A closer look at some of your health care costs and payments
A claim is a request to apply benefits for your health care coverage. Claims are submitted to Anthem Blue Cross for health care services, supplies, drugs, and/or equipment that are provided to you. In most cases, In Network Providers will send claims to Anthem Blue Cross for you. But if you received care from an Out of Network Provider that does not send the claim to Anthem Blue Cross on your behalf, it will be your responsibility to do so. You may obtain a copy of the Claim Form by contacting Anthem Blue Cross Customer Service at 855-634-3381 or at the links below.
| Links to Claim Form | Medical | Pharmacy | Dental |
|---|---|---|---|
| The physical address to mail your Claim Form to is |
Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007 |
CarelonRx Claims Department P.O. Box 52065 Phoenix, AZ 85072-2065 |
Anthem Blue Cross P.O. Box 1115 Minneapolis, MN 55440-1115 |
| Maximum Filing Time Limit | 180 Days | 365 Days | 365 Days |
In Network Providers have an agreement with Anthem Blue Cross. Out of Network Providers do not have an agreement with Anthem Blue Cross. Your personal financial costs when using Out of Network Providers may be considerably higher than when you use In Network Providers. Services provided by Out of Network Providers for non-emergency, non-urgent, and/or non-authorized services are not a covered benefit. This means you will be responsible for all charges performed by an Out of Network Provider. For care obtained from an out of network provider that is an emergency, urgent, and/or authorized service, you are responsible for any deductible, coinsurance, or copayment responsibility that we determine you may owe.For Covered Services performed at an In Network Facility at which, or as a result of which, you receive services provided by an Out of Network Provider, you will pay no more than the same cost sharing that you would pay for the same Covered Services received from an In Network Provider.
Anthem Blue Cross wants you to understand the benefits of your health care coverage so you can maximize your health care coverage with us. Anthem Blue Cross offers a variety of ways to assist and educate you to be a more informed consumer. For detailed information regarding the benefits of your plan, please refer to your Combined Evidence of Coverage and Disclosure Form. When logged in to www.anthem.com/ca you can also send messages to us electronically. Anthem Blue Cross is also available to answer any questions you have by contacting our Customer Service at 855-634-3381.
Grace period means the period of at least thirty (30) consecutive days beginning the day the Notice of Start of Grace Period is dated to allow a member who does not receive APTC or CAPS to pay an unpaid Premium amount without losing healthcare coverage. If you are getting financial help from the government to pay for your health coverage, once you have paid at least one monthly payment, you can get a grace period of up to three months if you fall behind on payments.
We will continue to consider services you receive during the first month of this grace period according to plan benefits. If you receive services after the first month of this grace period, we will hold (also called "pend") claims — meaning, we won’t pay them yet, but we’ll keep them and will process them after receipt of your premium payments.
It is best to pay your monthly payment on time every month, to avoid any chance of getting into your grace period.
If you are interested in setting up automatic payments, contact us at 855-634-3381.
Retroactive denial means going back and denying claims that were paid in the past. One way that could happen is if we paid a claim after we got your monthly payment; but then your bank says there is not enough money in your account and we never get a new payment from you. We will then go back and retroactively deny that claim, and we will need to get the money back that we paid for it.
If a claim was not paid yet, but we were just holding it (or pending it) as described in the previous section, Grace period for monthly payments — it can also be denied if you run out of your grace period. But since we did not pay the claim yet, we wouldn’t call it a retroactive denial. It is just called a denial.
One way you can avoid having your claims denied is by always paying your monthly payment on time. If you are late, be sure to pay before your grace period runs out. Contact us at 855-634-3381 to ask about setting up automatic payments if you think that can help you from missing your premium payment.
If you pay more than what you owe for your premium, we will either refund or credit the extra amount to you or your account. Our processes will identify any overpayment automatically. But if you believe you have paid more than you needed to, please contact us at 855-634-3381 or log in to your online account at wwww.anthem.com/ca and send us a message. Some health plans will describe this by the official terms "recoupment of overpayments," which means the same thing — getting your money back if you have overpaid.
Medical necessity is healthcare services that a medical practitioner, exercising professional clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, or disease or its symptoms, and that are:
• In accordance with generally accepted standards of medical practice
• Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease
• Not primarily for the convenience of the patient, doctor or other healthcare Provider, and
• Not more costly than an alternative service, including the same service in an alternative setting, or sequence of services that is medically appropriate and is likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s injury, disease, illness or condition
Sometimes, in order to help us figure out ahead of time (before you get the care) if a health service or device is medically necessary and covered by your plan, you or your doctor may need to contact us. This is called getting "prior authorization (pre-service review).”
When you go to a doctor or hospital in your plan, they will work with us to see if any of the care you are getting needs prior authorization. If you go to a doctor or hospital that is not in your plan, it's a good idea to check with us first — especially if it's more involved care, for example, surgery. If you are admitted to the hospital, contact us as soon as you can — ideally within 24 hours of admission. That's not necessary for childbirth admissions unless there's a complication and/or mother and baby are not discharged at the same time.
If you or your doctor do not get prior authorization for something that needs it, you could be responsible for more of the cost as stated in your Combined Evidence of Coverage and Disclosure Form.
We typically decide on requests for prior authorization for medical services within 72 hours of receiving an urgent request or within five (5) business days for non-urgent requests .
If you and your doctor feel you need a prescription drug that's not on your plan's drug list(non-formulary), your doctor or pharmacist must complete a uniform prior authorization form - You or Your doctor can get the form online at www.anthem.com/ca or by calling the number listed on the back of Your ID Card. We will make a decision within 72 hours of getting a non-urgent request. We will look at whether it is medically necessary and appropriate compared to the other drugs on our list.
If we deny coverage of the drug, you have the right to request an External Review by an Independent Review Organization (IRO). The IRO will make a coverage decision within 72 hours of receiving your request.
You or your doctor may also submit a request for a prescription drug that is not on your plan's drug list based on what's called "exigent circumstances". For example, if you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or if you are undergoing a current course of treatment using a drug not covered by your plan. In that case, we will make a decision within 24 hours of getting your request.
If we deny coverage of the drug that was requested based on exigent circumstances, you can request an external review by an IRO, similar to above. But a decision will be made more quickly, within 24 hours of getting your request.
After You receive medical care, You will generally receive an Explanation of Benefits (EOB). The EOB is a summary of the coverage You receive. The EOB is not a bill, but a statement from Us to help You understand the coverage You are receiving. The EOB shows:
• Total amounts charged for services/supplies received
• The amount of the charges satisfied by Your coverage
• The amount for which You are responsible (if any)
• General information about Your Appeals rights and for information regarding the right to bring an action after the Appeals process
When you or anybody else on your plan, like your spouse or kids, is covered by two different health plans — both plans may need to know about it. If your plan has coordination of benefits, we will work together to make sure you are getting the right benefits. From time to time, you may get a notice asking if anybody is covered by another plan. Not getting this information back to us may delay claim payments. So, if you are asked for this information, be sure to let us know as soon as possible. Further information about coordination of benefits can be found in your Combined Evidence of Coverage and Disclosure Form .