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Blue Shield Frequently Asked Questions

FREQUENTLY ASKED QUESTIONS ON THE NEW PA BLUE SHIELD PLAN

1. What do I do with 2002 major medical claims and where can I get claim forms?
   Services/claims incurred prior to July 1, 2002, must be submitted to Capital Blue Cross/Major Medical for processing using the old alpha prefix “SHE” prior to the ID number requested. To obtain a Capital Blue Cross form, go to http://www.capbluecross.com/, go to customer service, and click-on "products". Services/claims incurred July 1, 2002, and after must be submitted to PA Blue Shield on the new claim form. The new alpha prefixes prior to the ID number are ZAH for the indemnity plan and ZAL for those who carry either proponent of Medicare. Claim forms can be downloaded by clicking on the following hyperlink -- https://www.highmarkbcbs.com/pdffiles/1500A-1.pdf. Copies of the form can also be obtained at your local APSCUF office or University Personnel Office. At this time, PA Blue Shield is not providing blank forms with return claims. Copying of the form is permitted.
2. How do I complete the new claim form – do I have to have a doctor complete the bottom part even for prescriptions?
   Only the first eleven sections need to be completed on the claim form. The rest of the form remains blank. Attach all necessary pharmacy receipts and non-participating doctor bills and submit to PA Blue Shield at either PO Box 890173 Camp Hill PA 17089-0173 or PO Box 890062 Camp Hill PA 17089-0062. Make copies of all materials for your files.
3. How do I handle doctor office visits or consultations?
   Effective July 1, 2002, providers who participate with Blue Cross and Blue Shield will electronically bill the services for you. Therefore, there is no need to pay the provider on the day of your visit. Blue Shield will forward the charge to major medical. Major medical will review the information and determine whether or not you satisfied your annual deductible and out-of-pocket co-pay. If the deductible has not been satisfied, the provider will be notified and the provider will bill you for the full contract allowance. If the annual deductible has been satisfied, major medical will reimburse the doctor for 80% of the contracted allowance and you will be billed for the 20% co-insurance. If both the deductible and out-of-pocket maximum has been satisfied, the provider will be reimbursed the full amount of the contract allowance. If you use a non-participating provider, you or the patient may have to pay the provider directly for the incurred service. Obtain an itemized bill from the provider and submit the charge on PA Blue Shield’s claim form. PA Blue Shield will reimburse you according to the above-referenced method. Please remember that if you seek professional medical assistance outside of PA, PA Blue Shield’s major medical program will reimburse at three times the instate rate.
4. What is the out-of-pocket maximum?
   In calculating the level of reimbursement under major medical, PA Blue Shield must verify that the patient satisfied the annual deductible. Faculty members who retired prior to January 2, 1999, carry an annual deductible of $100.00. All others carry a $250.00 annual deductible. Once the deductible has been satisfied, major medical begins to reimburse at 80% of the contracted allowance. You are responsible for the other 20% of the contract allowance or to use PA Blue Shield’s terminology -- out-of-pocket co-insurance. Once the out-of-pocket co-insurance reaches its maximum, $350.00 for those who carry a $250.00 deductible or $380.00 for those who carry a $100.00 deductible, the reimbursement level increases from the 80% level to 100%. This is not a new provision under the health plan; the calculation method is just presented differently from how Capital Blue Cross represented the information in the past.
5. I satisfied my deductible and/or out-of-pocket maximum under Capital Blue Cross, but PA Blue Shield has taken out another deductible. What do I do?
   Locate your last Explanation of Benefits (EOB) from Capital Blue Cross and contact PA Blue Shield at 1-866-727-4935. Give the customer service representative the information listed on the Capital Blue EOB. PA Blue Shield may request that you forward a copy of this information for verification.
6. I submitted my last Capital Blue Cross EOB to the PA Health and Welfare Fund and didn’t make a copy. Now what do I do?
   Call Capital Blue Cross (1-800-433-7743 or 1-866-686-2242) and request a duplicate copy of your last EOB be sent to you.
7. PA Blue Shield is not allowing the same amount for services that Capital Blue Cross/Major Medical did in the past. I thought benefit levels were to remain at the same level and not be reduced?
   PA Blue Shield’s benefit plan levels are to be the same as they were under the old health plan. If you submit a charge to PA Blue Shield and the listed allowance for that benefit is lower than what Capital Blue Cross reimbursed, you will need to provide Blue Shield with a copy of an EOB from Capital indicating the amount allowed and a copy of the Statement of Claims from PA Blue Shield where the charge was listed at a lower rate.
   NOTE: This does not include participating doctor charges. These professionals signed a contract with PA Blue Shield agreeing to accept a certain rate for different procedures. The provider may only bill you up to your deductible and 20% of the contracted allowance.
8. The Statement of Claims from PA Blue Shield is very confusing. Not only does it provide multiple pages with different types of charges, it intermixes all the family members who may have had claims submitted. I can’t tell whether or not all charges are listed, let alone if I was reimbursed properly.
   The Blue Shield claim statements are very different from the previous forms furnished by Capital Blue Cross. This issue was raised with the State System, and the System is going to investigate the possibility of PA Blue Shield providing a more user-friendly format in the future.
9. Are we going to get new benefit booklets?
   Yes! The State System and PA Blue Shield are working on a benefit booklet. For the time being, you can refer to the old Benefits Program Handbook. The benefits are to be the same, so the information listed in the handbook is still accurate.
10. I am a retired faculty member. I submitted a claim form as I have done in the past for my spouse. I received a "denial of benefits, coverage terminated" notice. Why?
    PA Blue Shield implemented a rather complicated system of submission for some retirees. Below, locate your health care coverage for the employee, spouse and dependents, and then follow the instructions on submitting claims.

Coverage (type of medical coverage)		ID Card (name of insured ID number, and plan name)
1 2 3 4 5 6 7 8 9 10 11 12	Indemnity – Single Indemnity – Two Party Indemnity – Family Medicare A & B – Single Medicare A/Basic – Single Medicare A & B – Two Party Medicare A/Basic – Two Party Indemnity – Annuitant Medicare A&B – Dependent Indemnity – Annuitant Medicare A only – Dependent Medicare A only – Annuitant Indemnity – Dependent Medicare A&B – Annuitant Indemnity – Dependent Medicare A only – Annuitant Medicare A and B – Dependent Family Coverage	Annuitant’s name/ID – use for all Annuitant’s name/ID – use for all Annuitant’s name/ID – use for all Annuitant’s name/ID – use for all Annuitant’s name/ID – use for all Annuitant’s name/ID – annuitant use for all Dependent’s name/ID Annuitant’s name/ID – annuitant use for all Dependent’s name/ID Annuitant’s name/ID – annuitant uses for all and the dependent uses for MM only Dependent’s name/ID – use to supplement A and B Annuitant’s name/ID – annuitant uses for all and the dependent uses for MM only Dependent’s name/ID-use to supplement A and B Annuitant’s name/ID – use with A and Basic Annuitant’s name/ID – dependent use for all and annuitant use for MM Annuitant’s name/ID – use to supplement A and B Annuitant’s name/ID – dependent use for all, annuitant use for MM Annuitant’s name/ID – use for all Dependent’s name/ID – use for all

13   14   15 16

Medicare A and B – Annuitant Medicare A and B – Dependent Indemnity – Dependent(s) Medicare A only – Annuitant Medicare A only – Dependent Indemnity – Dependent(s) Medicare A and B – Annuitant Medicare A and B – Dependent Medicare A and B – Dependent Medicare A only – Annuitant Medicare A and B – Dependent Medicare A and B – Dependent

Annuitant’s name/ID – use to supplement A and B Dependent’s name/ID – use to supplement A and B Annuitant’s name/ID – dependent not under A and B use for all, annuitant and dependent under A and B, use for MM only Annuitant’s name/ID – use to supplement A/Basic Dependent’s name/ID – use to supplement A/Basic Annuitant’s name/ID – dependent(s) not under A, use for all, annuitant and dependent under A, use for MM only Annuitant’s name/ID – use for all Dependent’s name/ID – use for all Dependent’s name/ID – use for all Annuitant’s name – use for all Dependent’s name – use for all Dependent’s name– use for all

Medicare Complement is imprinted on the card for those who have coverage under Medicare Parts A and B or Medicare Part A only. Indemnity is imprinted on the card(s) of those who do not have any component of Medicare.

For claims submission, where it is indicated that the dependent is to use the card for all, the dependent listed on the card is to use as the patient and the insured. Do not list the annuitant as the insured.

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