Transparency in coverage

We recognize the value in sharing information with you. With the right information, you can make the best health-related decisions based on your needs. This page will give you a brief overview of some of our business practices. You can find information here about claims, cost-sharing, and coverage. Much of this information is available in your member handbook or summary of benefits. This page reviews the basics, so you can quickly understand commonly used terms and policies.

Member claims submission

A claim is a request for payment. You or your health care provider submits claims to your health insurer. The claims are for costs for health care services and/or supplies from a hospital, doctor, or other health care facility.

Certain medical services may require additional information. This could be notes from the provider, or payment or rejection notices from other insurance carriers. (Other insurance could be Workers’ Compensation, other health plans, Medicare, auto insurance, etc.). Other information also includes origin and destination points for ambulance transfers or accident information. Delays in submitting this special information, when required, may delay the claims from processing.

If you are a Preferred Provider Organization (PPO) member, you do not need to submit a claim when services are received by an in-network provider. If you choose to receive care from an out-of-network provider and your provider does not submit the claim, you should submit written notice of the claim within 20 days after completion of the covered services. Upon receipt of a notice of claim, you will be sent the necessary claim form. You have 12 months from the date of service to submit a claim for payment. You can also download the medical claim form. If you have additional questions, you may contact Customer Service at the number on the back of your member ID card.

If you are a Health Maintenance Organization (HMO) member, you generally do not need to submit claims for services received in-network. If your provider does not submit claims, you must notify us of the claim as soon as possible after receiving covered services. You can notify us by either in writing or by calling Customer Service at the number on the back of your member ID card. After we receive a notice of claim, we will send you the necessary claim form. We must then receive your completed claim form, with all itemized bills attached, within 90 days. You can also download the medical claim form. Claim forms should be submitted to the following address:

Claims Receipt Center
P.O. Box 211184
Eagan, MN 55121

Please refer to the last section at the bottom of this page for more information.

Nonpayment of premium and grace periods for members receiving premium tax credits

Per regulation 45 CFR 156.270(d), members who receive advance payments of the premium tax credit and have previously paid at least one full month's premium have a 90-day grace period when premium payments are not made on time. A grace period is additional time that a member is given to pay outstanding premium. During the grace period a member can make outstanding premium payments without losing coverage. If a member fails to make payment in full within 90 days, coverage will be terminated.

Claims received during the first 30 days of the grace period will be paid on schedule. Claims received during the remaining grace period may be pended as necessary, meaning we will neither pay nor deny the claim. If a member pays his or her outstanding premium in full during the 90-day grace period, claims will be paid accordingly. If the member fails to pay his or her outstanding premium, claims will be denied.

Per regulation 40 P.S. § 753(A)(3), members who do not receive advance payments of the premium tax credit and have previously paid at least one full month’s premium will have their claims paid during the 30 day grace period. After the 30 day grace period has ended, coverage will be terminated.

Retroactive denial of claims

A retroactive denial is the reversal of a previously paid claim. This occurs after services are rendered, where you may become liable for payment. Claims may be retroactively denied in certain situations, including, but not limited to the following:

• If your coverage is retroactively terminated
• If we determine you have other health care coverage that should have been the primary payer
• If there was a provider billing error

Ways to prevent a retroactive denial include the following:

• Ensure that premium payments are made on time
• Do not sign up for Marketplace coverage when you are eligible for Medicare, Medicaid, or other insurance that qualifies as Minimum Essential Coverage
• Ensure that you are not intentionally misrepresenting any material facts when signing up for health care coverage
• Review and understand your benefits
• Review your Explanation of Benefits (EOB) thoroughly

If you have any questions about the payment of your claim you may contact Customer Service at 1-800-ASK-BLUE (275-2583).

Member recoupment of overpayments

If you dispute a charge or payment, you may contact Customer Service for additional assistance by calling 1-888-879-4891.

Coordination of benefits

If you have more than one health insurance plan, those plans need to work together to make sure you’re getting the most out of your coverage. That process is referred to as Coordination of Benefits. Coordinating your benefits helps us process your claims faster and maximizes your benefits, which can lower your out-of-pocket costs. One plan becomes your primary plan and pays your claims first. Then the second plan pays toward the remaining cost.

Please refer to the last section at the bottom of this page for additional information.

Liability for non-network coverage and balance billing

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. Learn more.

The coverage and cost-sharing for care received outside of our network varies by plan type. PPO members that decide to receive care from a provider not within the plan network will incur much higher out-of-pocket expenses. This includes deductibles and coinsurance. The same is true for HMO members who receive care from an in-network provider without a referral from their primary care physician. The out-of-network provider also may charge you for the balance of their bill (balance billing). HMO and Exclusive Provider Organization (EPO) members do not receive any benefits when they decide to receive care from a provider not within the plan network. The exception is Emergency Care Services, which are covered no matter where they are obtained. To see the exact cost-sharing you would pay for out-of-network coverage for your plan, review your plan's Summary of Benefits.

Please refer to the last section at the bottom of this page for additional information.

Explanation of benefits

Your Explanation of Benefits (EOB) helps you understand your out-of-pocket costs for covered services. This includes how much your provider charged for the services, how much your health care plan paid, and what amount you owe. You will only receive an EOB if you are liable for any charges after the claim is adjudicated.

Find out how to read and understand your EOB. If you have any questions about your EOB, contact Customer Service at the number on the back of your member ID card.

Please refer to the last section at the bottom of this page for additional information.

Non-Formulary Drug Exception Process

Sometimes our members need access to drugs that are not listed on the plan’s formulary (drug list). These medications are initially reviewed by our pharmacy benefits manager through the formulary exception review process. The member or provider can submit the request to us by calling the pharmacy benefits manager at 1-888-678-7012. Providers can also send a fax to 1-888-678-5285. The exception request must describe your need for the drug. If the exception request is approved, we will cover the drug at the highest cost-share as listed in your benefits.

We will reply in two business days, not to exceed 72 hours. We will reply to urgent requests in 24 hours. If you do not receive a reply within these timeframes, please call the pharmacy benefits manager at 1-888-678-7012.

Quantity limits and age limits still apply to exception requests. If your request is denied, we will send you and your doctor each a letter, which will provide notification of the denial decision and details regarding your right to appeal.

PA Non-Formulary Drug Exception Appeal Process

An internal non-formulary appeal may be requested by a member/enrollee, an authorized representative of the member/enrollee, or a prescribing provider by mailing, calling, or faxing the request to:

Independence Blue Cross
Member Appeals Department
P.O. Box 41820
Philadelphia, PA 19101-1820
Phone: 1-888-671-5276
Fax: 1-888-671-5274

For initial standard non-formulary exception review of medical requests, the timeline for our review is seventy-two (72) hours from when we receive the request.

For initial expedited non-formulary exception review of medical requests, the timeframe for our review is twenty-four (24) hours from when we receive the request.

If our internal review of your non-formulary appeal request results in a denial determination, you may ask us to submit the case for an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO).

An IRO review may be requested by a member/enrollee, an authorized representative of the member/enrollee, or a prescribing provider by contacting:

Independence Blue Cross
Member Appeals Department
P.O. Box 41820
Philadelphia, PA 19101-1820
Phone: 1-888-671-5276
Fax: 1-888-671-5274

For external review of standard non-formulary exception requests that were initially denied, the timeframe for review is seventy-two (72) hours from when the IRO receives the request.

For external review of expedited non-formulary exception requests that were initially denied, the timeframe for review is twenty-four (24) hours from when the IRO receives the request.

IBC is required to follow the decision of the IRO.

Preapproval for coverage of services

Certain services require preapproval from Independence. (Preapproval is sometimes called precertification.) It is needed before the service is performed. Your doctor will submit the paperwork for this type of request. If your doctor has questions about our process, share with them the process information. We do not require members to submit a preapproval by a certain date. For emergent admissions, decisions are rendered within 72hrs of receipt of request. For non-urgent requests, upon receipt of complete clinical information a decision is rendered within two business days.

Providers registered with the Provider Engagement, Analytics & Reporting (PEAR) portal may submit requests electronically through PEAR Practice Management for services to be rendered at an acute care facility or ambulatory surgical center.

The manual is available to providers on the Provider News Center.

The Departments of the Treasury, Labor, and Health and Human Services (the Departments) have issued the Transparency in Coverage final rules (85 FR 72158) that require non-grandfathered group health plans and health insurance issuers in the individual and group markets to disclose certain cost-sharing information to a participant, beneficiary, or enrollee (or his or her authorized representative), upon request. To get a cost estimate, please log in at ibx.com/login and use the Care Cost Estimator. This notice contains important information about the cost estimate and information on the amount you may be required to pay for an item or service.

Additional information

For individual and/or family coverage:

• Please refer to the benefit booklet or Summary of Benefits and Coverage (SBC) of your plan of interest for more information.

The information on this page refers to the health plans offered to our individual members. If you are enrolled in a group plan provided by your employer, please refer to your specific plan benefit booklet or Summary of Benefits and Coverage documents for additional information available when you log in to the member portal at ibx.com.