View your credentialing status in Payer Spaces on Availity Essentials. Appeal form (PDF): Use this form to make your written appeal. Under no circumstances (with the exception of Emergency and Urgent Care) will we cover Services received from an Out-of-Network Provider/Facility unless we have Prior Authorized the Out-of-Network Provider/Facility and the Services received. http://www.insurance.oregon.gov/consumer/consumer.html. Does United Healthcare cover the cost of dental implants? Regence BlueShield serves select counties in the state of Washington and is an independent licensee of the Blue Cross and Blue Shield Association. If you receive APTC, you are also eligible for an extended grace period (see Grace Period). Payment will be made to the Policyholder or, if deceased, to the Policyholders estate, unless payment to other parties is authorized in writing. If enrollment under this Contract consists solely of children under the age of 21, the adult person who applied for such coverage shall be deemed to be the Policyholder. If you disagree with our decision about your medical bills, you have the right to appeal. The total amount you will pay Out-of-Pocket in any Calendar Year for Covered Services received. On rare occasions, such as urgent or emergency situations, you may need to use an Out-of-Network Pharmacy. For expedited requests, Providence will notify your Provider or you of its decision within 24 hours after receipt of the request. A single payment may be generated to clinics with separate remittance advices for each provider within the practice. A claim is a request to an insurance company for payment of health care services. You can find Providence Health Plans nationwide pharmacy network using our pharmacy directory. Learn more about our customized editing rules, including clinical edits, bundling edits, and outpatient code editor. If previous notes states, appeal is already sent. Premium is due on the first day of the month. RGA's self-funded employer group members may utilize our Participating and Preferred medical and dental networks. Blue Cross Blue Shield Federal Phone Number. Search: Medical Policy Medicare Policy . EvergreenHealth has notified us of their intent to end their contract with Premera Blue Cross on March 31, 2023. If you or your provider fail to obtain a prior authorization when it is required, any claims for the services that require prior authorization may be denied. If you wish to appoint someone to act on your behalf, you must complete an appointment of representative form (PDF) and send it to us with your grievance form (PDF). Do not add or delete any characters to or from the member number. Please present your Member ID Card to the Participating Pharmacy at the time you request Services. The Centers for Medicare & Medicaid Services values your feedback and will use it to continue to improve the quality of the Medicare program. All FEP member numbers start with the letter "R", followed by eight numerical digits. Company information about the Regence Group-BlueCross BlueShield affiliated health care plans located in Oregon, Washington, Utah and Idaho, and serving more than 3 million subscribers. Fax: 877-239-3390 (Claims and Customer Service) 601 SW Second Avenue Portland, Oregon 97204-3156 503-765-3521 or 888-788-9821 Visit our website: www.eocco.com Eastern Oregon Coordinated Care Organization Diabetes. Proving What's Possible in Healthcare 10700 Northup Way, Suite 100 Bellevue, WA 98004 If you qualify for a Premium tax credit based on your estimate, you can use any amount of the credit in advance to lower your Premium. Coinsurance means the dollar amount that you are responsible to pay to a health care Provider, after your Claim has been processed by us. ** We respond to medical coverage requests within 14 days for standard requests and 72 hours for expedited requests. Health Care Claim Status Acknowledgement. Please choose whether you are a member of the Public Employees Benefits Board (PEBB) Program or the School Employees Benefits Board (SEBB) Program. Remittance advices contain information on how we processed your claims. Contact us. If MAXIMUS disagrees with our decision, we authorize or pay for the requested services within the timeframe outlined by MAXIMUS. Specialty: A Network Pharmacy that allows up to a 30-day supply of specialty and self-administered prescriptions. Regence BlueCross BlueShield of Oregon. Claims information and vouchers for your RGA patients are available on the Availity Web Portal. Prior Authorization review will determine if the proposed Service is eligible as a Covered Service or if an individual is a Member at the time of the proposed Service. For example, we might talk to your Provider to suggest a disease management program that may improve your health. We generate weekly remittance advices to our participating providers for claims that have been processed. Learn more about billing and how to submit claims to us for payment, including claims for BlueCross and BlueShield Federal Employee Program (BCBS FEP) members. If a provider or capitated entity fails to submit a dispute within the required timeframes, the provider or capitated entity: Waives the right for any remedies to pursue the matter further The filing limit for claim submission for professional services to Blue Cross Blue Shield of Rhode Island (BCBSRI) for commercial members is 180 days from the date of service. To help providers and individuals meet timely filing rules, the period from March 1, 2020, to 60 days after the announced end of the National Emergency will not count towards timely filing requirements. Regence BlueShield of Idaho offers health and dental coverage to 142,000 members throughout the state. The person whom this Contract has been issued. Filing your claims should be simple. MAXIMUS will review the file and ensure that our decision is accurate. Prior authorization is not a guarantee of coverage. Members may live in or travel to our service area and seek services from you. You may purchase up to a 90-day supply of each maintenance drug at one time using a Participating mail service or preferred retail Pharmacy. An appeal qualifies for the expedited process when the member or physician feels that the member's life or health would be jeopardized by not having an appeal decision within 72 hours. Learn more about billing and how to submit claims to us for payment, including claims for BlueCross and BlueShield Federal Employee Program (BCBS FEP) members. Consult your member materials for details regarding your out-of-network benefits. Example 1: Durable medical equipment, including but not limited to: Certain infused prescription drugs administered in a hospital-based infusion center, Member ID number and plan number (refer to your member ID card), Provider name, address and telephone number, Date of admission or date services are to begin, Mail it to: Providence Health Plan, Appeals and Grievances Department, PO Box 4158, Portland, Oregon 97208-4158. The Blue Cross and/or Blue Shield Plans comprising The Regence Group serve Idaho, Oregon, Utah and much of Washington state Media. No enrollment needed, submitters will receive this transaction automatically, Web portal only: Referral request, referral inquiry and pre-authorization request, Implementation Acknowledgement for Health Care Insurance. Providence will notify your Provider or you of its decision within 72 hours after the Prior Authorization request is received. Providence will not pay for Claims received more than 365 days after the date of Service. Learn how to identify our members coverage, easily submit claims and receive payment for services and supplies. Blue Cross Blue Shield of Wyoming announces Blue Circle of Excellence Program with its first award to Powder River Surgery Center. Your Rights and Protections Against Surprise Medical Bills. If you are deaf, hard of hearing, or have a speech disability, dial 711 for TTY relay services. You are about to leave regence.com and enter another website that is not affiliated with or licensed by the Blue Cross Blue Shield Association. Learn more about global periods, modifiers, virtual care, unlisted codes and NCCI bypass modifiers. A determination that relates to eligibility is obtained no more than five business days prior to the date of the Service. Download a form to use to appeal by email, mail or fax. The Regence Group Plans use Policies as guidelines for coverage determinations in all health care insurance products, unless otherwise indicated. BCBSWY News, BCBSWY Press Releases. Premera Blue Cross Attn: Member Appeals PO Box 91102 Seattle, WA 98111-9202 . If you do not pay the Premium within 10 days after the due date, we will mail you a Notice of Delinquency. Claims received after 12 months will be denied for timely filing and the OGB member and Blue Cross should be held harmless. Regence BlueShield Attn: UMP Claims P.O. Providence will complete its review and notify the requesting provider or you of its decision by the earlier of (a) 48 hours after the additional information is received or, (b) if no additional information is provided, 48 hours after the additional information was due. Members will be responsible for applicable Copayments, Coinsurances, and Deductibles. Regence Administrative Manual . | September 16, 2022. View our clinical edits and model claims editing. Coordination of Benefits, Medicare crossover and other party liability or subrogation. We know it is essential for you to receive payment promptly. Benefits are not assignable; you will receive direct payment even if your patient signs an assignment authorization. Learn about electronic funds transfer, remittance advice and claim attachments. Learn about submitting claims. Both the Basic and Standard Option plans require that some services and supplies be pre-authorized. Copyright 2023 Providence Health Plan, Providence Plan Partners, and Providence Health Assurance. If the cost of your Prescription Drug is less than your Copayment, you will only be charged the cost of the Prescription Drug. Regence BlueShield of Idaho is an independent licensee of the Blue Cross and Blue Shield Association. Or, you can call the number listed on the back of your Regence BlueCross BlueShield of Oregon identification card. . 1/2022) v1. If you do not obtain your physician's support, we will decide if your health condition requires a fast decision. You may only disenroll or switch prescription drug plans under certain circumstances. Please reference your agents name if applicable.