Download Group Administrator`s Manual

Group Administrator’s Manual
Form No. 3-402 (5-13)
Table of Contents
Phone Numbers and Addresses ..................................................................................2
Who is Eligible for Healthcare Coverage ..................................................................3
Who Qualifies for Healthcare Coverage................................................................................. 3
Who is an Eligible Employee ................................................................................................... 3
Who is an Eligible Dependent.................................................................................................. 3
Enrollment Information ..............................................................................................4
Enrollee Certificate................................................................................................................... 4
Identification Cards .................................................................................................................. 4
Leave of Absence....................................................................................................................... 4
Retirement ................................................................................................................................. 5
Name or Address Change......................................................................................................... 5
Transfer of Enrollment............................................................................................................. 5
Summary of Benefits & Coverage Information ..................................................................... 6
Enrollment Procedures................................................................................................7
How to Enroll Newly Hired Eligible Employees .................................................................... 7
What to Do When a Newly Hired Eligible Employee Declines Coverage ........................... 7
How to Determine the Effective Date of Coverage ................................................................ 7
How to Add a New Eligible Dependent................................................................................... 7
How to Enroll Late Enrollees................................................................................................... 8
Who Qualifies as a Late Enrollee ............................................................................................ 8
Causes of Ineligibility.................................................................................................10
Employee Termination ........................................................................................................... 10
Divorce or Death of a Covered Dependent ........................................................................... 10
Dependent Child Status Ends ................................................................................................ 10
Termination of Employment and Death of Employee......................................................... 11
Consolidated Omnibus Budget Reconciliation Act ................................................12
What is COBRA?.................................................................................................................... 12
Qualifying Events and Periods of Continued Coverage...................................................... 12
Administration of COBRA..................................................................................................... 13
COBRA Administration Pricing Structure .......................................................................... 14
When COBRA Continuation Ends ....................................................................................... 14
Billing Adjustments....................................................................................................15
Due Date................................................................................................................................... 15
Billing Changes........................................................................................................................ 15
Billing Reconciliation.............................................................................................................. 15
How to File Health Claims ........................................................................................16
Claim Filing by Provider........................................................................................................ 16
Claim Filing by Member ........................................................................................................ 16
Notification of Payment.......................................................................................................... 16
Help Avoid Delays................................................................................................................... 17
External Review Policy..............................................................................................18
Standard External Review Request ...................................................................................... 19
Expedited External Review Request ..................................................................................... 19
Binding Nature of the External Review Decision................................................................. 20
How to File Prescription Drug Claims.....................................................................21
Benefits Through Blue Cross of Idaho Network Pharmacies............................................. 21
How to Use the Blue Cross of Idaho Pharmacy Network Prescription Drug Benefit ...... 21
How to Collect Benefits When Using a Non-Network Pharmacy....................................... 22
Mail-order Prescriptions ........................................................................................................ 22
Transferring Prescriptions..................................................................................................... 23
Ordering Refills....................................................................................................................... 23
Generic Drugs.......................................................................................................................... 23
Ordering Prescription Refills On-line................................................................................... 23
Dental Benefits............................................................................................................24
Claim Filing by Provider........................................................................................................ 24
Claim Filing by Member ........................................................................................................ 24
Help Avoid Delays................................................................................................................... 25
Dental Program Exclusions & Limitations........................................................................... 25
Vision Service Plan.....................................................................................................26
Benefits Available Through VSP........................................................................................... 26
When Using a VSP Participating Doctor.............................................................................. 26
When Using a VSP Non-participating Doctor...................................................................... 26
Prior Authorization....................................................................................................27
What is Prior Authorization .................................................................................................. 27
What is Inpatient Notification ............................................................................................... 27
Sample Forms.............................................................................................................29
This Group Administrator’s Manual is a general resource intended to help answer questions
members may have regarding their coverage. It covers parts of the policy in general terms.
Please refer to your Master Group Policy for complete details
for specific information regarding your healthcare plan.
Blue Cross of Idaho Group Administrator’s Manual
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Phone Numbers and Addresses
To Submit Medical & Dental Claims:
Blue Cross of Idaho
Claims Department
PO Box 7408
Boise, ID 83707-1408
or
Blue Cross of Idaho
Claims Department
3000 E. Pine Avenue
Meridian, ID 83642-5995
Blue Cross of Idaho Prior Authorization:
Toll-Free:
Boise calling area:
800-743-1871
208-331-7535
Customer Service:
Blue Cross of Idaho
Customer Service Department or
PO Box 7408
Boise, ID 83707-1408
Blue Cross of Idaho
Customer Service Department
3000 E. Pine Avenue
Meridian, ID 83642-5995
For Medical & Dental Customer Service:
Toll-free:
Boise calling area:
800-627-1188
208-331-7347
Toll-free:
800-877-7195
VSP
Blue Cross of Idaho’s website bcidaho.com
You can also email our customer service department. From our homepage, select Contact Us from the
upper left corner, then General Information under the Email subhead.
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Who is Eligible for Healthcare Coverage?
Refer to your Master Group Policy for details.
Who Qualifies for Healthcare Coverage?
All eligible employees and their dependents qualify for healthcare coverage when meeting eligibility
and enrollment criteria.
Who is an Eligible Employee?
An eligible employee is a full-time, regular employee who works a designated number of hours per
week as agreed upon by the employer and Blue Cross of Idaho.
The definition of eligible employee may also include officers and employees without regard to the
number of hours worked, at the discretion of the employer.
Newly hired employees qualify for coverage for themselves and their dependents after completing the
group’s designated probationary period, if any.
Who is an Eligible Dependent?
If an employer offers coverage for dependents, the following defines who is eligible as a dependent:
1. An eligible employee’s lawful spouse qualifies for coverage.
2. A dependent child (natural, stepchild, adopted, or legally placed with the employee for
adoption or guardianship) is eligible for coverage under either one of the following two
conditions
a)
Until the end of the month a child turns 26 years old
b)
If medically certified as disabled due to mental disability or physical disability
(subject to periodic recertification) and financially dependent upon the employee for
support, regardless of age.
OR
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Enrollment Information
Enrollee Certificate
The Enrollee Certificate describes your employees’ coverage based on your group policy. Blue Cross
of Idaho provides your group with a current Enrollee Certificate to distribute to each of your enrolled
employees.
Identification Cards
Blue Cross of Idaho sends each enrolled employee identification cards for his or her use and for the
use of any insured family members. Both cards list the employee’s name as the enrollee and include
the enrollee identification number (managed care cards include the dependents’ names on the cards as
well). Covered members should show the identification card to the healthcare provider whenever
receiving services. If your group provides prescription drug coverage, members should show the
identification card to the pharmacist whenever purchasing prescription drugs. Group admins or
members can order a paper copy of an ID card through our website, bcidaho.com, while waiting for a
hard copy to arrive in the mail.
The following generic ID card sample shows the card design:
Front
Back
NOTE: Managed care member ID cards include the name(s) of dependents and a PCP selection
(when applicable).
Leave of Absence
An employee with an approved leave of absence may continue to receive your group’s benefits for up
to 90 days, unless your group policy specifies otherwise. The Family and Medical Leave Act (FMLA)
of 1993 (applies to groups of 50 or more) requires continued coverage for up to 12 weeks, if eligible.
Please make a notation on your billing in the “Explanation” column on the roster page that the
employee is on an approved leave of absence and submit the appropriate amount (employee and
employer contributions) with your payment. To ensure continued coverage for the employee, your
group must continue making its regular payments for the employee’s coverage during the approved
leave of absence. We will not accept payments made directly by an employee.
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Retirement
Enrollees who retire at age 65, have both Medicare Part A and Part B, and are Idaho residents qualify
to purchase Blue Cross of Idaho’s Medicare supplement coverage. They may enroll in any of our
Medicare supplement programs without health statement approval during the six-month open
enrollment period following their 65th birthday or with enrollment in Part B of Medicare. Medicare
supplement policyholders can pay by bank withdrawal or receive a bill in the mail.
If the retiree has covered dependents, eligible family members under the age of 65 may have two
options for continuous coverage:
1.
If the dependent resides in Idaho, the dependent may be eligible to transfer to a Blue
Cross of Idaho individual program, if Blue Cross of Idaho receives a properly completed
application within 30 days from the group’s coverage termination date
2.
If your group qualifies, the dependent may be eligible for COBRA continuation coverage
(please refer to the Consolidated Omnibus Budget Reconciliation Act Section).
OR
Name or Address Change
To make a name or address change, the employee should complete a Member Name or Address
Change Form (4-125), then mail the form to Blue Cross of Idaho. When an employee has a name
change, the group administrator can note the change on the Group Bill Worksheet by noting the
Enrollee Identification Number, former name and new name. See the example in the Forms section of
this handbook. However, non-electronic enrollment groups can change information on the Blue Cross
of Idaho website, bcidaho.com. For groups using electronic enrollment, direct members making any
demographic changes or adding/deleting dependents must contact their group administrator.
Transfer of Enrollment
An enrolled employee or insured dependent may be eligible to transfer coverage, without lapse of
coverage or health statement approval for new coverage, when one of the following two conditions
applies:
OR

The member is no longer eligible for enrollment with the group, has no other health
coverage, and still resides in Idaho – The member living in Idaho may be eligible to
transfer to Blue Cross of Idaho individual medical and dental plans, if a completed
application is submitted to Blue Cross of Idaho within 30 days of the group coverage
termination date

The member lives or moves out of state – The member may transfer enrollment to the Blue
Cross and Blue Shield Plan that serves the state he or she is moving to. The member should
check with that plan for confirmation. Credit for waiting periods already satisfied in the
original state may apply in the new state. If a member moves out of state and elects new
coverage from an insurance company other than the Blue Cross and Blue Shield Plan that
serves the state where he or she is moving, transfer of enrollment with no lapse of coverage is
not guaranteed.
Transfer of enrollment gives employees continuous healthcare protection with credit for waiting
periods for preexisting conditions. Please explain to the employee or insured dependents that the
benefits and rates for the new coverage may differ from those offered by your group.
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Summary of Benefits & Coverage Information
Effective September 23, 2012, federal law will require health insurance providers to give individual
members access to summary of benefits and coverage information (SBC) regarding the member’s
healthcare coverage. The intent of the SBC is to provide consistent and comparable information about
a member’s health plan benefits. These materials will contain two key pieces of information that will
help members understand and evaluate their health insurance choices:
 A short, easy-to-understand summary of benefits and coverage (SBC); and
 A list of definitions (called the uniform glossary) that explains terms commonly used in
health insurance coverage such as “deductible” and “co-payment”.
As a part of this effort, Blue Cross of Idaho provides important information related to the SBC for
members and partners in the health insurance and healthcare industries.
Employers can view the SBC(s) for your group’s current coverage options and the uniform glossary
online at bcidaho.com/employers. Note: You must log in to access your specific account
information. If you have not registered on our website, you will need your group ID number to
complete the registration process.
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Enrollment Procedures
To see how to adjust your billing for new employees and new dependents, please refer to the Billing
Adjustments section.
How to Enroll Newly Hired Eligible Employees
Each newly hired eligible employee requesting coverage must complete an application and apply for
coverage within a 30-day period of becoming eligible or 30 days prior to completion of his or her
probationary period, referred to as the “initial enrollment period.” The group administrator should
send the employee’s application prior to the requested effective date. The employee’s effective date
will be the first day of the month following receipt of a completed application, provided the employee
completes any probationary periods as designated by the employer. Failure to submit a completed
application during the initial enrollment period may qualify the eligible employee as a late enrollee
(please refer to the Who Qualifies as a Late Enrollee section for more information).
If you or the new enrollee make changes to the application, or cross out items, the enrollee must sign
their initials next to the change before Blue Cross of Idaho receives the application.
Even though Blue Cross of Idaho guarantees coverage, we will return applications submitted
unsigned or undated, for completion, which could delay the effective date of coverage. Once Blue
Cross of Idaho processes and approves the application, Blue Cross of Idaho will bill for the employee
on the next statement.
If you would like to submit applications via email, you can send them to [email protected]. If
you submit via email, you do not need to mail original copies. We will send you a confirmation email in response to let you know we have received the applications.
What to Do When a Newly Hired Eligible Employee Declines Coverage
For small groups (less than 50 employees), when a newly hired employee chooses not to enroll or
chooses not to enroll any eligible family members in the offered group coverage, the Small Employer
Health Insurance Availability Act requires the employee complete an Employee’s Waiver of
Healthcare Coverage form. The employee must return the completed waiver form to Blue Cross of
Idaho within 30 days from either the date of hire or completion of the probationary period. Employees
in large groups (over 50 employees) are not required to submit a waiver.
How to Determine the Effective Date of Coverage
If the application for coverage is properly completed and submitted, a new employee’s coverage is
effective the first day of the month following Blue Cross of Idaho’s application receipt, provided the
eligible person completes the probationary period, if any. Blue Cross of Idaho will bill for the
employee on the next billing statement.
How to Add a New Eligible Dependent
To add an eligible dependent, the employee must complete an application and apply for coverage for
such eligible dependent within a 30-day, “initial enrollment period.” of the dependent becoming
eligible for coverage. If a dependent is a newborn natural child, adopted, or is eligible because of
marriage, the initial enrollment period is 60 days (see paragraph below). Failure to submit a
completed application during the initial enrollment period may qualify the eligible dependent as a late
enrollee (please refer to the Who Qualifies as a Late Enrollee section below for more information).
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Blue Cross of Idaho will return incomplete applications, including those submitted unsigned or
undated, for completion.
If the application is properly completed and submitted within 30 days of the eligibility date, coverage
for a new dependent becomes effective the first day of the month following Blue Cross of Idaho’s
receipt of the application.
To add a natural newborn or adopted child or a dependent who is eligible because of marriage, the
employee must complete an application and apply for coverage within a 60-day period of the
dependent becoming eligible for coverage. In the case of a newborn dependent who is the enrollee’s
natural child, the date of birth is the effective date, for an adopted child the date is the date of
placement. In addition, children that become eligible because the parent marries become eligible on
the first day of the month following the date of marriage, or first of the month following receipt of
application.
How to Enroll Late Enrollees
Ask the employee to complete an application and submit it to Blue Cross of Idaho 30 days prior to the
group’s anniversary date (or renewal date). The effective date of coverage will be the group’s renewal
date. All other enrollment procedures apply regardless whether during or after the initial enrollment
period.
Who Qualifies as a Late Enrollee
A late enrollee is an eligible employee or dependent who requests enrollment in your group’s
healthcare coverage after the initial 30-day enrollment period. Blue Cross of Idaho applies full
waiting periods to coverage for all late enrollees. If an individual does not qualify as a late enrollee
when applying for coverage after the initial enrollment period, we will apply credit for qualifying
previous coverage to preexisting condition waiting periods.
There are several common circumstances that preclude considering the employee as a late enrollee.
Do not consider an eligible employee or dependent a late enrollee under any of the four circumstances
described below:
1. The individual meets criteria a, b and c below:
a. The individual was covered under qualifying previous coverage at the time of initial
enrollment
b. The individual lost the qualifying previous coverage as a result of termination of
employment or eligibility, the involuntary termination of the qualifying previous
coverage, or the death or divorce of a spouse
c. The individual requests enrollment within 30 days after termination of the qualifying
previous coverage
OR
2. Your group offers multiple health benefit plans and the individual elects a different plan during
an open enrollment period
OR
3. The eligible employee and/or eligible dependent become eligible for a premium assistance
subsidy under Medicaid or the Children's Health Insurance Program (CHIP) and the member
requests coverage under the policy no later than 30 days after the date the eligible employee
and/or eligible dependent is eligible for such assistance.
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OR
4. Coverage under Medicaid or CHIP for an eligible employee and/or eligible dependent is
terminated because of loss of eligibility for such coverage, and coverage is requested under this
policy no later than 30 days after the date of termination of such coverage.
If the individual does not qualify as a late enrollee when applying for coverage after the initial
enrollment period, we apply the credit for qualifying previous coverage to preexisting condition
waiting periods for adults over age 19.
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Causes of Ineligibility
To see how to adjust your billings for any of the examples listed below, please refer to the Billing
Adjustments section.
Employee Termination
Group coverage terminates on the last day of the month that the group makes payment for the
terminated employee, or the day specified in your group policy.
Divorce or Death of a Covered Dependent
In the event of a divorce or death of an insured dependent, the employee should complete the front of
an enrollment application (also used as an enrollment change form), indicating the date of divorce or
death under Change Request, and list any covered dependents who should remain insured. Please
mail the enrolled employee’s application immediately to Blue Cross of Idaho. You may also note
changes on the group bill worksheet.
A newly divorced ex-spouse, who is a resident of Idaho, and with no other health coverage, may be
eligible to transfer to a Blue Cross of Idaho individual program if he or she submits a properly
completed application to Blue Cross of Idaho within 30 days from the group coverage termination
date. We will terminate group coverage for the ex-spouse at the end of the month in which the divorce
was final, if Blue Cross of Idaho receives the application within 30 days of the event. A newly
divorced ex-spouse may be eligible for COBRA continuation coverage (please refer to the
Consolidated Omnibus Budget Reconciliation Act section). You may also note changes on the group
bill worksheet
“Dependent Child” Status Ends
An insured child becomes ineligible for coverage as the employee’s dependent:
OR

At the end of the month a dependent child turns 26 years old

For stepchildren at the end of the month of the date of the divorce
Blue Cross of Idaho may extend coverage for dependent children medically certified as mentally
and/or physically disabled and who are financially dependent on the employee for support. Request a
Certification for Mentally Disabled or Physically Disabled Dependent Form from Blue Cross of
Idaho. Eligibility is subject to periodic recertification.
It is the employee’s responsibility to notify the group administrator or Blue Cross of Idaho when the
dependent child is no longer eligible for coverage within 30 days of the event. When a child no longer
qualifies for coverage, the employee should complete the change request section on the front of an
enrollment application. The covered employee should include the child’s name, date of marriage, or
the date the child ceased to be an eligible dependent under the terms of the group policy. You may
also note changes on the group bill worksheet.
The insured dependent child who is terminating does have choices for continuing insurance coverage.
Refer to the next section, “Termination of Employment and Death of Employee.”
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Termination of Employment and Death of Employee
Coverage for surviving covered family members ends on the last day of the month following the
employee’s death. A terminated employee and his or her dependents, and surviving insured
dependents of a deceased employee who live in Idaho, may:
OR

Transfer to a Blue Cross of Idaho individual program, if they have no other health coverage
in force, and if a properly completed application is received by Blue Cross of Idaho within
30 days from the group coverage termination date

Be eligible for COBRA continuation coverage if your group qualifies (please refer to the
Consolidated Omnibus Budget Reconciliation Act section)
A terminated employee and his and her dependents, and surviving insured dependents of a deceased
employee who are either moving or are already residing out of Idaho may:
OR
OR

Transfer enrollment to the Blue Cross and Blue Shield Plan that serves the state they are
moving to after checking with that Plan for confirmation

Elect new coverage from an insurance company other than the Blue Cross and Blue Shield
Plan that serves the state they are moving to; however, there is no guarantee of continuous
coverage

Be eligible for COBRA continuation coverage if your group qualifies (please refer to the
Consolidated Omnibus Budget Reconciliation Act section).
Blue Cross of Idaho Group Administrator’s Manual
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Consolidated Omnibus Budget Reconciliation Act
What is COBRA?
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) applies only to certain
employers who sponsor group healthcare programs for their employees and who have employed 20 or
more employees on a typical day (at least 50 percent of the time) in the previous year. If your group
meets these criteria, we strongly recommend that you seek advice from your company’s legal counsel
about how COBRA provisions may apply to your group.
Title X of COBRA amends the Internal Revenue Code, the Public Health Service Act, and Title 1 of
the Employee Retirement Income Security Act (ERISA) to require certain employers to provide
continuation of healthcare coverage, at the employee’s expense, to certain employees and their
eligible dependents that would otherwise become ineligible for coverage because of certain
“qualifying events” listed below.
Law requires employers to notify new employees and their spouses of COBRA continuation when
healthcare coverage begins and to send a notice to any employee at the time of the event that qualifies
the employee or dependents for COBRA continuation (see Information Concerning Group Health
Coverage Continuation sample form at the end of this section).
Qualifying Events and Periods of Continued Coverage
COBRA health coverage continuation is available to employees and/or eligible dependents covered
by their group’s healthcare program at the time of a qualifying event that would otherwise result in
the loss of group coverage. Qualifying events and applicable periods of continuation for eligible
employees and/or dependents include one of the following:
OR
OR
OR
OR

Employment terminates (other than for gross misconduct)
Term: up to 18 months1 for employee and eligible dependents

Reduced work hours
Term: up to 18 months1 for employee and eligible dependents

Death of employee
Term: up to 36 months for eligible dependents

Employee becomes eligible for Medicare2
Term: up to 36 months for eligible dependents

Employee and spouse divorce or legally separate
Term: up to 36 months for eligible dependents

Dependent child ceases to be so under the terms of the group health program; i.e., child turns
age 26.
Term: up to 36 months for that child.
OR
1
Qualified beneficiaries who are or have been determined to be disabled by the Social Security Administration at any time
during the first 60 days of continuation coverage may be entitled to coverage for up to 29 months instead of 18 months. This
extension is dependent upon when Medicare coverage begins.
2
Please note that a person who retires before reaching age 65, elects COBRA continuation, and then turns age 65 and is eligible
for Medicare, becomes ineligible for COBRA, even if he or she has not completed the COBRA continuation period.
Blue Cross of Idaho Group Administrator’s Manual
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Administration of COBRA
After receiving a notice of a qualifying event, a group administrator needs to provide the employee
and/or eligible dependents with a notice and election form (see Group Health Coverage Continuation
Notice and Election in the “Sample Forms” section) and:
1. Process billing forms according to instructions under the Causes of Ineligibility section if the
employee doesn’t elect COBRA continuation coverage or doesn’t make the COBRA
payment before the expiration of existing coverage. At that point, Blue Cross of Idaho
considers the employee and/or dependents terminated from group coverage until they enroll
in the COBRA continuation program. The option to elect COBRA continuation expires 60
days after the date of termination or date the employer notifies the employee of COBRA
continuation eligibility.
2. Submit the Blue Cross of Idaho Group Coverage Continuation Application for COBRA
along with the necessary payment when an individual elects COBRA continuation. Be sure
to keep a record of the continuation notice and election form in your files.
3. Collect payment for coverage from the COBRA beneficiaries and submit it on their behalf
within 45 days of election. Payment must be retroactive to the coverage expiration date in
effect at the time of the qualifying event. Please note that Blue Cross of Idaho will not
accept COBRA continuation payment directly from the COBRA beneficiary or apart from
the group’s payment. COBRA continuation payment must be included in the group’s regular
payment.
Important note: Within six months prior to the end of the COBRA continuation term, federal law
requires the group administrator to notify the beneficiaries living in Idaho, who have no other health
coverage, that upon completion of the full term of COBRA continuation they may be eligible for
continuous coverage under a Blue Cross of Idaho individual program. Blue Cross of Idaho must
receive a properly completed application within 30 days from the termination date of COBRA health
coverage to ensure continuous coverage (see “Transfer of Enrollment” under the Enrollment
Information section).
Blue Cross of Idaho administered group billings list all COBRA beneficiaries separately from active
employees.
However, under Blue Cross of Idaho COBRA administration, groups must still notify Blue Cross of
Idaho in a timely manner of COBRA qualifying events to ensure prompt notification of the newly
eligible member.
Blue Cross of Idaho’s full service COBRA administration service includes:






Informing new group subscribers and members of their COBRA rights
Sending notice and election information to members at the time of a qualifying event
Sending application to members who elect to accept COBRA coverage
Billing COBRA enrollees at their home address and tracking payments
Informing enrollees of changes in rates and/or benefits after the group’s annual renewal is
finalized
Monitoring claims for possible other group coverage and termination of the COBRA
extension upon disqualification
Blue Cross of Idaho Group Administrator’s Manual
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


Sending notice of termination of coverage before the end of the maximum COBRA
extension period when eligibility for continuing coverage ends
Sending notice of termination during the 180 days prior to the end of the COBRA extension
Administration of COBRA ARRA benefits
COBRA Administration Pricing Structure
In 2013, Blue Cross of Idaho changed the pricing structure for COBRA administration.
Blue Cross of Idaho’s new monthly COBRA administration rates vary depending on the number of
insured employees under an employer’s specific group plan. Refer to the chart below for specific
information.
Number of Insured Employees
Less than 40 contracts
40 to 99 contracts
100 to 499 contracts
500 to 999 contracts
1000 or more contracts
Monthly Group Fee
$60/mo. flat rate per group
$1.50 per contract
$1.25 per contract
$1.00 per contract
$.85 per contract
Please note we will break out the COBRA administration billing for small-groups (less than 40
contracts) on monthly statements. However, for larger groups, we will incorporate the cost into the
total due and not break out the charge as a separate line item.
When COBRA Continuation Ends
For group administered COBRA, when a COBRA beneficiary loses eligibility because, for example,
payment isn’t received or the continuation period expired, please note the enrollee ID number,
enrollee name, effective date and comments on the Group Bill Worksheet, the reason for terminating
COBRA continuation, and deduct the amount under the “Amt deduct” column.
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Billing Adjustments
For your reference an example of a billing statement, including sample detail, is included in the sample
billing worksheet at the end of the Forms section.
Due Date
Payment is due to Blue Cross of Idaho on or before the first day of the month or benefit period.
Members will not receive benefits if payment isn’t made, and Blue Cross of Idaho will terminate
group coverage as of the last day of the month we do not receive payment. Promptly paying the
amount due avoids delays in claims processing and/or payment.
Billing Changes
Include all changes to your group’s enrollment with your Group Bill Worksheet.
1.
Enter rates that need to be added to your bill next to “Amt Added” for:
 new enrollees
 new eligible dependents, if addition(s) changes rates
When adding a newborn to a single, two-party or two-party no spouse contract, please
submit a full month’s premium for the child if his or her date of birth falls on or between
the 1st and 15th day of the month. No premium is required for the first partial month if the
child’s date of birth falls on or between the 16th and the last day of the month. For some
groups, a member’s rates may change depending on how many dependents they add.
2.
Enter rates that need subtracted from your bill (for a terminating or deceased
enrollee) next to “Amt deduct.” These rates include:
 divorce
 death
 a dependent child’s status ends because “child turns 26,” or “child
independent”
 termination of employment
 death of employee
 reduction in hours worked
3.
Adjust the amount for the total due under “Revised amount owed to Blue Cross
of Idaho for this month” at the bottom of the Group Bill Worksheet.
4.
Use the “Explanation” column on the roster page of your bill to explain the
change (birth, death, divorce, or termination) and date of the event.
Billing Reconciliation
After you make all necessary changes for the month, recheck the billing for accuracy:
“Amt Added” – The total of all your additions for the month.
“Amt Deduct” – The total of all your deductions for the month.
“Revised amount owed to Blue Cross of Idaho for this month”: – The revised total.
When you send your payment, please include:
1. The yellow group bill worksheet
2. Any applications for new hires or additions and terminations; and
3. Your check for the amount due
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How to File Health Claims
To receive benefits for covered services, Blue Cross of Idaho must receive claims in one of two ways.
Claim Filing by Provider
The healthcare provider (physician, specialist, dentist, hospital or other professional facility) files a claim
and works closely with Blue Cross of Idaho to help members obtain their benefits.
1.
For services supplied by an Idaho provider, the member should present his or her Blue Cross of
Idaho identification card and ask the provider to submit the claim to Blue Cross of Idaho.
2.
For services supplied by a provider outside of Idaho, the member should present his or her Blue
Cross of Idaho identification card and ask the provider to submit the medical claims to the local
Blue Cross and Blue Shield Plan. This procedure ensures the member receives any discount
arrangement the provider has with the local Blue Cross and Blue Shield Plan. Submit all dental
claims directly to Blue Cross of Idaho.
Claim Filing by Member
Members submitting their own claims should follow these steps:
1.
Ask the covered provider for an itemized billing, listing each service provided and its procedure
code, the date the service he or she provided the service, the diagnosis code and the charge for
each service. Blue Cross of Idaho cannot accept billings that only say “Balance Due,” “Payment
Received,” or similar billing notations.
2.
Obtain a member claim form (see example in the Forms section of the resource handbook) from
the covered provider or from any Blue Cross of Idaho office. Follow the instructions at the top of
the member claim form. Complete one form for each patient. Group administrators may order a
supply of member claim forms to keep on hand for their employees.
3.
Send the member claim form and itemized billing to:
Claims Department
Blue Cross of Idaho
OR
PO Box 7408
Boise, ID 83707-1408
Claims Department
Blue Cross of Idaho
3000 E. Pine Avenue
Meridian, ID 83642
4.
Submit all claims directly to Blue Cross of Idaho. Blue Cross of Idaho will process Idaho provider
claim(s) and forward the claims for medical services furnished by a provider outside Idaho to the
Blue Cross and Blue Shield Plan in that state.
5.
Members must file claims within 12 months of the date of service to be eligible for benefits. For
questions, your employees can contact Blue Cross of Idaho customer service at the phone number
on the back of their ID card.
Notification of Payment
As soon as Blue Cross of Idaho processes the claim, we will send the member an explanation of benefits
(EOB). The EOB (see example) lists each patient, the servicing provider, date of service, type of service,
charge and an explanation of how we processed the claim. The EOB will indicate if we sent payment to the
Blue Cross of Idaho Group Administrator’s Manual
16
provider or the member. EOBs do not contain prescription drug claim information when the Blue Cross of
Idaho pharmacy management vendor processes the prescription drug claim.
Help Avoid Delays
Filing a claim and receiving payment should be a simple process for your employees. Our ongoing
performance studies show that we process about 90 percent of our claims within two weeks of the day we
receive them. However, delays occasionally occur. Listed below are some common reasons for delays and
ways you and your employees can avoid them.
1.
Blue Cross of Idaho may delay payment because the member forgets to ask the provider to submit
a claim. Members should present their Blue Cross of Idaho identification card each time they visit a
healthcare provider, and ask that the provider file a claim. This ensures the provider has the correct
identification number.
2.
An incomplete or inaccurate member claim form takes longer to process. Members submitting their
own claims must give Blue Cross of Idaho all the information requested on the member claim
form. Check that you provide all the requested information, especially the enrollee number. Using
the wrong number slows claims processing unnecessarily.
3.
In some cases, members with other insurance, or those involved in an accident, affect the amount
allowed for payment. In these situations, we may need additional information. We will write and
ask the member for additional information to enable the complete processing of the claim.
4.
Occasionally, we may have questions or need to see medical records before processing a claim. We
will write and ask the member or the provider for the information
5.
Finally, it is important that we have a current address for all members. This helps us promptly
notify your employees of their benefits. Members should use an enrollment address change form to
notify us of address changes.
Blue Cross of Idaho Group Administrator’s Manual
17
External Review Policy
If an Insured or their authorized representative requests an independent external review of a
claim, the decision made by the independent reviewer will be binding and final. The Insured or
their authorized representative will the right to further review of the claim by a court, arbitrator,
mediator or other dispute resolution entity only if your plan is subject to the Employee Retirement
Income Security Act of 1974 (ERISA), as more fully explained below under “Binding Nature of the
External Review Decision."
If Blue Cross of Idaho issues a final Adverse Benefit Determination of an Insured’s request to provide or
pay for a health care service or supply, an Insured may have the right to have Blue Cross of Idaho’s
decision reviewed by health care professionals who have no association with Blue Cross of Idaho. An
Insured has this right only if Blue Cross of Idaho’s denial decision involved:
 The Medical Necessity appropriateness, health care setting, level of care, or effectiveness of an
Insured’s health care service or supply, OR
 Blue Cross of Idaho’s determination that an Insured’s health care service or supply was
Investigational.
An Insured must first exhaust Blue Cross of Idaho’s internal grievance and appeal process. Exhaustion of
that process includes completing all levels of appeal. Exhaustion of the appeals process is not required if
Blue Cross of Idaho failed to respond to a standard appeal within thirty-five (35) days in writing or to an
urgent appeal within three business days of the date the Insured filed the appeal, unless the Insured
requested or agreed to a delay. Blue Cross of Idaho may also agree to waive the exhaustion requirement for
an external review request. The Insured may file for an internal urgent appeal with us and for an expedited
external review with the Idaho Department of Insurance at the same time if any delay would seriously
jeopardize your life, health or ability to regain maximum function.
An Insured may submit a written request for an external review to:
Idaho Department of Insurance
ATTN: External Review
700 W State St, 3rd Floor
Boise ID 83720-0043
For more information and for an external review request form:
 See the department’s web site, doi.idaho.gov, or
 Call the department’s telephone number, 208-334-4250, or toll-free in Idaho, 800-721-3272.
An Insured may act as their own representative in a request or an Insured may name another person,
including an Insured’s treating health care provider, to act as an authorized representative for a request. If
an Insured wants someone else to represent them, an Insured must include a signed “Appointment of an
Authorized Representative” form with the request. An Insured’s written external review request to the
Department of Insurance must include a completed form authorizing the release of any medical records the
independent review organization may require to reach a decision on the external review, including any
judicial review of the external review decision pursuant to ERISA, if applicable. The department will not
act on an external review request without an Insured’s completed authorization form. If the request qualifies
for external review, Blue Cross of Idaho’s final adverse benefit determination will be reviewed by an
independent review organization selected by the Department of Insurance. Blue Cross of Idaho will pay the
costs of the review.
Blue Cross of Idaho Group Administrator’s Manual
18
Standard External Review Request
An Insured must file a written external review request with the Department of Insurance within four
(4) months after the date Blue Cross of Idaho issues a final notice of denial.
1. Within seven (7) days after the Department of Insurance receives the request, the
Department of Insurance will send a copy to Blue Cross of Idaho.
2. Within fourteen (14) days after Blue Cross of Idaho receives the request from the
Department of Insurance, we will review the request for eligibility. Within five (5) business
days after Blue Cross of Idaho completes that review, we will notify the Insured and the
Department of Insurance in writing if the request is eligible or what additional information is
needed. If Blue Cross of Idaho denies the eligibility for review, the Insured may appeal that
determination to the Department.
3. If the request is eligible for review, the Department of Insurance will assign an independent
review organization to your review within seven (7) days of receipt of Blue Cross of Idaho’s
notice. The Department of Insurance will also notify the Insured in writing.
4. Within seven (7) days of the date you receive the Department of Insurance’s notice of
assignment to an independent review organization, The Insured may submit any additional
information in writing to the independent review organization that they want the
organization to consider in its review.
5. The independent review organization must provide written notice of its decision to the
Insured, Blue Cross of Idaho and to the Department of Insurance within forty-two (42) days
after receipt of an external review request.
Expedited External Review Request
An Insured may file a written “urgent care request” with the Department of Insurance for an
expedited external review of a pre-service or concurrent service denial. The Insured may file for an
internal urgent appeal with us and for an expedited external review with the department at the same
time.
“Urgent care request” means a claim relating to an admission, availability of care, continued stay or
health care service for which the covered person received emergency services but has not been
discharged from a facility, or any Pre-Service Claim or concurrent care claim for medical care or
treatment for which application of the time periods for making a regular external review
determination:
1. Could seriously jeopardize the life or health of the Insured or the ability of the Insured to
regain maximum function;
2. In the opinion of the Covered Provider with knowledge of the covered person’s medical
condition, would subject the Insured to severe pain that cannot be adequately managed
without the disputed care or treatment; or
3. The treatment would be significantly less effective if not promptly initiated.
The Department of Insurance will send your request to us. Blue Cross of Idaho will determine, no
later than the second (2nd) full business day, if the request is eligible for review. Blue Cross of Idaho
will notify the Insured and the Department of Insurance no later than one (1) business day after
Blue Cross of Idaho’s decision if the request is eligible. If Blue Cross of Idaho denies the eligibility
for review, the Insured may appeal that determination to the Department of Insurance. If the request
is eligible for review, the Department of Insurance will assign an independent review organization
to the review upon receipt of Blue Cross of Idaho’s notice. The Department of Insurance will also
notify the Insured. The independent review organization must provide notice of its decision to the
Blue Cross of Idaho Group Administrator’s Manual
19
Insured, Blue Cross of Idaho and to the Department of Insurance within seventy-two (72) hours
after the date of receipt of the external review request. The independent review organization must
provide written confirmation of its decision within forty-eight (48) hours of notice of its decision. If
the decision reverses Blue Cross of Idaho’s denial, Blue Cross of Idaho will notify the Insured and
the Department of Insurance of the our intent to pay the covered benefit as soon as reasonably
practicable, but not later than one (1) business day after receiving notice of the decision.
Binding Nature of the External Review Decision
If the Group is subject to the federal Employee Retirement Income Security Act (ERISA) laws
(generally, any plan offered through an employer to its employees), the external review decision by
the independent review organization will be final and binding on Blue Cross of Idaho. The Insured
may have additional review rights provided under federal ERISA laws.
If the Group is not subject to ERISA requirements, the external review decision by the independent
review organization will be final and binding on both Blue Cross of Idaho and the Insured. This
means that if the Insured elects to request external review, the Insured will be bound by the
decision of the independent review organization. The Insured will not have any further
opportunity for review of Blue Cross of Idaho’s denial after the independent review
organization issues its final decision. If the Insured chooses not to use the external review process,
other options for resolving a disputed claim may include mediation, arbitration or filing an action in
court.
Under Idaho law, the independent review organization is immune from any claim relating to its
opinion rendered or acts or omissions performed within the scope of its duties unless performed in
bad faith or involving gross negligence.
Blue Cross of Idaho Group Administrator’s Manual
20
How to File Prescription Drug Claims
This section applies only if your group coverage includes prescription benefits through Blue Cross of Idaho.
For complete details of your group’s prescription coverage, please refer to your Master Group Policy.
Benefits through Blue Cross of Idaho Network Pharmacies
Blue Cross of Idaho contracts with a third-party vendor, called a pharmacy benefits manager
(PBM), that is responsible for maintaining a network of participating pharmacies (the Blue Cross
of Idaho pharmacy network) and for processing prescription drug claims. A directory of
participating network pharmacy providers is available on the pharmacy portion of Blue Cross of
Idaho’s website, bcidaho.com.
The Blue Cross of Idaho enrollee identification card contains prescription processing information
for the Blue Cross of Idaho pharmacy network. After network pharmacists enters this information
into their system, a computerized system automatically provides them with a member’s benefit
information at the point-of-sale, including:
1. A member’s eligibility status;
2. If the prescription drug is covered; and
3. The amount of deductible, coinsurance and/or copayment to collect from the member.
This immediate access to current information prevents the use of expired insurance cards or
payment on benefits for ineligible prescriptions.
Prescription drug benefits include reviews of prescription drug use for the member’s health and
safety. If there are patterns of over-use or misuse of drugs, Blue Cross of Idaho may notify the
member’s personal physician and pharmacist. Blue Cross of Idaho reserves the right to limit
prescription drug benefits to prevent over-use or misuse of prescription drugs.
Certain prescription drugs may require prior authorization. If the member’s physician or other
provider prescribes a drug that requires prior authorization, either the provider or the pharmacist
should inform the member that prior authorization is required. To obtain prior authorization the
member’s physician must contact Blue Cross of Idaho.
How to Use the Blue Cross of Idaho Pharmacy Network Prescription Drug Benefit
Pharmacies within Blue Cross of Idaho’s pharmacy network provide the prescription drug
services for your group’s prescription drug benefit, (i.e. processing claims, dispensing
medications, and counseling members regarding their drugs).
To receive prescriptions from a participating Blue Cross of Idaho network pharmacy, members
should follow these steps:
1. Inform the pharmacist that he or she is a Blue Cross of Idaho member. Present the enrollee
identification card along with the new or refill prescription request.
2. After the pharmacist enters the enrollee identification number in the computer, the system
responds with the correct out of pocket amount the member owes the pharmacist.
3. Sign a form verifying receipt of the prescription.
Blue Cross of Idaho Group Administrator’s Manual
21
If the member pays the pharmacist in full at the time of purchase, the member must file a claim to
collect benefits.
How to Collect Benefits Using a Non-Network Pharmacy
If an enrollee obtains prescription drugs from pharmacy that is not in the Blue Cross of Idaho
Pharmacy Network (non-participating pharmacy), the member must pay the pharmacist the full cost
of the prescription drugs at the time of purchase and file a claim (see Prescription Drug Claim Form
in the Forms section of the Resource Handbook).
To file a claim, a member should:
1. Get a Prescription Drug Claim Form from the group administrator, any Blue Cross of Idaho
district office, or our website, bcidaho.com. The group administrator may order an
additional supply of Prescription Drug Claim Forms from Blue Cross of Idaho;
2. Complete the form;
3. Attach the original NDC paid pharmacy receipt, including the required drug information, to
the claim form; and
4. Send the claim and recipient details to the address on the back of the form.
The pharmacy network formula of payment determines reimbursement based on the pharmacy
network formula, less the deductible and/or copayment, rather than on the retail price.
Mail-order Prescriptions
PLEASE NOTE: Not all Blue Cross of Idaho policies include mail order pharmacy benefits.
Please check your policy, if you are unsure, or contact your broker, account representative, or
customer service at 800-627-1188.
We want you to know that you can save time and money on prescriptions by ordering your
medications through CVS Caremark, Blue Cross of Idaho’s mail-order prescription service.
CVS Caremark can transfer existing prescriptions from your pharmacy if you have refills remaining
or you can get a new prescription from your healthcare provider for faster service. Visit the Blue
Cross of Idaho website, bcidaho.com, and log on as a member. Select Pharmacy Benefits, then OK
to enter the CVS Caremark site. From the top menu, select Forms for Print under the Order
Prescriptions option, then Mail Service Order Form. After establishing prescriptions under a CVS
Caremark account, simply order refills before you expect to run out with sufficient time (typically
two weeks or more) to receive, process, fill and deliver your order. Your new prescriptions will show
up on your doorstep a few days later.
NOTE: CVS Caremark cannot transfer refills of controlled drugs or compounded prescriptions like
Darvocet, Tylenol #3 and Vicodin. If you need refills of controlled or compounded drugs, CVS
Caremark requires a new prescription.
The mail-order prescription service CVS Caremark offers Blue Cross of Idaho members is easy, fast,
and economical. Please take advantage of this cost-saving program to help cut your prescription
Blue Cross of Idaho Group Administrator’s Manual
22
medication costs. If an employee has a new prescription, is ready to order a refill, or has questions,
call CVS Caremark at 855-839-5205 (available 24/7).
Mail-order prescriptions:

Save Time—Medications arrive via UPS or First Class U.S. Mail. Remember, the larger the
order, the less often a member has to place an order.

Save Paperwork— No claim forms to fill out, no receipts to save, and no waiting for
reimbursement. You can order by phone, mail, or online. Prescription order forms are
available from our website, bcidaho.com. Simply log on as a member, select Pharmacy
Benefits and register with CVS Caremark. Choose Forms for Print under the Order
Prescriptions subhead, then Mail Service Order Form.

Save Money—CVS Caremark makes generic substitutions for brand name medications
whenever possible. Generic prescriptions are equally effective as their brand-name
counterparts, but cost significantly less. Also, you can order a 90-day supply, which in the
long run, means your copayment is less.
Transferring Prescriptions
If a member takes has a mail-order prescription-drug benefit, the mail order vendor can transfer
existing prescriptions from your present pharmacy if there are any refills remaining or members can
get a new prescription from their provider for faster service.
Ordering Refills
Order refills three weeks before you expect to run out. This allows sufficient time to receive, process,
fill and deliver the order. PLEASE NOTE: Not all Blue Cross of Idaho policies include mail
order pharmacy benefits. Please check your policy, if you are unsure, or contact your broker,
account representative, or customer service at 800-627-1188.
Generic Drugs
Most prescription drugs have a brand name (or trademark) version and a generic (or chemical name)
version. By law, both brand name and generic drugs must meet the same standards for safety, purity,
quality, and strength. Generic drugs can save money for the member and the group health plan.
Inform your employees to ask their physician to prescribe generics whenever possible.
Ordering Prescription Refills On-line
Members may log-on to caremark.com for information about their retail prescription history or to
manage mail-order prescriptions.
Blue Cross of Idaho Group Administrator’s Manual
23
Dental Benefits
This section applies only if your group coverage includes dental benefits. For complete details of your
group’s dental benefits, please refer to your Master Group Policy. If you would like to add dental to your
plan, contact your broker or one of our district offices at 800-365-2345.
Claim Filing by Provider
The healthcare provider (physician, specialist, dentist, hospital or other professional facility) files
a claim and works closely with Blue Cross of Idaho to help members obtain their benefits.
1. For services supplied by an Idaho provider, the member should present his or her Blue
Cross of Idaho identification card and ask the provider to submit the claim to Blue Cross
of Idaho.
2. For services supplied by a provider outside of Idaho, the member should present his or her Blue
Cross of Idaho identification card and ask the provider to submit the medical claims to the local
Blue Cross and Blue Shield Plan. This procedure ensures the member receives any discount
arrangement the provider has with the local Blue Cross and Blue Shield Plan. Submit all dental
claims directly to Blue Cross of Idaho.
Claim Filing by Member
Members submitting their own claims should follow these steps:
1.
Ask the covered provider for an itemized billing, listing each service provided and its procedure
code, the date the service he or she provided the service, the diagnosis code and the charge for
each service. Blue Cross of Idaho cannot accept billings that only say “Balance Due,” “Payment
Received,” or similar billing notations.
2.
Obtain a member claim form (see example in the Forms section of the resource handbook) from
the covered provider or from any Blue Cross of Idaho office. Follow the instructions at the top of
the member claim form. Complete one form for each patient. Group administrators may order a
supply of member claim forms to keep on hand for their employees.
3.
Send the member claim form and itemized billing to:
Claims Department
Blue Cross of Idaho
OR
PO Box 7408
Boise, ID 83707-1408
Claims Department
Blue Cross of Idaho
3000 E. Pine Avenue
Meridian, ID 83642
4. Submit all claims directly to Blue Cross of Idaho. Blue Cross of Idaho will process Idaho
provider claim(s) and forward the claims for medical services furnished by a provider outside
Idaho to the Blue Cross and Blue Shield Plan in that state.
Members must file claims within 12 months of the date of service to be eligible for benefits. For
questions, your employees can contact Blue Cross of Idaho customer service at the phone number on the
back of their ID card.
Blue Cross of Idaho Group Administrator’s Manual
24
Help Avoid Delays
Filing a claim and receiving payment should be a simple process for your employees. Our ongoing
performance studies show that we process about 90 percent of our claims within two weeks of the day we
receive them. However, delays occasionally occur. Listed below are some common reasons for delays and
ways you and your employees can avoid them.
1. Blue Cross of Idaho may delay payment because the member forgets to ask the provider to submit
a claim. Members should present their Blue Cross of Idaho identification card each time they visit
a healthcare provider, and ask that the provider file a claim. This ensures the provider has the
correct identification number.
2.
An incomplete or inaccurate member claim form takes longer to process. Members submitting
their own claims must give Blue Cross of Idaho all the information requested on the member
claim form. Check that you provide all the requested information, especially the enrollee number.
Using the wrong number slows claims processing unnecessarily.
3.
In some cases, members with other insurance, or those involved in an accident, affect the amount
allowed for payment. In these situations, we may need additional information. We will write and
ask the member for additional information to enable the complete processing of the claim.
4.
Occasionally, we may have questions or need to see medical records before processing a claim.
We will write and ask the member or the provider for the information
Finally, it is important that we have a current address for all members. This helps us promptly notify your
employees of their benefits. Members should use an enrollment address change form to notify us of
address changes.
Dental Program Exclusions & Limitations

Your Master Group Policy lists all of the dental services that have benefits paid by the
program. No benefits are available for services not included in the list.

If alternate procedures produce professionally satisfactory results, Blue Cross of Idaho
bases payment of benefits on the procedure with the lesser charge.

If a member changes dentists during a treatment program, or if more than one dentist
performs the same procedure, Blue Cross of Idaho pays benefits as if only one dentist
performed the services. To submit a claim, write or call us at:
Blue Cross of Idaho
Customer Service
PO Box 7408
Boise, ID 83707-1408
800-627-1188
Blue Cross of Idaho Group Administrator’s Manual
or
Blue Cross of Idaho
Customer Service
3000 E. Pine Avenue
Meridian, ID 83642
208-363-8755
25
Vision Service Plan
This section applies only if your group coverage includes vision benefits through VSP. For complete
details of your group’s vision coverage, please refer to your Master Group Policy.
Benefits Available Through VSP
Blue Cross of Idaho provides vision benefits through Vision Service Plan (VSP). The Vision Care
Plan brochure provides benefit information specific to your group policy, including copayments and
reimbursement schedules.
Before making an appointment for a member or a covered dependent, members should find a VSP
participating doctor by using the VSP directory, calling VSP at 800-877-7195, or using VSP’s on-line
doctor directory service at vsp.com.
Once a member finds a doctor, he or she should call the office to schedule an appointment and
provide the information below. The VSP doctor will contact VSP and verify the member’s benefits
before delivering any services.
1. Indicate he or she is a VSP member
2. Blue Cross of Idaho identification number
3. Date of birth
Your vision policy covers eye examinations once during a benefit period, as specified in your Master
Group Policy. The policy may also cover contact lenses or glasses (with frame and lenses) in
accordance with the Master Group Policy. Please check your policy for benefit coverage.
VSP provides no benefits for medical or surgical treatment of the eyes, however, discounts for laser
surgery such as LASIK are available through VSP contracted laser centers.
When Using a VSP Participating Doctor
When enrolled employees choose a VSP participating doctor, they simply pay the appropriate
copayments to the doctor. Your group policy lists your employees’ copayments. In addition to the
copayments, employees are responsible for selected optional items not covered by the plan.
When Using a VSP Non-participating Doctor
An employee may choose to see a provider who is not participating with VSP, in which case your
plan will reimburse the services at specified levels detailed in your group policy. VSP reimburses
your employees for services received from any licensed optometrist, ophthalmologist, or optician.
Employees must pay the non-participating doctor in full and submit an itemized bill to VSP.
The reimbursement schedule does not guarantee full payment nor can VSP guarantee patient
satisfaction when members receive services from a non-participating doctor.
Blue Cross of Idaho Group Administrator’s Manual
26
Prior Authorization
What is Prior Authorization?
Prior authorization is a request by the member’s contracting provider to Blue Cross of Idaho, or
delegated entity, for authorization of a member’s proposed treatment. Blue Cross of Idaho may
review medical records, test results and other sources of information to ensure the service is covered
and make a determination as to medical necessity of the service or alternative treatments, or the
prescription of pharmaceutical drugs.
The member is responsible for obtaining prior authorization when seeking treatment from a
non-contracting provider.
If contracting providers perform non-medically necessary services or prescribe some pharmaceutical
drugs without the prior authorization by Blue Cross of Idaho, and Blue Cross of Idaho denies
benefits, the costs of said services or products are not the financial responsibility of the member.
However, the member is financially responsible for non-medically necessary services provided
by a non-contracting provider.
Please check the Blue Cross of Idaho website at bcidaho.com, or call customer service at 800-7431871 to determine if a proposed service requires prior authorization. To request prior authorization,
the contracting provider must notify Blue Cross of Idaho of the member’s intent to receive services
that require prior authorization. The member is responsible for notifying Blue Cross of Idaho if a
non-contracting provider performs the proposed treatment.
The notification may be completed by telephone call or in writing and must include the information
necessary to establish that the proposed services or drugs are covered under the member’s plan and
medically necessary. Blue Cross of Idaho will respond to a request for prior authorization received
from either the provider or the member within two business days of the receipt of the medical
information necessary to make a determination.
What is Inpatient Notification?
As specified in your policy, your plan requires non-emergency preadmission notification or
emergency admission notification for all inpatient services. Some inpatient services also require the
provider to obtain prior authorization.
Non-emergency preadmission notification
Non-emergency preadmission notification is when the member notifies Blue Cross of Idaho and it is
required for all inpatient admissions, except covered services subject to emergency or maternity
admission notification. A member should notify Blue Cross of Idaho of all proposed inpatient
admissions before admittance. Non-emergency preadmission notification informs Blue Cross of
Idaho, or a delegated entity, of the member’s proposed inpatient admission to a licensed general
hospital, alcohol or substance abuse treatment facility, psychiatric hospital, or any other facility
provider. This notification alerts Blue Cross of Idaho of the proposed stay. When a member provides
timely notification of an inpatient admission to Blue Cross of Idaho, payment of benefits is subject to
the specific benefit levels, limitations, exclusions and other provisions of this plan.
For non-emergency preadmission notification, call Blue Cross of Idaho at the telephone number listed
on the back of the member identification card.
Blue Cross of Idaho Group Administrator’s Manual
27
Emergency or Maternity Admission Notification
When an emergency admission occurs for emergency medical conditions, an unscheduled cesarean
section delivery, or maternity delivery services, and notification cannot be completed prior to
admission because of the member’s condition, the member, or his or her representative, should notify
Blue Cross of Idaho within 24 hours of the admission. If the admission is on a weekend or legal
holiday, notify Blue Cross of Idaho by the end of the next working day after the admission. If the
emergency medical condition, unscheduled cesarean section delivery (if covered under this plan) or
maternity delivery services render it medically impossible for the member to provide such notice, the
member should immediately notify Blue Cross of Idaho of the admission when it is no longer
medically impossible to do so. This notification alerts Blue Cross of Idaho to the emergency stay.
Continued Stay Review
Blue Cross of Idaho will contact the hospital utilization review department and/or the attending
physician regarding the member’s proposed discharge. If the hospital doesn’t discharge the member
as originally proposed, Blue Cross of Idaho will evaluate the medical necessity of the continued stay
and approve or disapprove benefits for the proposed course of inpatient treatment. Payment of
benefits is subject to the specific benefit levels, limitations, exclusions, and other provisions of this
plan.
Discharge Planning
Blue Cross of Idaho will provide information about benefits for various post-discharge courses of
treatment.
Blue Cross of Idaho Group Administrator’s Manual
28
Sample Forms
The following forms are samples for you to reference in case you need to share or review a document
with an employee. Some forms are available on the Blue Cross of Idaho Web site, bcidaho.com,
however, if you need additional copies of any documents, please contact your local district office at
208-365-2345.
Blue Cross of Idaho Group Administrator’s Manual
29
SAMPLE
Member Name or Address Change
If you move from your present address, or change your name,
use this form to notify us promptly.
Enrollee Name:
Group/Program Number:
Identification Number: Daytime Phone:
Change of Name:
Previous Enrollee Name
New Enrollee Name
(Please Print)
(Please Print)
Change of Address:
Previous Mailing Address:
Enrollee Name
Street or P.O. Box:
City:
New Mailing Address:
Street or P.O. Box:
City:
Home Telephone:
Signature:
Please Return to:
(Please Print):
State:
Zip:
State:
Zip:
Date:
Blue Cross of Idaho
Attn: EBS
P.O. Box 7408
Boise, ID 83707 1408
3000 E. Pine Avenue, Meridian, ID 83642-5995 • P.O. Box 7408, Boise, ID 83707-1408 • (208) 345-4550 • www.bcidaho.com
An Independent Licensee of the Blue Cross and Blue Shield Association
Form No. 4-125 (12-05)
SAMPLE
Employee’s Waiver of Health Care Coverage
If you decline to enroll either yourself or your eligible family members in the health care coverage offered by your
employer, we ask that you complete this form. Qualified late enrollees who decline coverage may not reapply for
coverage until their employer’s policy renewal date.
I certify that I have been informed of the availability of coverage under my employer’s health benefit plan, but I
choose not to enroll (please check all that apply and list each eligible family member’s name):
■ myself
■ my eligible child(ren):
■ my spouse:
I have chosen to decline health care coverage at this time because:
■ I and/or my dependents have other group or individual coverage with (name of insurance company)
through (insured’s name and relationship)
■ Is your current employer contributing toward your other coverage? ■ Yes ■ No
■ Other reason(s) to waive coverage (please specify):
I understand that if, at this time, I decline coverage offered by my employer for myself or my eligible family
members, and then choose to apply for coverage later, the insurer may exclude coverage, or may limit coverage
to exclude a preexisting condition for up to but not exceeding 12 months, except in the following instances:
1. The individual meets each of the following:
a. The individual was covered under qualifying previous coverage at the time of the initial enrollment;
b. The individual lost coverage under qualifying previous coverage as a result of termination of
employment or _eligibility, the involuntary termination of the qualifying previous coverage;
c. The employer stops contributing towards your or your dependents' other coverage; and
d. The individual requests enrollment within 30 days after termination of the qualifying previous coverage.
2. The individual is employed by an employer that offers multiple health benefit plans and the individual elects
a different plan during an open enrollment period;
3. A court has ordered that coverage be provided for a spouse or minor or dependent child under a covered
employee’s health benefit plan and request for enrollment is made within 30 days after issuance of the court
order; or
4. If an individual seeks to enroll a dependent during the first sixty (60) days of eligibility, the coverage of the
dependent shall become effective:
a. in the case of marriage, not later than the first day of the first month beginning after the date the
completed request for enrollment is received;
b. in the case of a dependent’s birth, as of the date of such birth; or
c. in the case of a dependent’s adoption or placement for adoption, the date of such adoption or
placement for adoption.
The insurer shall waive any time period applicable to a preexisting condition exclusion or limitation period with
respect to particular services for the period of time an individual was previously covered by qualifying previous
coverage that provided benefits with respect to such services, provided the qualifying previous coverage was
continuous to a date not more than sixty-three (63) days prior to the effective date of the new coverage.
Please print name
Name of group
Social Security number
Group number
Employee’s signature
Date
Group administrator’s signature An Independent Licensee of the Blue Cross and Blue Shield Association
Form No. 3-467 (01-09)
Date
SAMPLE
SAMPLE
Helpful Definitions
Amount We Paid - This is the amount we have paid to you or
your provider.
Deductible Status has been met as of the date of this statement. Claims that are
Charges - This is the amount your provider billed for the services
you received.
status.
Copayment/Coinsurance - The copayment is the amount separate
from the coinsurance that you are responsible to pay for certain
services. The coinsurance is the amount you pay for services after
your deductible is met. Providers may require payment when you
receive service.
Deductible - This is the amount you pay to providers each year
before we start paying benefits under your plan.
bill you for these charges.
Network Savings - This is the amount you saved by using a
contracting provider. Providers may be contracting with Blue
Cross of Idaho or with other Blue Cross Blue Shield plans
depending on the state in which services are provided.
not have to pay providers for this amount.
Noncovered - This is the portion of the charges not covered
by this benefit plan. Your provider may bill you for these
charges.
Other Insurance - This is the amount your other insurance
paid for these services.
Appeal 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 believe our
claim decision was incorrect must be sent to the Appeals and Grievance Coordinator within 180 days after receipt of the Explanation of
Benefits. Any written comments, documents, or other relevant information may be included. We will mail a written decision within 30 days
after we receive the appeal. You or your authorized 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 a second written appeal to our Appeals and Grievance Coordinator stating
the reasons for requesting further review. Your request must be sent within 60 days of our mailing of the initial appeal decision. A final
decision on the appeal will be made within 30 days after our receipt of the second appeal. Please refer to your employee benefit handbook
under the appeals section to check for any variation from these procedures.
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 complete appeal 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 of determinations based on medical necessity or experimental and/or investigational treatment exclusions may also be
obtained upon request.
Blue Cross of Idaho is a third-party payer, providing administrative service only (i.e. claims payment and network access) to your group.
Your group assumes most, or all, financial obligations for claims. Blue Cross of Idaho may bear financial risk for some claims.
THANK YOU FOR ALLOWING US TO SERVE YOU
SAMPLE
Street Address:
3000 E. Pine, Meridian, ID 83642-5995
Mailing Address:
P.O. Box 7408, Boise, ID 83707-1408
(208) 345-4550
Member Claim Form
This form must be filled out for all claims submitted by a member.
1. If any of the services were related to an accident, you must also complete the ACCIDENTAL INJURY INFORMATION section below.
2. Circle the charges on your provider’s statement that you are submitting, and staple the statement to this form. The provider’s statement must
show, for each service: a procedure code and diagnosis code, the date it was furnished, and the charge for the service. You will need a separate
member claim form for each different provider and for each person.
3. For prescription drug claims, the pharmacy receipt should include the NDC number, name of drug, quantity and dosage.
4. To file charges for more than one patient, even if the charges are all on one bill, please:
• Complete a separate form for each patient AND attach a separate copy of the provider’s bill to each patient’s form, if needed.
• If a claim is submitted for services rendered by an Out of State Provider, we may forward your claim to the appropriate Blue Card Plan to
be processed.
5. Mail all forms to:Blue Cross of Idaho Health Service, Inc.
Box 7408
Boise, Idaho 83707
You should hear from us in about three weeks or less. Please do not re-submit these charges to us in the meantime.
PATIENT AND ENROLLEE INFORMATION
Patient’s Name (First Name, Middle Initial, Last Name)
Do you or any of your dependents have other health coverage?
(This includes other Blue Cross and Blue Shield coverage as well as Medicare.)
Type of Coverage
If Medicare
■ YES
■ Medical
■ Part A
■ no
■ Dental
■ Part B
■ Vision
■ Part D
Patient’s Date of Birth
Enrollee’s Name (First Name, Middle Initial, Last Name)
Patient’s Sex
■ Male
(with Alpha Prefix)
Patient’s Relationship to
Enrollee
■ Self
■ Child
Coverage is for (Check all applicable boxes)
■ Enrollee
■ Spouse
■ Children
Name and Address of Other Carrier
■ Female
■ Spouse
■ Other
Enrollee’s Blue Cross of Idaho Identification Number
Enrollee’s Group No. (or Program Number)
Enrollee’s Address (Street, City, State, Zip Code)
ID Number with Other Carrier
▲
Was this condition the result of an accident?
If NO, enter date of service, sign at the
■ No ■ Yes
bottom, and return the form to us.
Date of Service
Group Number/Name with
Other Carrier
Effective Date with Other
Carrier
▲
accidental injury information (Please complete if claim is related to an injury)
Date of Injury
mm/dd/yy
Describe how and where the injury occurred.
To your knowledge, who was responsible for the accident?
Have you received settlement from
the responsible party?
■ YES
■ no
Do you intend to make a claim against the
responsible party?
■ no
■ Possibly
■ YES
Is an attorney representing you in this matter? If so, please give your attorney’s name and address. (Blue Cross of Idaho may be contacting your
attorney regarding this matter.)
Was the condition the result of an auto accident?
■ YES
■ no
Was this injury or illness sustained while performing work required by the patient’s employment?
■ YES
■ no
(If your claim is work-related and you have received a denial please attach a copy.)
Is the patient covered by Workers’
Compensation?
■ YES
■ no
Is the patient self-employed?
■ YES
■ no
Has the patient filed a claim with the
Industrial Accident Commission?
■ YES
■ no
Is the patient covered by a liability coverage other than Workers’
Compensation for work-incurred injuries?
■ YES
■ no
Signature of Enrollee
Make Payment to
Has the patient notified his or her
employer of this condition?
■ YES
■ no
Has the patient filed a claim with his or her employer’s liability coverage?
■ YES
■ no
■ Enrollee (Attach proof of payment)
■ Provider
Date Submitted
warning: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete,
or misleading information, is guilty of a felony. In cases of proven fraud, Blue Cross of Idaho will terminate agreements for services and benefits, seek restitution
of dollars lost, and pursue criminal prosecution to the full extent of the law.
Thank You For Your Help
Form No. 5-175 (08-06)
Consolidated Omnibus Budget Reconciliation Act (COBRA)
GROUP COVERAGE CONTINUATION APPLICATION
SAMPLE
Applicant Information
SECTION I – General Enrollment Information
(Please complete each section of this application in ink)
Your Name (first, initial, last)
Social Security Number
/
Mailing/Billing Address (street or route)
Your Business Phone
Blue Cross Identification No.
(if currently enrolled)
/
Date of Birth (mm/dd/yy)
/
City, State, Zip Code
Your Home Phone
Age
/
County
Marital Status: ❏ Male
❏ Female
❏ Single ❏ Married ❏ Divorced ❏ Widowed
Employee name:______________________________________________________ Group number:_ ____________________________________________________________
Blue Cross enrollee number:_____________________________________________ Group name:_______________________________________________________________
Social Security Number:________________________________________________ Group address:_____________________________________________________________
Date of qualifying event:________________________________________________
/ /
mm dd yy
Please check appropriate box indicating qualifying event for continuation of group coverage under COBRA:
❏
❏
❏
❏
❏
❏
Divorce or legal separation
Death of employee
Dependent child no longer eligible (i.e., attainment of limiting age, marriage or child provides majority of his or her financial support)
Left employment – reason_ ________________________________________________________________________________________________________________________
Covered family member(s) loses continuation coverage because qualified beneficiary becomes entitled to Medicare
Other (please indicate reason)______________________________________________________________________________________________________________________
Family Member Information
List family members you wish to enroll under your membership, including all eligible unmarried dependent children. The employer’s benefit plan will determine their eligibility. If any
family members wish to enroll separately, please submit separate applications.
Family Member’s Name (first, initial, last)
Social Security Number
Family Member’s Name (first, initial, last)
Social Security Number
Family Member’s Name (first, initial, last)
Social Security Number
Family Member’s Name (first, initial, last)
Social Security Number
/
/
Family Member’s Name (first, initial, last)
/
/
/
/
/
/
/
/
Dental coverage (check one if applicable)
❏
❏
❏
❏
❏
Self only
Self and spouse
Self, spouse and children
Self and one child
Self and two or more children
/
❏ Male
❏ Female
/
Date of Birth (mm/dd/yy)
❏ Male
❏ Female
/
Date of Birth (mm/dd/yy)
/
/
/
/
❏ Male
❏ Female
Date of Birth (mm/dd/yy)
❏ Male
❏ Female
Date of Birth (mm/dd/yy)
Social Security Number
Type of Enrollment
Health coverage (check one)
❏ Self only
❏ Self and spouse
❏ Self, spouse and children
❏ Self and one child
❏ Self and two or more children
/
Date of Birth (mm/dd/yy)
Relationship to Applicant
(spouse, child, stepchild, etc.)
/
Change Request
❏ Male
❏ Female
/
Change current enrollment because of the following event:
❏ Marriage ❏ Divorce ❏ Birth ❏ Involuntary loss of coverage ❏ Death
❏ Court order (copy of court order required)
Other_________________________________________________________________
Date event occurred_ ___________________________
/ /
mm dd yy
Please sign Section II – Statement of Understanding on reverse side of this application.
FOR OFFICE USE ONLY
Group Number
Subgroup
HIPAA
Credit Days
Start
Effective Date
End
Plan ID
M
D
Class
Reason Code
V
3000 E. Pine Ave. • Meridian, Idaho 83642 • (208) 345-4550
Mailing Address: P.O. Box 7408 • Boise, ID 83707-1408
Form No. 4-149 (11-04)
Auditor _ ________
Prior and/or Current Coverage Information
Is any person listed on this application now covered or has he or she been covered by any other health insurance (including Medicare or Medicaid) during any part of the
63 days (excluding any group probation period) prior to the effective date of coverage under this program? ❏ YES
❏ NO
If the other coverage has terminated, please attach a copy of your certificate of creditable coverage; this will ensure proper credit for any preexisting conditions, if applicable.
If the other coverage is still active and will remain active, please list the persons covered under that policy and their effective dates:
_____________________ __________________
_ _____________________ _ _________________
/ /
/ /
mm dd yy
mm dd yy
_____________________ __________________
_ _____________________ _ _________________
/ /
/ /
mm dd yy
Name of other health insurance carrier: ________________________________ Policy number: _ ______________ Is this coverage for:
mm ❏ MEDICAL
dd ❏ DENTAL
yy
❏ VISION
If any person listed on this application is covered by Medicare, please complete the following:
____________________________________________ Name
_______________________________________ Medicare Beneficiary Number
Part A
Date of Medicare Entitlement Part B
_________________________
/ /
mm dd _ ______________________________________________
Reason for Medicare Entitlement (age, disability or ESRD)
________________________
/ /
yy
mm dd yy
Continuation Information
I understand and agree that the continuation of my group health coverage shall immediately terminate if I fail to pay any premium when due or if the employer through which this
continued group health coverage is provided ceases to provide group health coverage to its employees. Also, my group health coverage shall immediately terminate for me or any
covered family member who becomes:
1) covered under any other group health coverage that does not contain any exclusion or limitation with respect to any preexisting condition that I or any other covered family
member have, or
2) entitled to Medicare benefits due to age or disability.
I will immediately notify Blue Cross of Idaho or the employer through which the continued group health coverage is provided if I or any covered family member becomes covered
under any other group health coverage that does not contain any exclusion or limitation with respect to any preexisting condition that I or any other covered family member has, or
if I or any covered family member becomes entitled to Medicare benefits as a result of age or disability.
X
_____________________________________________________________________ Applicant’s Signature (also sign in Section II)
SECTION II – Statement of Understanding
Date__________________________________________________________________
(This section must be signed by all applicants)
By signing this application, I represent that all my answers are complete and accurate, and
that I understand and agree to the following conditions:
• No independent producer, agent, or employee of Blue Cross of Idaho can change any
part of this application or waive the requirement that I answer all questions completely
and accurately, nor can any such person change the terms of the policy, except by
endorsement issued expressly for that purpose over the signature or facsimile signature
of the President of Blue Cross of Idaho.
• Blue Cross of Idaho may deny benefits or terminate or rescind my policy retroactive to
its effective date for any misrepresentation, omission, or concealment of fact by,
concerning, or on behalf of any persons listed on this application that was or would
have been material to Blue Cross of Idaho’s acceptance of a risk, extension of
coverage, provision of benefits, or payment of any claim.
• Blue Cross of Idaho may review this application and, at its discretion, request
supplemental information from me, any family member listed on this application, or any
health care providers before deciding whether to approve or reject the application.
• If this application is not approved for the program applied for, any payment submitted
with this application will be refunded. Upon the refund of the payment, Blue Cross of
Idaho will have no further obligations to me or any family member listed on this
application.
• If this application is approved, coverage for myself and any eligible family members
named on this application will begin on the date assigned by Blue Cross of Idaho.
• I acknowledge and understand my health plan may request or disclose health
information about me or my dependents (persons who are listed for benefits coverage
on the enrollment form) from time to time for the purpose of facilitating health care
treatment, payment or for the purpose of business operations necessary to administer
health care benefits; or as required by law. For more information about such uses and
disclosures, including uses and disclosures required by law, please refer to the Blue
Cross of Idaho Notice of Privacy Practices that is available at www.bcidaho.com.
• If you have had group or individual health coverage or a government health care
program for at least 12 months, you are entitled to receive a Certificate of Creditable
Coverage from your previous employer or insurance company. This document will state
the effective date of prior coverage and the termination date of coverage for you and
any covered dependents. Your previous employer or insurance company will furnish
you this certificate upon request. If you need assistance in obtaining a certificate, your
current employer or Blue Cross of Idaho can assist you.
• I affirm that I have reviewed all the answers given on this application and, if an
independent producer or other person has filled out the answers for me and on
my behalf, I verify the answers accurately reflect all the information given by me.
I understand that this application will become part of any agreement or policy
that Blue Cross of Idaho issues.
X
Applicant’s Signature
Date
SAMPLE
Form No. 4-149 (11-04)
SAMPLE
Important!
4336-BCI-0313
Prescription Reimbursement Claim Form
* Always allow up to 30 days from the time you receive the response to allow for mail time plus claims processing.
* Keep a copy of all documents submitted for your records.
* Do not staple or tape receipts or attachments to this from.
* Reimbursement is not guaranteed and other contractor will review the claims subject to limitations, exclusions and provisions of the plan.
STEP 1
Card Holder/Patient Information
Card Holder Information
This section must be fully completed to ensure proper reimbursement of your claim.
Group No./Group Name
Identification Number (refer to your prescription card)
Name (Last Name)
(First Name)
(MI)
Address
Address 2
City
State
Zip
Country
Patient Information-Use a separate claim form for each patient.
Name (Last Name)
(First Name)
Date of Birth
Relationship to Primary member
Spouse
Member
Male
Child
(MI)
Phone Number
Female
Other_______________
Other Insurance Information
COB (Coordination of Benefits)
Are any of these medicines being taken for an on-the-job injury?
Yes
No
Is the medicine covered under any other group insurance?
Yes
No
If yes, is other coverage:
Primary
Secondary
If other coverage is Primary, include the explanation of benefits (EOB) with this form.
Name of Insurance Company____________________________ ID#________________________
Important! A signature is REQUIRED
NOTICE
Any person who knowingly and with intent to defraud, injure, or deceive any insurance company, submits a claim or application containing
any materially false, deceptive, incomplete or misleading information pertaining to such claim may be committing a fraudulent insurance
act which is a crime and may subject such person to criminal or civil penalties, including fines, denial of benefits, and/or imprisonment.
I certify that I (or my eligible dependent) have received the medicine described herein. I certify that I have read and understood this form,
and that all the information entered on this form is true and correct.
X
Signature of Plan Participant
Date
(Over)
STEP 2
Submission Requirements:
You MUST include all original “pharmacy” receipts in order for your claim to process. “Cash register” receipts will only be
accepted for diabetic supplies. The minimum information that must be included on your pharmacy receipts is listed below:
• Patient Name
• Prescription Number
• Medicine NDC number
• Date of Fill
• Metric Quantity
• Total Charge
• Days Supply for your prescription (you need to ask your pharmacist for this “Day Supply” information)
• Pharmacy Name and Address or Pharmacy NABP Number
If the Prescribing Physician’s NPI (National Provider Identification) number is available, please provide: ____________
If this is from a foreign country, please fill in below:
Country:_______________ Currency:______________ Amount:________________
Additional Comments
STEP 3
Mailing Instructions:
Mail to :
CVS Caremark
P.O. Box 52136
Phoenix, AZ 85072-2136
SAMPLE
IMPORTANT REMINDER
To avoid having to submit a paper claim form:
•
•
•
•
Always have your card available at time of purchase.
Always use pharmacies within your network.
Use medication from your formulary list.
If problems are encountered at the pharmacy, call the number on the back of your card.
CVS Caremark provides pharmacy claims processing services for Blue Cross of Idaho members. CVS Caremark is an independent company that
operates separately from Blue Cross of Idaho.
SAMPLE
SAMPLE
SAMPLE
Member Registration Instructions
www.bcidaho.com
1
Visit bcidaho.com and select the
Register now! link on the left side of the
page. You will need your Member ID card to
register.
1
2
Select Member on the registration page.
2
3
Enter your registration information and select
the Register button at the bottom of the
page.
3
continued
An Independent Licensee of the Blue Cross and Blue Shield Association
Form No. 4-126 (10-11)
4
5
You will get a message telling you that your
registration was successful. If you do not
receive this message,the data you entered
may not match the information in our
enrollment system, or you may already be
registered. Please review the information you
entered and make any necessary corrections.
If you are still unable to register, please call
the customer service number on the back of
your ID card.
4
After your successful registration, you can
return to the Blue Cross of Idaho website
and log in with your new username and
password.
5
6
You will then move to the member home
page where you will have access to:
• benefits, eligibility and claims history
tools
• medical self-help tools
• wellness tools
SAMPLE
Benefits, eligibility and claims history tools
6
Wellness Tools