A claim is a written or electronic request to your health insurance company for payment of healthcare services you have that are covered by your plan. In most cases, claims must be submitted within 15 months of the date of service or your health plan will deny the benefits. For self-funded plans, the time frame could be shorter.
Doctors and healthcare providers normally file claims. But, if you need to send a claim for a healthcare service, please mail a paper claim to:
HMO Louisiana, Inc.
PO Box 98024
Baton Rouge, LA 70898-9024
When you send in the claim, please take the following steps so your claim is handled quickly:
NOTE: If any information from steps 5-7 is missing, ask your healthcare provider to help you fill in the missing information.
If you have any questions about sending in a claim, call Customer Service at the number on the back of your member ID card.
If you get financial help in the form of subsidies from the federal government to pay for the premiums on a health plan you buy through healthcare.gov and you pay at least one full month of your premium, you will have a three-month grace period if you do not pay your premium on time. In cases where you receive help to pay your premiums, your health plan will pay claims on any services obtained during the first month of your grace period. After that first month, if you have not paid your full premium, your health plan will mail a delinquency notice to the address you listed when you bought your health plan. If you still have not paid any premium you owe by the second month, your health plan will pend (hold) claims for any services you have and will not pay them until you pay your premium. Claims pending means that your health plan will not immediately pay claims for health services provided during the second and third month of your grace period. Your health plan will notify your healthcare providers that you have not paid your premium and your claims are being pended (held). At the end of the three months, if you have not paid your full premium amount, your health plan coverage will be cancelled, effective at the end of the first month of your three-month grace period.
For example, if your grace period is January, February and March and your healthcare coverage is cancelled after March (the third month), your coverage will be terminated dating back to January 31st (the first month of your grace period).
If you do not get financial help to pay your premiums, you have a 30-day grace period that starts on the premium due date. If you have not made your premium payments by the end of the 30-day period, your coverage will be cancelled effective the last day you were paid in full on your premiums.
For example, if your grace period is in April and your premium due date was April 1, if you do not pay, your coverage will be terminated after April 30 dating back to March 31 (the last day you were paid in full on your premiums).
Sometimes, your health plan may pay for a claim on a healthcare service you received and then realize later that the claim should not have been covered. In those cases, the health plan can retroactively deny the claim and you would be responsible for paying the claim.
This may happen because:
This usually happens if you are no longer eligible for coverage or you do not pay your healthcare premiums on time. Your health plan may also recoup a claim payment if it was overpaid or paid incorrectly.
You should make sure to pay your premium on time every month to avoid being dropped and/or having a claim denial.
U.S. Centers for Medicare and Medicaid Services definition: A retroactive denial is the reversal of a previously paid claim by which the enrollee then becomes responsible for payment.
If your health plan finds out you paid more than you owed for your healthcare premium, you will be owed a refund. If you are still an active member of your health plan your health plan will apply the amount you overpaid as a credit on your next premium bill unless you request a refund. You can request a refund check by sending in a signed written request or by calling Customer Service at the number on the back of your ID card.
U.S. Centers for Medicare and Medicaid Services definition: Enrollee recoupment of overpayments is the refund of a premium overpayment by the enrollee due to over-billing by the insurer.
Medically necessary services are defined as:
Health care services, treatment, procedures, equipment, drugs, devices, items or supplies that a provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:
Prior authorization is when your health plan determines if a healthcare service, treatment plan, drug or piece of equipment is medically necessary.
If your health plan requires prior authorization for a service, work with your healthcare provider to follow the required prior authorization steps.
In general, the timeframe for prior authorization requests is:
An urgent care request means a request for a health care service, or course of treatment, to which the time periods for making a non-urgent care request determination could either seriously jeopardize the life or health of the covered person, or the ability of the covered person to regain maximum function or would, in the opinion of a physician with knowledge of the covered person’s medical condition, subject the covered person to severe pain that cannot be adequately managed without the health care service. Any request that a physician with knowledge of the covered person’s medical condition determines is an urgent care request will be treated as an urgent care request.
Penalties for Failure to Obtain Authorization - Admissions, Outpatient Services, and Other Covered Services and Supplies
If Authorization is not requested prior to Admission or receiving other Covered Services and supplies requiring an Authorization, we will have the right to determine if the Admission or other Covered Services and supplies were Medically Necessary. If the services were not Medically Necessary, the Admission or other Covered Services and supplies will not be covered and the Member must pay all charges incurred.
If the services were Medically Necessary, Benefits will be provided based on the participating status of the Provider rendering the services, as follows:
(1) If a Network Provider or a Participating Provider fails to obtain a required Authorization, we will reduce Allowable Charges by the penalty amount stipulated in the Provider's contract with us or with another Blue Cross and Blue Shield plan. This penalty applies to all covered Inpatient charges. The Network Provider or Participating Provider is responsible for all charges not covered. The Member remains responsible for any applicable Copayment or Deductible and Coinsurance percentage shown on the Schedule of Benefits.
(2) If a Non-Participating Provider fails to obtain a required Authorization, we will reduce Allowable Charges by the amount shown on the Schedule of Benefits. This penalty applies to all covered Inpatient charges. The Member is responsible for all charges not covered and for any applicable Copayment, Deductible and Coinsurance percentage shown on the Schedule of Benefits.
Additional Member responsibility if Authorization is not requested for an Inpatient Admission to a Non-Participating Provider Hospital: $1,000.00 reduction of the Allowable Charges.
b. Outpatient Services, Other Covered Services and Supplies
(1) If a Network Provider fails to obtain a required Authorization, we may reduce the Allowable Charge by thirty percent (30%). This penalty applies to all services and supplies requiring an Authorization, other than Inpatient charges. The Network Provider is responsible for all charges not covered. The Member remains responsible for his Copayment or Deductible and applicable Coinsurance percentage shown on the Schedule of Benefits.
(2) If a Non-Network Provider fails to obtain a required Authorization, Benefits will be paid at the lower Non-Network level shown on the Schedule of Benefits. The Member is responsible for all charges not covered and remains responsible for the Copayment, Deductible and applicable Coinsurance percentage shown on the Schedule of Benefits.
Our Drug Utilization Management Program is designed to promote Member safety and appropriate, cost-effective use of medications, and monitor healthcare quality. As part of Our Drug Utilization Management program, Members and/or Physicians must request and receive prior Authorization for certain Prescription Drugs and supplies in order to access Prescription Drug Benefits. The list of categories of Prescription Drugs that require prior Authorization is available for viewing on our website at www.bcbsla.com/pharmacy or by calling the customer service telephone number on the Member’s ID Card. If a Prescription Drug requires prior Authorization, the Member’s Physician must call the medical Authorization telephone number on the Member’s ID Card to obtain the Authorization. Failure to obtain an Authorization may result in Benefits being denied if the Prescription Drug is later determined not to be Medically Necessary.
U.S. Centers for Medicare and Medicaid Services definition: Medical necessity is a term used to describe care that is reasonable, necessary and appropriate based on evidence-based clinical standards of care. Prior authorization is a process through which an issuer approves a request to access a covered benefit before the insured accesses the benefit.
Your doctor could prescribe a drug that is not on your covered drug list (formulary). In these cases, you or your doctor can request that your health plan cover the drug under the drug formulary exceptions process.
These initial requests first go to Express Scripts, an independent company that serves as our pharmacy benefit manager for your health plan. You or your doctor can contact Express Scripts by telephone or fax. Go to www.bcbsla.com to see contact information. Express Scripts will review the initial request and make a decision within three days (72 hours) of getting it. You or your doctor can ask for the request to be reviewed within one day (24 hours) if you need a decision sooner. Express Scripts will let both you and the doctor prescribing the drug for you know what they decide.
If the request is denied, you or your doctor can appeal that decision. There are different levels of appeal. In order to start an appeal, you or your doctor can contact Express Scripts by telephone or fax. For denials that are reviewed internally by Express Scripts, they will let both you and the doctor prescribing the drug for you know what they decide no more than 15 days from the date of the request.
Alternatively, you or your doctor can request a denial be reviewed externally by an Independent Review Organization (“IRO”). The IRO will make a decision within three days (72 hours). If you need a decision sooner, your doctor can ask for the denial to be reviewed within one day (24 hours) of getting it. Express Scripts will let both you and the doctor prescribing the drug for you know what the IRO decided.
If the request is approved, it will be treated like other drugs on the covered drug list. What you pay out of pocket (copay or coinsurance) for the drug will depend on your plan type and pharmacy benefits. Check your plan contract for more information.
Your Explanation of Benefits (EOB) is sent to you after you receive medical treatment or service to explain what your health plan paid and what amount (if any) you will need to pay out of pocket. This depends on your plan type or benefits. Your EOB is not a bill. It gives you more information about services you received and how they were covered by your health plan.
You get an EOB every time you see a healthcare provider. Your health plan sends your EOB after getting a claim for a healthcare treatment or services.
An EOB includes things like total charges for a service, any discount you got on the service, how much of the bill is not covered by your health plan, and how much your health plan paid for the service. The EOB will also show how much you owe the healthcare provider after your health plan has paid its share of the charges, so you know what to expect. Your EOB tells you how to contact your health plan if you need to file an appeal or grievance.
EOBs can be delivered to members via one of two methods. A traditional paper EOB is mailed to members unless they choose to receive those documents electronically. A pdf version of the EOB is made available to members via the Blue Cross website if the member has chosen electronic delivery of EOBs.
U.S. Centers for Medicare and Medicaid Services definition: An Explanation of Benefits (EOB) is a statement sent to the enrollee to explain what medical treatments and / or services were paid for on an enrollee’s behalf, the amount paid and the enrollee’s financial responsibility based on the terms of the policy.
When you have healthcare coverage through more than one plan, the different plans will need to coordinate your benefits to determine which plan pays for which services.
Benefits may be coordinated across different plans as allowed by law. With coordination of benefits, no more than the allowable charge (what the health plan pays) is paid on any of the plans for the same healthcare service or treatment.