go deeper - blue cross of idaho · spread the flu to people at high risk. for specifics about if...

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one oneTO

newsletter for members

deePer:Get to know your coverage better

go

-life of a Claim

-a key to your eob

-save money on medications

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welcome:

Autumn is an invigorating season in Idaho. Bold colors and dropping temperatures signal the shift from growing time to harvest time.

The articles in this issue of One to One follow this theme of harvesting. We hope you’ll gather the bounty of information about insurance so that you can take full advantage of your benefits and become a truly informed member of Blue Cross of Idaho.

Have you ever talked about health coverage with a friend who’s also insured by Blue Cross only to wonder why he seems to have different benefits? We explain why this is the case in our feature story, on page 4. We also offer tips for becoming a more knowledgeable and engaged healthcare consumer.

We encourage you to harvest the information in these pages and use it to improve your care and maintain your health.

a healthyharvest

looking for a way to stay healthy? Start here: wellconnected.

wellconnected is the Blue cross of Idaho health and well-being program that offers six online personal health assessments, with personalized scores and reports to help you improve your lifestyle.

It’s the perfect way to prioritize your health goals—or check on your progress if you’ve already made a commitment to get on track to wellness.

Better yet, it’s confidential, easy to use and accessible from anywhere you can go online. Just go to bcidaho.com, and under "Health & wellness" on the top navigation bar select "wellness Support Tools," then log in.

=w e l l c o n n e c T e d

Next on Your To-Do List= P r e v e n T I o n

Time to Get Your Flu ShotEvery year, the flu bug rears its ugly head. And on come the chills, fever and aches that characterize it.

Help prevent the bug by getting a flu shot. You’re a prime candidate for this vaccine if you’re at high risk for getting the flu or if you could easily spread the flu to people at high risk.

For specifics about if you need a flu shot, visit bcidaho.com and under “Health and Wellness” in the top navigation bar, select “Preventive Guidelines” and go to your age group.

Blue Cross of Idaho provides pharmacy benefits for eligible members when they receive a flu vaccine at an in-network pharmacy. Ask your local pharmacist about your eligibility and flu vaccine availability.

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Drug: Used to Treat: Other Similar Prescription Drugs:

Prilosec Heartburn aciphex, nexium, Prevacid, Protonix, Zegerid

Zyrtec Allergies Allegra, Clarinex, Xyzal

claritin allergies allegra, clarinex, Xyzal

Brand Name: Generic Name: Medication Use:

Sonata zaleplon Sleep

Activella estradiol/ norethindrone

Women's health

Precose acarbose diabetes

Dovonex calcipotriene Skin (psoriasis)

requip ropinirole Parkinson's disease

Paxil CR paroxetine Mental health: antidepressants

wellbutrin Xl 150mg

bupropion Xl mental health: antidepressants

Below, we lIST THe Brand-name drugS recenTly releaSed In a generIc form.


= Q & a

We’ve Got Answers“What’s an HSA?”

a health savings account (HSa) is a tax-exempt savings account used to pay for qualified healthcare

expenses. They are a good solution for some individuals because they can offer more control over how you spend your healthcare dollars.

Think of it like a savings account for your health and wellness needs. The money you put into your HSa account is considered federal tax-deductible, and withdrawals are not taxed so long as they are used to pay for qualified medical expenses. additionally, you can earn tax-deferred interest on any unused balances, and you will never pay federal taxes on the interest as long as you use it for qualified medical expenses.

you can find more details at bcidaho.com or by calling (866) IdaHo-1-2-1.

Qa

= S av e m o n e y

MeDiCATioN UPDATEduring the past 30 years, the food and drug administration (fda) has approved more than 700 prescription medications for availability without a prescription, or “over the counter” (oTc). The fda only approves

a medication after it ’s been determined to be safe and effective for use without a doctor’s prescription. Some of the most recent medications that moved to oTc include:

talk to your doctor or pharmacist

todayyou can save money by taking advantage of over-the-counter

medications (oTc). most oTcs are available as a brand product and a generic product, and the generic is typically the least expensive.

So, why wait? Talk to your doctor or pharmacist

today about moving to an oTc medication.

for example, to treat allergies:$50 to $100*

PreScrIPTIon

$25*

Brand oTc

$5*

generIc oTc*average cost for 30 days

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4 blue cross of idaho bcidaho.com

ThiS iS your coverageBe Informed:

( )Get intimate with your health insurance to make the most of your benefits.

You’re talking with a friend and the subject of health insurance comes up. You swap information about things like copays, deductibles and coverage for some procedures. You become aware

of some differences in what your insurance policies pay for, under what conditions and at what cost out of your pockets. But hold on: Both you and your friend are insured through Blue Cross of Idaho. Shouldn’t

your coverage be alike? Not necessarily. Read on to learn what’s behind the differences and how

you can get the most out of your insurance coverage.

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TO THE SOUrCE A key factor in why coverage varies is where your insurance came from. Did you obtain it through a group, such as an employer, or did you buy it on your own—an individual policy?

Employers aren’t required to offer health insurance to their employees, but many do. It’s an employee benefit lots of people seek, so companies may offer group coverage to attract and keep good workers.

Each employer decides the type and number of health plans to offer employees, what each plan’s coverage will be (within state and federal laws), and what share of the insurance premium employees enrolled in the plan must pay.

THE COST CONSIDErATIONThe challenge for employers is to provide insurance with a scope of coverage that includes what employees want and can afford. Cost considerations account for most of the differences in coverage from plan to plan and employer to employer.

Cost also influences coverage if you buy insurance on your own. Several factors influence premiums for individual health insurance plans. These include your age, your health status and your lifestyle habits. For instance, smokers will typically pay more for personal health insurance than non-smokers, as will people who are overweight or have pre-existing conditions. The biggest financial jolt with individual insurance is that you’re responsible for the entire premium, not just an employee portion.

To get the insurance protection you need at a cost you can afford, you may have to

make some coverage trade-offs—say, switching to a plan with a higher deductible and more limited outpatient benefits to reduce your premium.

WHAT YOU CAN DO No matter how you got your coverage, it benefits you to take charge and learn all you can. Think of this as an ongoing effort to stay knowledgeable about your insurance just as you make an ongoing effort to stay well. Some suggestions:

1 Know your coverage. Become familiar with your

current coverage. Read all coverage-related handbooks, like the Plan Summary (for group insurance) or Policy Description (for individual plans). Zero in on details of what is and isn’t covered. Review all available coverage options during enrollment and renewal periods so you can make an informed choice.

2Ask questions and voice concerns. Some information

is bound to be confusing, especially if you’re not a health insurance expert. So, speak up. Talk to your employee benefits administrator or insurance company representative whenever you need answers, explanations or advice.

3 Stay on top of changes. Be proactive. Pay attention

to announcements about coverage. Then, repeat action steps 1 and 2 as needed.

= FOr MOrE INSIGHT: BCIDAHO.COMno matter what time of day or night or whether you’re at the office or on the couch, you can learn more about your insurance at bcidaho.com. The site offers explanations of coverage details, treatment estimates and a hospital comparison tool.

EXPLANATION OF BENEFITSTHIS IS NOT A BILL

If you have a question about your claim, please call Customer Service at

208-331-7319 or 1-800-627-6654 March 17, 2003 www.bcidaho.com

SUMMARY

Patient

Jacob Lastname

Identification No.

XMH000000000

Group

00000000 – Name of Group

SERVICES BILLED BY CHARGES NETWORKSAVINGS

Amount saved by usinga Blue Cross of Idahocontracting provider.

OTHERINSURANCE

Amount yourother insurance

paid.

AMOUNTWE PAID

Payment madeto provider.

WHAT YOU OWEPROVIDER

Health Care Clinic 46.00 0.00 238.20 59.80

TOTAL

344.00

344.00 46.00 0.00 238.20 59.80

DEDUCTIBLE STATUSFor claims processed through 05/05/03

For benefit period 01/01/03-12/31/03, the following has been satisfied:• 250.00 of the 250.00 out-of-network deductible

DETAILHealth Care Clinic

Provider Bill CureallPatient Account 0000000

Insurance Claim 000000000000

ServiceDate

ServiceDescription

Charges NetworkSavings

OtherInsurance

NonCovered Deductible

Copayment/Coinsurance

AmountWe Paid Notes

02/21/03 PhysicianCare

329.00 46.00 4.00 223.20 1

02/21/03 Laboratory 15.00 0.00 15.00

CLAIMTOTAL

344.00 46.00 4.00

55.80

55.80 238.20

Notes

1 Amounts listed in the Network Savings column exceed the allowable amount for this service. You are not responsible forfor this amount. Amounts listed in the Noncovered column exceed the allowable amount for this service. You areresponsible for this amount.

Suspect fraud? Please help by calling our hotline at 1-800-682-9095.

THANK YOU FOR ALLOWING US TO SERVE YOUAPPEAL PROCEDURES: If you would like to appeal a claim decision, you may do so through the following: A written appeal stating the reasons why you believeour claim decision was incorrect must be sent to the Appeals and Grievance Coordinator within 180 days after receipt of this Explanation of Benefits. Any writtencomments, documents, or other relevant information may be included. We will mail a written decision within 30 days after we receive the appeal. You or yourauthorized representative may request copies of all documents that are relevant to this appeal. If the original claim decision is upheld upon appeal, you may send asecond written appeal to our Appeals and Grievance Coordinator stating the reasons for requesting further review. Your request must be sent within 60 days of ourmailing of the initial appeal decision. A final decision on the appeal will be made within 30 days after our receipt of the second appeal.

Under section 502(a) of the Employment Retirement Income Security Act, you may have the right to file a civil action following the exhaustion of the completeappeals process if you are not satisfied with the outcome.

If this EOB indicates that we relied on an internal guideline in determining your claim, a copy of that guideline may be obtained upon request. Explanations ofdeterminations based on medical necessity or experimental and/or investigational treatment exclusions may also be obtained upon request.

EOB 05/03 XMH530842151 02 03/17/2003

P.O. Box 7408 Boise, Idaho 83707-1408




SUMMARY

Patient

Jacob Lastname

Identification No.

XMH000000000

Group




OTHERINSURANCE


paid.

AMOUNTWE PAID




TOTAL

344.00

344.00 46.00 0.00 238.20 59.80






ServiceDate

ServiceDescription


OtherInsurance



AmountWe Paid Notes


329.00 46.00 4.00 223.20 1

02/21/03 Laboratory 15.00 0.00 15.00

CLAIMTOTAL

344.00 46.00 4.00

55.80

55.80 238.20

Notes






EOB 05/03 XMH530842151 02 03/17/2003


ID-6


you SHould know:

If you’ve recently received medical care or visited your doctor, you’ll probably receive an explanation

of benefits, or EOB. This is a form that gives you information about your medical claims and their status. It’s not a bill, but it’s a good idea to file it with your health insurance documents. It gives you details about what services your provider has billed us, how we processed them and how much you owe your provider.

Get Yours NowWe generate and send EOB forms after

we have processed a claim. But if you

don’t receive an EOB for treatment in a reasonable amount of time, you can still check to see if we have received a claim and if it’s in process.

Go to bcidaho.com, log in to your member page, then select “Claims History” in the middle of the screen under the welcome greeting.

After selecting “Claims History,” choose the “Claims” tab and you will see your claims.

the FACTS of the EOB

The who, what, why and where of this insurance form.

= LEArN MOrE ONLINE

For a detailed key to the explanation of benefits (EOB) form, go online to bcidaho.com, move your mouse over "About Us" on the top menu bar, select "Company Information" on the drop-down menu, then select "Explanation of Benefits (EOB) Fact Sheet" under "Health Insurance Education" in the middle of the page.




SUMMARY

Patient

Jacob Lastname

Identification No.

XMH000000000

Group




OTHERINSURANCE


paid.

AMOUNTWE PAID




TOTAL

344.00

344.00 46.00 0.00 238.20 59.80






ServiceDate

ServiceDescription


OtherInsurance



AmountWe Paid Notes


329.00 46.00 4.00 223.20 1

02/21/03 Laboratory 15.00 0.00 15.00

CLAIMTOTAL

344.00 46.00 4.00

55.80

55.80 238.20

Notes






EOB 05/03 XMH530842151 02 03/17/2003





SUMMARY

Patient

Jacob Lastname

Identification No.

XMH000000000

Group




OTHERINSURANCE


paid.

AMOUNTWE PAID




TOTAL

344.00

344.00 46.00 0.00 238.20 59.80






ServiceDate

ServiceDescription


OtherInsurance



AmountWe Paid Notes


329.00 46.00 4.00 223.20 1

02/21/03 Laboratory 15.00 0.00 15.00

CLAIMTOTAL

344.00 46.00 4.00

55.80

55.80 238.20

Notes






EOB 05/03 XMH530842151 02 03/17/2003


ID-7


life of a ClAImever wonder how medical claims are processed? Join us as we follow a claim, from start to finish.

PrOVIDEr’S FrONT DESK

let’s imagine you’ve got a friend named Ben. He’s a Blue Cross of Idaho member and just visited his doctor. like every good member, he was well prepared for his appointment and presented his member ID card.

Once he leaves, a claim is created. Any Blue Cross of Idaho in-network provider will submit an electronic or paper claim directly to us.

Claims are typically prepared by the administrative staff at a provider’s office and must contain specific information about the patient and provider.

BLUE CrOSS OF IDAHO CLAIMS PrOCESSING

Once we convert Ben’s claim to a standardized, electronic format and if all required information is present, the claim moves to the validation stage, where these five rules must be met:

The provider is on file in our network and is covered for the services according to in-network or out-of-network provider status.

The patient is a valid member.

The claim doesn’t duplicate one that’s already been paid.

Procedure codes and diagnosis codes submitted are valid and the services for those codes are covered under the patient’s plan.

The service is covered by the member contract.

DOES BEN’S CLAIM PASS?

If there is any incomplete information or discrepancies, it does not. It is routed to a claims examiner for resolution.

For example: let’s say that Ben’s claim includes an imaging test called an mRI. His coverage requires preauthorization for an mRI except in emergencies, but there’s no record of either an authorization or an emergency. The claims examiner routes the claim to medical Review to determine if the mRI was medically necessary. If yes, the claim is 100-percent validated. If no, the claim is not accepted, and Ben has the option of appealing the decision.

If it passes, the claim is 100-percent validated. As an accepted claim, it moves to the next stage.

WOrKFLOW

The workflow stage involves electronic routing of accepted claims to two areas:

• Explanation of Benefits (EOB), which is prepared for Ben.

• Detail of Remittance, which readies payment of the claim. Payment goes directly to providers contracted with Blue Cross of Idaho. If the provider Ben used doesn’t have a contract with us, the payment is sent to Ben along with the EOB, and Ben must pay that provider the amount owed.

STeP By STeP:

WHAT’S THE TUrNArOUND TIME FOr PrOCESSING A CLAIM? It depends on a lot of factors—including how long it takes your provider to get the claim to Blue cross of Idaho and how complete the information is. as a member, you can help yourself and the claims process by knowing your plan coverage and asking questions in advance.

out-of-State claims where the provider is contracting with the host Blue Cross and Blue Shield Plan follows the same process but may take a little longer as we must depend on the host plan's personnel to validate the claim information before transmitting it to Blue Cross of idaho.

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You want freedom of choice. And we give you more

choices than any health plan in the state. In fact, you can choose from more than 2,700 providers and all Idaho hospitals in our traditional and PPO networks.

A large network of providers means you have more opportunities to save money. How? We have special contracts with the providers in our network. When you use one of them, you often pay a lower copayment, lower deductible and lower coinsurance, depending on your plan.

Use an out-of-network provider, however, and you will most likely have to pay

a higher deductible and higher coinsurance, or you may not have out-of-network benefits. You may also have to pay for the difference between the Blue Cross of Idaho allowed amount and the amount charged by the out-of-network physician and facility. You can bet your cost will be a lot higher than your copayment—perhaps hundreds or thousands of dollars, depending on the procedure or treatment.

You can search for a network provider using our Provider Directory at bcidaho.com.

Choice is GoodWe offer the largest group of providers in the state.

your one-SToP Source:

=A POINT ABOUT PrOVIDErS If you’ve ever wondered what “provider” means, remember this: Healthcare providers provide healthcare. Doctors, specialists, clinics/facilities and hospitals are all providers.

= d o T H I S

PIck your PcP If you’re an Hmo member, you need to authorize one doctor as your primary care physician (PcP). This doctor will be in charge of your overall healthcare, and may be chosen from our list of contracted general practitioners, family practitioners, internists, pediatricians, and obstetricians and gynecologists.

If you aren’t happy with your PcP, you can switch doctors online from your personalized member page, or you can call customer Service.

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go deeper - blue cross of idaho · spread the flu to people at high risk. for specifics about if...

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