Understanding
Health Care Reform

Blue Cross of Northeastern Pennsylvania
Can Help You Prepare

Health Care Reform is here. Understanding how the Affordable Care Act (ACA) impacts your health insurance is important.

Transparency in Coverage and Cost-Sharing

We recognize the value in sharing information with you so you can make the best health-related decisions based on your needs. This page will give you a brief overview of some of our business practices with regard to: claims payment and appeal procedures; enrollment; cost sharing and financial disclosures. While some of this information is available in your contract/policy for health care coverage and/or on our corporate website, bcnepa.com, this section of our health care reform site is intended to serve as a “one stop shop” for a variety of information about health insurance coverage and cost-sharing.

We also give you the tools to compare cost and quality of care among area doctors and hospitals. Identifying how much a procedure costs and what doctors and hospitals charge is important—especially if you want to save money. Generally, the less you are charged, the lower your out-of-pocket costs will be.

Quality of care is equally important. When it comes to choosing a doctor or hospital, you want to know how safe is the hospital, how successful are their outcomes, and how effective is your doctor compared to other doctors.

Now, you can see what many other patients like yourself have experienced. Our online directory lets you read and write reviews and rate your own patient experience!

We have the tools you need to check out costs, quality of care and patient reviews. Just register for or login to Self-Service, then click on the “Doctors & Hospitals” tab to get started!

Appeals Process

If you have questions about the complaint or grievance process or your Explanation of Benefits statement, please call our BlueCare Service Representative at the number on the back of your ID card.

If you disagree with the determination of a claim, you may contact the Customer Service Department to attempt to informally resolve the matter. The individual member, or their authorized representative, who received the service(s) can contact Member Services if he/she also requires diagnosis information in order to identify the claim.

You have the right to file a formal complaint or grievance with the Plan within 180 days from the date of this notice. If your denial is related to medical necessity, appropriateness, health care setting or level of care, you may also request an external review following the final review of the appeal if your appeal is denied. For more information concerning the complaint and grievance procedures, see your member materials.

A copy of any rule, guidance or protocol that was relied upon in making any adverse benefit determination is available upon request.

You can also receive assistance with the internal claims and appeals and external review processes by contacting the Pennsylvania Insurance Department Office of Consumer Services at 1.877.881.6388.

If you are a member of an ERISA group, you have the right to bring civil action under section 502(a) of the Employee Retirement Income Security Act of 1974 once all administrative remedies have been exhausted.

Claims Payment and Policies

A claim is an itemized statement of costs for health care services and/or supplies provided by a facility, doctor or other health care provider.

Certain services may require additional information, such as medical notes from the provider, payment or rejection notices from other insurance carriers (including Workers’ Compensation, other health plans, Medicare, auto insurance, etc.), origin and destination points for ambulance transfers or accident information. Delays in submitting this special information, when required, may delay claims processing.

Claims must be sent to us within one year of the date of the service in order to be considered for payment. In most cases, participating/preferred providers will send the claim for you. But if your provider does not send a claim, it will be your responsibility to do so. All claims must include the following information on an itemized bill from the provider:

Although the process for filing a claim is very similar across all products, we have outlined the specific procedures for each coverage plan. Please refer to your member handbook and the section that describes your health care coverage’s specific instructions. Click here to view your handbook.

Cost-Sharing and Payments for Non-Network Coverage

All of our BlueCare plan benefits summaries outline the coverage and cost-sharing responsibilities for each plan. Benefits summaries can be found on our corporate site bcnepa.com. Click here to view all of our plans, and once on the plan pages, click on the “Benefits Summary” for an overview, by plan, of all cost-sharing responsibilities.

Enrollment/Disenrollment Data

Click here to see our most recent enrollment and disenrollment rates.

Periodic Financial Disclosures

The following are our most recent financial disclosures.