EOB they receive and keep them with other important records. Additional information on how to read and understand your EOB can be found here.

Coordination of Benefits (COB)

Coordination Of Benefits

Participants often have other coverage providing duplicate benefits. BCBSWY will coordinate your benefits with any other healthcare coverage you may currently have or have had in the past. Current coverage information is important to ensure you receive the most out of your benefits. Update your COB information here.