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Blue Cross Blue Shield Claims Administration
Medical Claims
Vision and Hearing Care Claims
Filing Your Claims

BLUE CROSS BLUE SHIELD CLAIMS ADMINISTRATION

Member Services is a critical link between you and the Blue Cross Blue Shield network. The Member Services customer service line is answered by trained Blue Cross Blue Shield representatives. Call Member Services at 1-888-979-4514to:

Obtain the most current provider information
Find out about network providers (for example, a provider's address, or whether a provider now accepts new patients)
Check on features and procedures under the medical plan options
Change your PCP (if you are enrolled in the POS option)
Find out if there are Blue Cross Blue Shield network providers in a particular location
Request a new provider directory
Provide comments or feedback regarding a provider's performance
Ask questions about claims or reimbursements
Request claim forms
Ask for assistance in filing out-of-network claims (if you are not using a network provider)
Report lost ID cards and request new ones.

MEDICAL CLAIMS

In most cases, you do not need to file a claim for health care reimbursements. When you receive care from a network provider, he or she files your claim for you.
You are responsible for completing and submitting claim forms when you:

Use an out-of-network provider, even when your PCP authorizes the care (When your PCP authorizes out-of-network care, you may have to file a claim, but you receive in-network benefits.)
Incur vision or hearing expenses.

You must submit claims that you incur during the benefit plan year within 12 months after the benefit plan year ends. If you need a claim form or have questions about filing claims, call Blue Cross Blue Shield at the toll-free telephone number listed on the back of your medical ID card.

VISION AND HEARING CARE CLAIMS

When you visit an optometrist, ophthalmologist, or hearing care professional for exams or appliances, you pay the provider at the time you receive the services. Then, you file a claim with Blue Cross Blue Shield for reimbursement of eligible expenses. Use the standard Blue Cross Blue Shield claim form-, there is no special claim form for these services.

FILING YOUR CLAIMS

Generally, when you visit a network provider, he or she files your claim for you electronically. If the claim is not filed for you, you need to do the following:

Complete a Blue Cross Blue Shield claim form and submit it to the address printed on the form.
Attach the appropriate paperwork or itemized receipts. (The claims administrator cannot accept canceled checks as a receipt.)
Attach an explanation of benefits (EOB) if you receive reimbursement from another plan, such as your spouse's plan.
Write the group number and your Blue Cross Blue Shield identification number (which consists of a three-digit alpha code plus your Social Security number) on each claim form - even if the claim is for an enrolled family member. Both numbers are listed on your ID card.
Indicate whether payment should be made to you or directly to your provider.
Keep a copy of everything you send to Blue Cross Blue Shield.

If You Are Dissatisfied with the Resolution of Your Claim

If for any reason you are not satisfied, you are entitled to file a complaint with Blue Cross Blue Shield Member Services. Your complaint may relate to quality of care, service, a denied claim or any decision by Blue Cross Blue Shield. You must exhaust all Blue Cross Blue Shield resolution options before filing an appeal with Vought Benefits, the plan administrator.

Call Blue Cross Blue Shield Member Services at the toll-free telephone number listed on your ID card. When corresponding with Member Services on any complaints or appeals, include your name, address, daytime telephone number, group number (listed on your ID card), and member ID number. To obtain the correct mailing address, call the toll-free telephone number listed on your ID card.

After you contact Member Services you will receive a response to your complaint:

The same day, if a delayed response to your complaint would significantly increase your health risk
Within 30 working days of Blue Cross Blue Shield's receipt of your complaint, unless Blue Cross Blue Shield informs you that further investigation or review by a Medical Director is necessary
Within 45 working days after Blue Cross Blue Shield received all necessary additional information to complete its investigation or review by a Medical Director.

Filing an Appeal with Blue Cross Blue Shield

If you are not satisfied with Blue Cross Blue Shield's decision regarding your complaint, you have 30 days to file an appeal with the Level One Appeals Committee. Appeals should be sent to:

Level One Appeals Committee
Blue Cross Blue Shield of Illinois
PO. Box A3464
Chicago, IL 60690-3464

After you file your Level One appeal, you will receive a response within 20 working days of receipt of the appeal, unless the Appeals Committee informs you within the 20-day period that it needs a 10-working-day extension.

If you remain dissatisfied with Blue Cross Blue Shield's response to your complaint, you may file a second appeal within 30 days of receipt of the first appeals decision. All second appeals must be submitted in writing to:

Level Two Appeals Committee
Blue Cross Blue Shield of Illinois
PO. Box A3464
Chicago, IL 60690-3464

After you file your second appeal:

The Level Two Appeals Committee has 45 working days from receipt of the appeal to review your case, and you will be notified if the committee needs additional time
You and/or your designated representative may present your case in person or via conference call to the committee during the 45-working-day period
The committee notifies you of its decision within five working days after it completes the review

The decision of the Level Two Appeals Committee is Blue Cross Blue Shield's final decision. If you still are not satisfied with Blue Cross Blue Shield's decision after your second appeal, you can appeal to the plan administrator. The claim appeal process is described in the General Plan Administration section. The plan administrator has the discretion to interpret and construe the terms of the Vought Aircraft medical plan.