Identification cards | We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter. If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 850-383-3311 or write to us at Capital Health Plan, 2140 Centerville Place, Tallahassee, FL 32308. You may also request replacement cards through our website: www.capitalhealth.com. |
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Where you get covered care | You get care from “Plan providers” and “Plan facilities.” You will only pay copayments and you will not have to file claims. |
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Balance Billing | FEHB Carriers must have clauses in their in-network (participating) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract. |
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Plan providers | Plan providers are physicians and other healthcare professionals in our service area that we employ or contract with to provide covered services to our members. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to national standards. You must select a primary care physician to direct all of your medical care. Capital Health Plan offers you a choice of primary care physicians at many different locations in the greater Tallahassee area.
Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website, www.capitalhealth.com.
This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health.
Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex, or gender.
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Plan facilities | This plan provides Care Coordinators for complex conditions and can be reached Capital Health Plan Member Services 850-383-3311 for assistance. Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website, www.capitalhealth.com. Primary care physician offices in our two health centers at Centerville Road and Governors Square Boulevard also offer the convenience of lab, x-ray, and vision care. |
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What you must do to get covered care | It depends on the type of care you need. First, you and each family member must choose a primary care provider. This decision is important since your primary care provider provides or arranges for most of your health care.
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Primary care | Your primary care provider can be a family practitioner, internist, or pediatrician. Your primary care provider will provide most of your healthcare, or give you a referral to see a specialist.
It is important to understand the difference between a referral and an authorization, and how to obtain each one.
If you want to change primary care provider or if your primary care provider leaves the Plan, call us. We will help you select a new one.
Capital Health Plan's Directory of Physicians and Service Providers lists the primary care providers and their office locations. You can make your selections from this list. This directory is provided to all new members at the time of enrollment, on request by calling CHP's Member Services Department at 850-383-3311, or on our website at www.capitalhealth.com. This directory is subject to change and is updated on a regular basis. On occasion, some physicians may not accept new patients. CHP's Member Services staff gladly will assist you with your selection of a primary care physician. |
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Specialty care | Your primary care provider will refer you to a specialist for needed care. CHP has eliminated the need for a CHP Authorization number of most but not all local network practitioner office based on specialty covered services. You will need a referral or written orders for specialty care. CHP endorses and encourages referrals for clinical recommendations from the primary care provider. Some specialty care offices may have a policy requiring an authorization number before making an appointment or require new patients to be seen by their primary care provider first. Primary care providers and specialists communicate with each other to coordinate members’ care as needed. CHP authorization numbers still are required for certain medical services including, but not limited to:
- All inpatient services
- Outpatient Hospital based services for Wound Care, Hyperbaric oxygen treatment (HBO), and Observation
- All non-participating practitioners or facilities in or out of Capital Health Plan's service area
- All nonemergency services received outside CHP’s service area, including out of area contracted practitioners and facilities (ex. Shands)
- All services related to the mouth and/or teeth
- Speech Therapy
- All home health care services except hospice care
- Services that may be investigational or outside the realm of accepted mainstream medical care.
- All procedures or surgery that have Capital Health Plan clinical criteria requires review and an authorization at any location. See a listing of Capital Health Plan Clinical Criteria on the Medical Policies page:
http://www.www.capitalhealth.com/Providers/clinical-criteria.
If you have any questions regarding the referrals system, please call CHP Member Services at 850-383-3311 or visit www.capitalhealth.com/providers/Clinical-Criteria.
Here are some other things you should know about specialty care:
- If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care provider will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals.
- Your primary care provider will create your treatment plan, the physician may have to get an authorization or approval from us beforehand. If you are seeing a specialist when you enroll in our Plan, talk to your primary care provider. Your primary care provider will decide what treatment you need. If they decide to refer you to a specialist, ask if you can see your current specialist.
- If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
- If you are seeing a specialist and your specialist leaves the Plan, call your primary care provider, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
- If you have a chronic and disabling condition and lose access to your specialist because we:
- terminate our contract with your specialist for other than cause;
- drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
- reduce our service area and you enroll in another FEHB plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days. |
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Hospital care | Your Plan primary care provider or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility. |
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If you are hospitalized when your enrollment begins | We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 850-383-3311. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
- you are discharged, not merely moved to an alternative care center;
- the day your benefits from your former plan run out; or
- the 92nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment. |
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You need prior Plan approval for certain services | Since your primary care provider arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services.
- You must get prior approval for certain services. Failure to do so will result in services not being covered.
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Inpatient hospital admission
| Your Plan primary care provider or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.
Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. |
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Other services | Your primary care provider has authority to refer you for most services. For certain services, however, your primary care provider must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. You must obtain prior authorization for:
- Admissions (non-emergent) to all facilities, including:
- Hospitals
- Rehabilitation Facilities
- Skilled Nursing Facilities
- Bariatric Surgeries (Surgery for Clinically Severe Obesity)
- Behavioral Health services including:
- Inpatient admissions, non-emergent
- Partial hospitalization services
- Residential treatment (Ex. Eating Disorder and Substance Abuse Facilities)
- Non-routine outpatient services including Applied Behavioral Analysis (ABA) and Transcranial Magnetic Stimulation
- Breast Reduction and Reconstruction Surgeries
- Cardiac Rehabilitation
- Clinical Trials (only routine patient costs for items and services are covered)
- Cochlear Implants
- Computed Tomographic Colonography (Virtual Colonoscopy or CT Colonoscopy)
- Continuous Glucose Monitoring Systems
- Continuous Passive Motion Device
- Cosmetic/Reconstructive Surgery including:
- Abdominoplasty
- Blepharoplasty / Ptosis repair
- Destruction of Vascular Cutaneous Lesions
- Mastectomy for Gynecomastia
- Orthognathic Surgery
- Panniculectomy/Removal of Excess Tissue
- Ptosis repair
- Reduction Mammoplasty (Breast Reduction)
- Removal of Breast Implants
- Repair of Congenital Chest Wall Deformities
- Rhinoplasty
- Scar revision
- Septoplasty
- Dental and Oral Surgery Services
- Enzyme Replacement Therapy
- Experimental Items and Services
- Formulas and Enteral Nutrition
- Functional Neuromuscular Stimulation
- Gender Reassignment Surgeries (limited to those surgeries that can be performed by a general surgeon such as mastectomies, hysterectomies, oophorectomies and gonadectomies.)
- Genetic Testing
- Gynecomastia Surgery
- Hearing Devices - Implantable
- Hip Arthroplasty/Hip Replacement
- Home Health Care services
- Hospice Services – Inpatient
- Hospital Admissions (Non-emergent)
- Hyperbaric Oxygen (HBO) Therapy
- Implantable Neurostimulators
- Infertility Services
- Inpatient Non-emergent Admissions to all Facilities
- Insulin Infusion Pumps and Supplies
- Investigational Items and Services
- Knee Arthroplasty/Knee Replacement
- Left Atrial Appendage Closure Device (WATCHMAN™)
- Negative Pressure Wound Therapy Pump
- New Technologies that have not been assessed and incorporated into Capital Health Plan benefits
- Non-Emergent Medical Transportation
- Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders
- Osteogenesis Stimulators
- Outpatient Diagnostic Imaging Services including:
- Magnetic Resonance Imaging (MRI) of the cervical spine (neck)Magnetic Resonance Imaging (MRI) of the lumbar spine (back)
- Outpatient Pulmonary Rehabilitation
- Outpatient Speech/Language Therapy
- Physical and/or Occupational Therapy services require prior authorization if services are expected to exceed the member’s benefit limit.
- Out-of-Network / Non-contracted provider referrals
- Prosthetic Devices
- Proton Beam Therapy
- Pulmonary Rehabilitation
- Quantitative Elecrtoencephalography (QEEG)
- Radiation Oncology
- Respiratory Assist Devices (CPAP, APAP, BiPAP)
- Seat Lift Mechanisms
- Selected Medical Benefit drugs and biologicals: See CHP's website
www.capitalhealth.com/Physicians-Providers/Medication-Center.
- Shoulder Arthroplasty/Shoulder Replacement
- Speech Generating Devices
- Spinal Cord Stimulation
- Spine Surgeries including:
- Cervical (Neck)
- Lumbar (Back)
- Kyphoplasty
- Vertebroplasty
- Subcutaneous Implantable Cardioverter-Defibrillator (ICD)
- Thoracic Outlet Syndrome Surgery
- Transcranial Magnetic Stimulation
- Transplant Services
- Tumor treatment field therapy
- Wearable and Non-Wearable Cardioverter-Defibrillators (WCD)
- Weight Control Services (including services provided at the Tallahassee Memorial Hospital Bariatric Center)
- Wheelchairs – Powered or customized wheelchairs only
- Wound Treatment Centers
The following are just a few of the services that have clinical criteria and require a review and a prior authorization:
- Genetic Testing
- Back (lumbar) and neck (cervical) surgery also known as spinal surgery, and MRI's
- Transcranial Magnetic Stimulation
- Implantable Hearing Devices
- Certain Durable Medical Equipment (DME), such as: External Insulin Infusion Pumps & Supplies, Continuous Glucose Monitoring, and Power Wheelchairs
- Gender Reassignment Surgeries (limited to those surgeries that can be performed by a general surgeon such as mastectomies, hysterectomies, oophorectomies and gonadectomies.)
Questions about Capital Health Plan’s prior authorization process?
Call Member Services at (850) 383-3311. For TTY/TDD – Telecommunication Device for the Deaf (for speech or hearing impaired) service, call (850) 383-3534 or 711. Outside the area? Call us toll-free at 1-877-247-6512.
Prior Authorization
Capital Health Plan requires prior authorization (prospective review of medical necessity, clinical appropriateness, eligibility, and level of benefits) for selected medications, procedures, services and items. Authorization and denial decisions are made in a timely manner that accommodates the clinical urgency of the situation. Providers are responsible for obtaining prior authorizations when required. Your physician will submit authorization requests electronically, by phone, or in writing by fax or mail. If approved, an authorization number is then generated by Capital Health Plan and is available to you via CHPConnect. If the requested service is not authorized, the member and provider are notified in writing with the specific reasons for the denial. Members are responsible for ensuring a prior authorization is in place prior to receiving these services. Failure to comply with these prior authorization requirements will result in denial of the claim payment. Prior authorization requirements are subject to change. For up-to-date information on services requiring a prior authorization, Members should contact the Member Services Department (850-383-3311) or visit our website at www.capitalhealth.com/Members/items-and-services-requiring-prior-authorizations.
Referrals and Authorizations
It is important to understand the difference between a referral and an authorization, and how to obtain each one.
Referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. Your primary care physician will refer you to a participating specialist or a health care service provider if they cannot personally provide the care you need. Many referrals do not require an authorization number.
Authorization, also known as precertification or prior authorization, is a process of reviewing certain medical, surgical or behavioral health services to ensure medical necessity and appropriateness of care prior to services being rendered. The review also includes a determination of whether the service being requested is a covered benefit under your benefit plan. Authorizations are only required for certain services. |
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How to request precertification for an admission or get prior authorization for Other services | First, your provider, your hospital, you, or your representative, must call us at 850-383-3311 before admission or services requiring prior authorization are rendered.
Next, provide the following information:
- enrollee's name and Plan identification number,
- patient's name, birth date, identification number and phone number,
- reason for hospitalization, proposed treatment, or surgery,
- name and phone number of admitting physician,
- name of hospital or facility; and
- number of days requested for hospital stay.
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Non-urgent care claims | For non-urgent care claims, we will tell the provider and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.
If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information. |
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Urgent care claims | If you have an urgent care claim (i.e. when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision with 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.
If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.
We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.
You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 850-383-3311. You may also call OPM’s Health Insurance 3 at 202-606-0755 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, then call us at 850-383-3311. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim). |
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Concurrent care claims | A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.
If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim. |
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- Emergency inpatient admission
| If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. |
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Maternity care | Maternity Care is defined as hospital services provided to a member for normal pregnancy, delivery, miscarriage, or pregnancy complications within the CHP service area only, unless the need for these services was not, and reasonably could not have been, anticipated before leaving the service area.
You do not need precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.
Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.
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- If your treatment needs to be extended
| If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim. |
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What happens when you do not follow the precertification rules when using non-network facilities | Capital Health Plan is a health maintenance organization (HMO). We require you to see specific provider, hospitals, and other providers that contract with us. When you receive services from plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments described in this brochure. When you receive emergency services from non-plan providers, you may have to submit claim forms.
Benefits are available for care from non-plan providers in a medical emergency only if a delay in reaching a plan provider would result in death, disability, or significant jeopardy to your condition. Capital Health Plan members can access out-of-area urgent and emergency care at any affiliated Blue Cross and Blue Shield provider in the country through the BlueCard network and claims automatically will be routed to CHP.
Out-of-Area Services
Capital Health Plan has a variety of relationships with other Blue Cross and Blue Shield Plans and their Licensed Controlled Affiliates (“Licensees”). Generally, these relationships are called “Inter-Plan Programs.” These Inter-Plan Arrangements operate based on rules and procedures issued by the Blue Cross Blue Shield Association ("Association"). Whenever a Member obtain Covered Services outside of the Service Area, the claims for these services may be processed through one of these Inter-Plan Programs.
When a Member receives care for Covered Services outside of the Service Area, the Member will receive the care from one or two kinds of providers. Most providers ("participating providers") contract with the local Blue Cross and/or Blue Shield Plan in that geographic area ("Host Blue"). Some providers ("nonparticipating providers") do not contract with the Host Blue. Capital Health Plan explains below how Capital Health Plan pays both kinds of providers.
Capital Health Plan covers only limited healthcare services received outside of the Service Area. As used in this section “Out-of-Area Covered Healthcare Services” include emergency care, urgent care, or care authorized by Capital Health Plan obtained outside of the Service Area. Any other services will not be covered when processed through any Inter-Plan Programs arrangements. unless authorized by the Member's Primary Care Physician.
A. BlueCard® Program
Under the BlueCard® Program, when a Member obtains Out-of-Area Covered Healthcare Services within the geographic area served by a Host Blue, Capital Health Plan will remain responsible for fulfilling our contractual obligations. However the Host Blue is responsible for contracting with and generally handling all interactions with its participating healthcare providers. The BlueCard® Program enables a Member to obtain Out-of-Area Covered Healthcare Services, as defined above, from a healthcare provider participating with a Host Blue, where available. The participating healthcare provider will automatically file a claim for the Out-of-Area Covered Healthcare Services provided to the Member, so there are no claim forms for the Member to complete. The Member will be responsible for the Member Copayment amount, as stated in his or her Summary of Benefits and Coverage.
Emergency Care Services: If a Member experiences a Medical Emergency while traveling outside Capital Health Plan’s Service Area, the Member should go to the nearest Emergency (or Urgent Care) facility.
When a Member receives Out-of-Area Covered Healthcare Services outside of the Service Area, and the claim is processed through the BlueCard® Program, the amount the Member pays for Out-of-Area Covered health Care Services, if not a flat dollar copayment, is calculated based on the lower of:
- The billed covered charges for Covered Services; or
- The negotiated price that the Host Blue makes available to Capital Health Plan.
Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to the Member's healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with the Member's healthcare provider or provider group. These arrangements may include types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price.
Estimated pricing and average pricing, going forward, also take into account adjustments to correct for over- or underestimation of modifications of past pricing of claims, as noted above. However, such adjustments will not affect the price Capital Health Plan uses for the Member's claim because they will not be applied retroactively to claims already paid.
Federal or state laws or regulations may require a surcharge, tax or other fee that applies to insured accounts. If applicable, Capital Health Plan will include any such surcharge, tax or other fee as part of the claim charge passed on to you.
B. Non-Participating Healthcare Providers Outside Our Service Area
1. Member Liability Calculation
When Out-of-Area Covered Healthcare Services are provided outside of Capital Health Plan by nonparticipating providers, the amount the Member pays for such services will generally be based on either the Host Blue’s nonparticipating healthcare provider local payment or the pricing arrangements required by applicable state law. In these situations, the Member may be responsible for the difference between the amount that the nonparticipating healthcare provider bills and the payment Capital Health Plan will make for the Out-of-Area Covered Healthcare Services as set forth in the Member's Employer Sponsored Plan. Federal or state law, as applicable, will govern payments for out-of-network emergency services.
2. Exceptions
In certain situations, Capital Health Plan may use other payment bases, such as billed covered charges, the payment Capital Health Plan would make if the healthcare services had been obtained within the Service Area, or a special negotiated payment to determine the amount Capital Health Plan will pay for services provided by nonparticipating providers. In situations where services are provided by nonparticipating providers, the Member may be liable for the difference between the amount that the nonparticipating healthcare provider bills and the payment Capital Health Plan will make for the Out-of-Area Covered Services.
C. BlueCross BlueShield Global® Core
If a Member is outside the United States, they may be able to take advantage of the BlueCross BlueShield Global® Core Program when accessing covered healthcare services. The BlueCross BlueShield Global® Core Program is unlike the BlueCard Program available in the United States in certain ways. For instance, although the BlueCross BlueShield Global® Core Program assists Members with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when a Member receives care from providers outside the United States, they may typically have to pay the providers and submit the claims as provided below to obtain reimbursement for these services. If a member needs to access emergency services (including locating a doctor or hospital) outside the United States, they should (a) go to https://bcbsglobalcore.com or download the BlueCross BlueShield Global® Core mobile app to access a list of providers and facilities, or (b) call BlueCross BlueShield Global® Core Program Service Center at 1-800-810-BLUE (2583) or collect at 1-804-673-1177, 24 hours a day, seven days a week. An assistance coordinator, working with a medical professional, will arrange a Physician appointment or Hospitalization, if necessary. Please note: Medical services obtained internationally that are not urgent or emergent in nature are not covered services.
In most cases, if a Member contacts the BlueCross BlueShield Global® Core Program BlueCard Worldwide Service Center for assistance, Hospitals will not require the Member to pay for covered inpatient services, except for his or her cost share amount. In such cases, the Hospital will submit the Member's claims to the BlueCross BlueShield Global® Core Program BlueCard Worldwide Service Center to begin claims processing. However, if the member paid in full at the time of service, he or she must submit a claim to receive reimbursement for covered healthcare services.
Providers, urgent care centers and other outpatient providers located outside the United States will typically require a Member to pay in full at the time of service. In such cases, the Member must submit a claim to obtain reimbursement for covered healthcare services.
- Submitting a BlueCross BlueShield Global® Core Program Claim
When a Member pays for covered emergency healthcare services outside the BlueCard service area, they must submit a claim to obtain reimbursement. For institutional and professional claims, the Member should register and complete the claim form online at https://bcbsglobalcore.com to initiate claims processing. Following the instructions on the website will help ensure timely processing of the claim. If a Member needs assistance with his or her claim submission, the Member should call the BlueCross BlueShield Global® Core Program Service Center at 1-800-810-BLUE (2583) or call collect at 1-804-673-1177, 24 hours a day, seven days a week. |
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Circumstances beyond our control
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Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.
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If you disagree with our pre-service claim decision | If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive call 850-383-3311.
If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8. |
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To reconsider a non-urgent care claim | Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.
In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to
1. Precertify your hospital stay, or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
3. Write to you and maintain our denial. |
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To reconsider an urgent care claim | In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.
Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by telephone, electronic mail, facsimile, or other expeditious methods. |
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To file an appeal with OPM | After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure. |
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