Frequently Asked Questions

Below are questions commonly received by our customer service representatives. For additional information, see the Benefits section or the Products and Services section. If you do not find your question answered here, call Customer Service at the number on your ID card or e-mail Customer Service.

• Benefits
• BlueCard®
• CHIP
• Claims
• Health Plan Definitions
• ID Card
• Primary Care Network

1. If I have questions about claim status or benefits, whom do I contact?

For assistance, call Customer Service at the number on your ID card.
You also may check your benefits online.

2. I have received an Explanation of Benefits (EOB) explaining payment of a claim. If I have questions about the EOB, whom do I contact?

For assistance with inquiries about your claims payment, call the customer-service number on your ID card or e-mail Customer Service. For more information about reading your EOB, visit the Understanding Your EOB section of our site.

3. If I do not agree with a denial of benefits, how do I request a review?

Requests for review of benefit denial must be made in writing and sent to:

Additional pertinent information must accompany the request for review. A written response will be sent to you after review is completed. Any appeal from the review must be forwarded to your group plan administrator.

4. I have received a COB questionnaire from BlueAdvantage. Why do you want to know if I have other coverage?

Under your contract's coordination of benefits provision, if you are covered by more than one health plan, a decision must be made as to which plan is responsible for primary payment. Once the claim has been paid under the primary plan, the secondary plan pays its share of the allowed charges. Total payments will not equal more than 100 percent of allowed charges. For more information, visit the Coordination of Benefits section of our site.

1. What is BlueCard?

The BlueCard program provides the opportunity for members to take their health-care benefits with them when they travel or live outside of Arkansas. The program is available throughout the 50 states and around the world in 28 countries. It provides innovative methods of lowering costs and promoting customer satisfaction. The BlueCard PPO (preferred provider organization) allows members to receive discounts through local Blue Plan contract arrangements. Currently more than 85 percent of hospitals and physicians throughout the United States contract with independent Blue Cross and Blue Shield plans.

To determine if you participate in this program, contact your employer or call Customer Service at the number on your ID card. The Blue Cross and Blue Shield logo and a suitcase emblem on your ID card indicate participation in this program.

2. What is ITS?

The Inter-Plan Teleprocessing Services (ITS) is a software tool that links all Blue Cross and Blue Shield plans. It is the data clearinghouse for the BlueCard program. The ITS system houses claim submission and payment data. Each participating plan provides benefit determinations to the ITS system.

This is how it works:

• Member travels or lives outside the local plan area.
• Member seeks services from a participating provider.
• Provider files claim with host plan.
• Host plan submits the claim to the member's home plan via the ITS system.
• Home plan advises the host plan of the available benefit via the ITS system.
• Home plan issues an Explanation of Benefits to the member.
• Host plan pays the provider.

3. What is a "home plan"?

In reference to participation in the BlueCard program, BlueAdvantage is considered the home plan. This means that BlueAdvantage is responsible for providing customer service to our members, maintaining eligibility, adjudicating plan benefits for notification to the host plan, and issuing explanations of benefits to members.

4. What is a "host plan"?

In reference to participation in the BlueCard program, a host plan would be any Blue Cross and Blue Shield plan whose contracted providers are servicing a BlueAdvantage member outside the home plan area. The host plan is responsible for providing customer service to the provider, submission of claims to the home plan after validation of information and application of pricing, and issuing payment to the provider.

1. How can payments be made?

Monthly on automatic bank draft or quarterly by check. With bank draft, the first month is billed direct; then the draft starts the following month.

2. When does a person NOT qualify for CHIP?

1. If a person has Medicare
2. If a person receives any kind of state or government funding including Medicaid
3. If group coverage or COBRA is available (even though benefits may be less)

3. When may a person change his/her deductible?

Increases to the deductible amount may be requested at any time. The change will be effective the first of the month after the change request is received. Decreases to the deductible amount may only be made on January 1 of each calendar year.

4. How are pharmacy (prescription drug) claims filed?

Manually. Claim forms are provided with the new enrollment packet. Payment is made at 80 percent (after deductible has been satisfied), and payment is made directly to the policyholder. There is no pharmacy network for CHIP. Click here to download a claim form (43 KB PDF) from this site.

5. When does the deductible start over?

January 1 of each year.

6. Can an individual purchase the pre-existing condition waiver rider if applying as a resident-eligible?

Yes, but he/she must qualify for this rider by being involuntarily terminated from the coverage and must apply for the rider within 30 days of such termination.

7. How long does an individual have to apply as a federal-eligible?

He/she must apply within 62 days following termination of group or COBRA coverage.

8. Can an individual qualify if he/she has an individual policy with high rates?

Yes, but the rates must be at least 50 percent higher than those of CHIP, or the policy must have substantially lesser benefits.

1. How do I file a claim?

Most providers will file your claim for you. You can file the claim when the provider does not. You may download a form (43 KB PDF) from this site. If you need help completing the form, call Customer Service at the number on your ID card or e-mail Customer Service.

2. Where do I mail the claim?

Mail the claim form to:

3. Will I be notified when you have processed my claim?

Yes, an Explanation of Benefits (EOB) will be mailed to you. The EOB details the amount paid to the service provider, any amount denied with the reasons for denial, and the portion you are responsible for paying.

1. What is preadmission certification, prenotification or precertification, and what do they have to do with my coverage?

Preadmission certification, prenotification and precertification are terms relating to medical cost-containment programs. They involve review of medical necessity and whether alternate treatment methods are more appropriate. You may have a penalty deducted from your medical benefits if you are required to prenotify or precertify and fail to do so. Your claim also could be denied if the service is not medically necessary. For more information, see Utilization Management. Consult your benefit booklet or call Customer Service at the number on your ID card to determine if you are subject to prenotification or precertification prior to receiving certain medical services.

2. What is a third-party claims administrator?

A third-party claims administrator is a company that provides claim-payment services to employer groups that are self-funded. The employer group designs the benefit package and establishes the guidelines for processing of claims. The third-party administrator issues the claim payments in accordance with these guidelines. The employer group reimburses the claim payments, as well as a fee for administration of the claims.

3. What is a provider?

A provider is a hospital, health-care facility, physician or other medical professional that provides health-care services.

4. What is a PPO?

PPO stands for preferred provider organization. A PPO is a health-care system that provides services to members at a discount or fixed fee. Preferred providers are those who participate in the network and agree to the discounts or fee schedule. Participating providers' charges for medical services usually are lower than those of providers outside the network. The lower charges save money for members (covered persons). Members also avoid filing claims since providers are responsible for filing claims with BlueAdvantage.

One of the PPOs available to BlueAdvantage groups is the Arkansas' FirstSource® PPO. Arkansas' FirstSource PPO has contracted with a group of providers statewide to form a network. To receive discounts and to have claims filed by the network provider, members must use those physicians and facilities that have contracted with the PPO.

5. What is an HMO?

HMO stands for health maintenance organization, a health-care system that assumes or shares both the financial and delivery risks associated with providing comprehensive medical services to a voluntarily enrolled population in a particular area, usually in return for a fixed, prepaid fee.

6. What is POS?

A point-of-service (POS) plan gives covered persons the option of going outside a designated network. However, reimbursement usually is significantly reduced for out-of-network services. For this reason, out-of-network utilization is traditionally very low.

7. What is CMM?

Under comprehensive major medical (CMM or Major Medical), covered persons pay a deductible, which is the first covered dollars of eligible charges incurred during the contract year. After the deductible has been met, the member will pay a percentage of the covered dollars until the calendar year, coinsurance maximum is reached. CMM is a traditional fee-for-service plan that provides the same level of benefits regardless of the medical provider chosen by the covered person. One difference between CMM and a PPO is that CMM has no network.

1. If I lose my identification (ID) card, how do I replace it?

Call Customer Service at 1-888-872-2531 to request a new ID card. You may order a replacement ID card through our self-service centers, My BlueLine or My Blueprint.

2. Why is it important to show my ID card to my provider of service?

Your ID card contains important information regarding program participation. It lets your provider of service know whether you participate in specific physician networks so that you may receive the highest benefit you are allowed. It also provides the ID number that is reflected in our claim processing system. This number is necessary to match the claim with the member when the claim is submitted and expedites the processing of your claim payment.

1. What is PCN?

PCN stands for primary care network. Participation in a PCN requires the selection of a primary care physician (PCP). The covered persons must consult first with their PCP, who will handle their treatment or, if necessary, refer them to a specialist or admit them to a hospital.

The benefit structure of the PCN differs somewhat from both a comprehensive major medical (CMM) plan and a preferred provider organization (PPO). A PCN commonly offers 100-percent reimbursement after an office-visit copayment for any services billed by the PCP (with the exception of inpatient surgery and obstetrics). Typically, specialist benefits are not eligible for reimbursement without being referred, ordered, arranged and authorized by the PCP (except for life/limb-threatening emergencies or other exceptions defined by the health plan).

2. What is a primary care physician (PCP)?

A primary care physician (PCP) is a medical professional who serves as a member's first contact with a plan's health-care system. The PCP is also known as a primary care provider, personal care physician or personal care provider. If your health plan has a primary care network, you will be required to select a PCP.

3. Do I need a referral from my primary care physician for specialist services?

For referral requirements, consult your benefit plan booklet or call Customer Service at the number on your ID card. You may choose to check your benefits online.

4. I participate in a primary care network (PCN). Do I have to select the same primary care physician for my entire family?

No. Primary care physician selection is specific to each member. Selection must be made from physicians authorized in your particular network. Contact your employer for a list of primary care physicians or go to Provider Directory.

5. May I change my primary care physician?

Yes. You may change your primary care physician, but your health plan may limit the frequency of changes. Contact your employer for information about changing your PCP. Ask your employer if you will need to complete a change form.

6. What should I do if my primary care physician is out of the office and I need immediate care?

Contact your primary care physician's office. Request services from your physician's backup. (All primary care physicians are required to have a backup.)

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