Frequently Asked Questions
Below are questions commonly received by our customer service representatives. For
additional information, see the Benefits section
or the Plans & Products 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.
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:
BlueAdvantage Administrators of Arkansas
P.O. Box 1460
Little Rock, AR 72203
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.
CHIP (Comprehensive Health Insurance Pool)
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?
If a person has Medicare
If a person receives any kind of state or government funding including Medicaid
- 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 (PDF)
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.
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 (PDF)
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:
BlueAdvantage Administrators of Arkansas
P.O. Box 1460
Little Rock, AR 72203
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.
Health Plan Definitions
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
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
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
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
Contact your primary care physician's office. Request services from your physician's
backup. (All primary care physicians are required to have a backup.)