"What Do I Do When..."

Your Subscriber Claim Summary explains how we processed a claim. It is not a bill, and you should not send any payment to us (if there is a balance listed, the health care provider will notify you of your responsibility).

The Subscriber Claim Summary includes the name of the health care provider who sent us the claim, the date of service, the type of service (lab, surgery, medical care, etc.) and the amount the provider charged for the service. It also includes any deductible, copayment, or co-insurance that applies, and any patient balance. Deductibles, copayments, or co-insurance are included on some health plans, and simply indicate how much you share in the cost of health care.

If you have questions about the services rendered, you should contact the health care provider. If you have questions about how any patient balance was determined, you can create an accountor login to view your account or check your member literature to determine coverage, including any applicable deductible, copayment, or co-insurance that might apply. If you have questions, please contact Member Service at the number on the front of your ID card.

It's important to carry your ID card with you at all times. Your Blue Cross Blue Shield of Massachusetts card is recognized around the world. If you lose your card and need a replacement, simply create an account or login to Member Central to request a new card online, or call Member Service. If you have a family plan, and have access to another family member's ID card, please call the Member Service number shown on the front of the card. If you do not have access to another family member's card, you should call 1-800-462-5601.

Making changes to your membership is simple. If you have your coverage through your employer, simply contact your employer's benefits office to complete the appropriate form. If you have direct-payment coverage (e.g., Access Blue^SM Saver II, HMO Blue^® Basic Value), call Member Service at the toll-free number on the front of your ID card. We'll send you a form to complete and return. For all of our standard plans, we must receive notification within 30 days of the qualifying event.

As a result of the health care reform law in Massachusetts, changes have been made that affect dependent eligibility.

For more information, visit Health Care Reform.

If your child is between the ages of 18 and 21, it may be the right time for him or her to transition from their pediatrician to an "adult" doctor. We can help with that. Check out our Find a Doctor & Estimate Costs tool to search for a new doctor for your young adult.
 

When you receive a bill from your doctor, it is often for your copayment, co-insurance, or deductible. These are features of health plans, and basically have the member share in some of the cost of their health care. For example, some health plans require that the member pay $10 for an office visit and the rest is covered by the plan.

If you have additional questions, please call Member Service at the number on the front of your ID card. Be sure to have your ID number, health care provider's name, and the date of service handy when you call.

Since all network specialists can verify if you have a referral electronically, you should not be asked if you obtained a referral. If you are ever asked, you should advise the specialist to check electronically or they can call Member Service at the number on the front of your ID card, and our Provider Services staff will assist them.

If you have a managed care plan (like HMO Blue or Blue Choice^®), your primary care provider (PCP) provides or arranges for most of the care you need. If you require the care of a specialist, in most cases you must obtain a referral from your PCP to receive coverage.

Create an account or login to Member Central to review your Summary of Benefits or check your benefit materials (In most cases, this is called either the Member Handbook, Subscriber Certificate, or the Summary Plan Description.) Materials are organized in general categories like inpatient care, outpatient care, surgery, medical equipment, prescription drugs, etc. Virtually all questions can be answered with a quick check of your benefit materials.

If you have additional questions or concerns, please contact Member Service at the number on the front of your ID card. When you call, it is important for you to know the specific type of service involved so that a representative can help you.

Everyone has different priorities, and therefore their needs in a health plan can differ. However, here are some key elements that most everyone would find important in the benefits of a health plan:

• Does the provider network include your physician and hospital?
• Can your physician make referrals to specialists without first checking in with the health plan?
• Is the health plan recognized across the country and around the world?
• Does the health plan cover the services you are interested in receiving?
• Does the health plan have convenient customer service hours?
• What are the special features of being a member (for example, health club reimbursement and discounts on complementary medicine services)?

People sometimes have insurance coverage under more than one health plan, so we periodically send a survey to our members asking them if they have other coverage. This is to ensure that claims are processed correctly and that overpayments are not made. We see significant cost savings by coordinating payments with other insurers—savings that ultimately result in more affordable premiums for our members.

When you receive a survey, it's important that you complete and return it so that we have the most up-to-date information and can process your claims correctly. We make it easy for you to reply by providing postage-paid return envelopes and 24-hour telephone reply options.

We regularly survey a random sample of our members to determine how satisfied they are with the coverage and services we provide. By listening to this feedback, we have taken steps to bring satisfaction to world-class levels. If you do receive a survey, please complete and return it. Your participation is critical to the direction we take on coverage and service issues.

We don't expect that you will ever have a concern, but if you do, most issues can be handled with just one phone call. For help resolving a problem or concern, please first call Member Service at the toll-free number on the front of your ID card. A Member Service representative will work with you to help you understand your coverage and resolve your problem or concern as quickly as possible. If you disagree with the resolution provided by the Member Service representative, you may request a review through our formal Appeal and Grievance Program.

Please contact your Human Resources department to ensure that they have your new address on file. Periodically, your employer will submit updated enrollment information to Blue Cross Blue Shield of Massachusetts. If your Human Resources department has your old address on file, your new address may be overwritten.