2016 Traditional Care Network (TCN) Benefits at a glance for General Motors UAW Trust members Group Number: 71436
Contents Traditional Care Network ................................................................ 2 Cost sharing summary and benefits at a glance.......................... 4 Understanding important terms ..................................................... 5 Explanation of benefits.................................................................. 14 Claims questions and appeals..................................................... 16 Contact information ......................................................Back cover
1
Traditional Care Network You have many options when it comes to choosing health care. Thank you for choosing the Blues.
ms/definitions
Hospital care
Call/nursing telephone support
Hospital and other services Alternatives to hospital care
Plan benefits
Ready to join
Maternity care
We offer: • Traditional Care Network (TCN) health plan (for members under and over 65 years old) Who can join
• Medicare Advantage health plan (for members enrolled in Medicare who are at least 65 or deemed eligible for Medicare)
and other services es to hospital care
nal medicare
Plan benefits
Ready to join
Maternity care
Other services
Mental health and substance abuse treatment
Questions
Leaving the hospital
DME
Organ transp
• Blue Care Network and Blue Care Network Advantage health plans (in Michigan only) Who can join
Member
Physicians/Providers
As a member of the UAW Retiree Medical Benefits Trust, you can choose one of several Blue plans that meet your needs and those of your family. Each plan offers you the same great benefits that come with being a Blue Cross Blue Shield of Michigan member.
he hospital
Questions
DME Preventive care
Prescription drugs
Deductible, coinsurance and dollar maximums
Reasons to join
Physicians/Providers Call/nursing telephone support
Eye car
Organ transplant
Member
Missouri
Customer service
There is always extra value when you choose Blue. With every Blue card, you receive additional support. Some of the programs we offer members include: Important terms/definitions
com/online/live n drugs
MyBlue Medicare Magazine Deductible, coinsurance and dollar maximums
Important terms/definitions
Hospital care
Physician office services Reasons to join
Hospital care
Outpatient diagnostic services
Hospital and other services Alternatives to hospital care
Surgical services
Call/nursing telephone support
Beyond original medicare Tobacco cessation Surgical services
heart failure or COPD
SilverSneakers Facing a complex medical condition
hearing
Hospital and other services Alternatives to hospital care
care PlanEye benefits
Ready to join
Other services Emergency hearing services
Shot
Who can join
Pneumonia
Customer service
Mental health and substance abuse Leaving the hospital treatment Coping with heart failure or COPD Facing a complex medical condition
Questions
DME
Where am i covered
Who can join Research monitors
Case Management solutions that assist with medical issues, give you access to experts who can coordinate treatments, and provide guidance and support. Questions Other services Mental health and substance abuse Leaving the hospital DME treatment You can call 1-800-845-5982 for direction. Shot
Beyond original medicare
Ready to join
Our tobacco cessation program that teaches you self-management and coping skills for smoking intervention and cessation. You can call 1-800-775-2583 to get started. Missouri
s diagnostic services
Plan benefits
Where am i covered
Pneumonia
Preventive care
Member
Physicians/Providers
Prescription drugs
Research monitors
Deductible, coinsurance and dollar maximums
Reasons to join
Physicians/Providers
Online health resources at bcbsm.com that include more than 90,000 medically reviewed resources in a number of formats, such as: Missouri
SilverSneakers Internet/bcbsm.com/online/live coaching
Preventive care
Prescription drugs
– libraries, encyclopedias and directories
MyBlue Medicare Magazine
Physician office services
Outpatient diagnostic services
Deductible, coinsurance and dollar
Surgical servicesmaximums
Customer ser
Reasons to join
hearing
Shot
– videos, calculators, podcasts, and animations
Pneumonia Missouri
– decision making guides and interactive quizzes Internet/bcbsm.com/online/live Everyday savings coaching
MyBlue Medicare Magazine
Tobacco cessation
Physician office services
Emergency services
Outpatient diagnostic services
Coping with heart failure or COPD
Surgical services
Facing a complex medical condition
hearing
Where am i covered
Research monitors
Shot
Pneum
Healthy Blue XtrasSM and Blue 365® programs offering discounts and exclusive savings on products, nutrition, travel, recreation, and gym memberships.
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Everyday savings
Tobacco cessation
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Research monitors
With the Traditional Care Network product (referred to as TCN), you have access to the largest network of doctors, hospitals, and other health care providers from which to choose within our preferred provider care organization (PPO). Our large network gives your family access to thousands of doctors and hospitals. More than likely, any doctor or hospital you choose will be in the network. Along with our expansive network, you will usually pay less when you use an in-network provider. Deductibles, co-insurance, copayments, and overall out of pocket expenses are less when you choose to use an in-network provider. If you go outside of the vast network of providers however, you will have to pay more for services. It’s easy to check to see if your provider is in the network by calling customer service at 1-877-832-2829 or going to bcbsm.com and searching under “Find A Doctor.” If you ever have any questions about • your coverage • bills you may have received • your explanation of benefits contact customer service at 1-877-832-2829. You can always find that number on the back of your card. Customer service representatives will be happy to answer any questions you may have. Thank you for being a member of Blue Cross Blue Shield of Michigan. Thank you for choosing the Traditional Care Network product.
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Plan benefits
Ready to join
2016
Questions
Benefits at a glance with cost sharing summary
Maternity care
Who can join
DME Organ transplant
Monthly contribution and out-of-pocket expenses Member
Physicians/Providers
Deductible, coinsurance and dollar maximums
You pay In network
Reasons to join
Monthly contribution –
Eye care
The monthly amount you must payMissouri in order to have coverage Customer service for yourself and your dependents hearing Deductible – per calendar year
Surgical services
Shot
Pneumonia
Coinsurance am i covered Out‑of‑pocketWhere maximum – per calendar year Research monitors
Facing a complex medical condition
Combination of deductible and coinsurance
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Out of network
Individual: $17 Family: $34
Individual: $385
Individual: $1,000
Family: $650
Family: $1,700
10%
30%
Individual: $755
Individual: $3,000
Family: $1,395
Family: $5,550
Understanding important terms Important terms/definitions
Hospital care
Call/nursing telephone support
Hospital and other services Alternatives to hospital care
Beyond original medicare
Other services
Mental health and substance abuse treatment
Leaving the hospital
Plan benefits
Ready to join
Insurance pays 100% Out-of-pocket maximum met
Questions
DME
$$$
Coinsurance
SilverSneakers
Preventive care
Deductible met Internet/bcbsm.com/online/live coaching
MyBlue Medicare Magazine
Prescription drugs
(you andDeductible, insurance coinsurance and dollar maximums share cost)
Reasons to join
$$ Physician office services
Outpatient diagnostic services
Surgical services
hearing
Deductible (you pay)
Everyday savings
Tobacco cessation
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Deductible — The amount you must pay toward covered medical services within a calendar year before the Plan begins to pay. This does not apply to services that require a copay. Coinsurance — The percentage you pay for covered services after you have met your deductible. Out-of-pocket maximum — The total amount you will pay in a calendar year. It is a combination of the deductible and coinsurance. Once paid, all covered services are paid at 100% for the rest of the calendar year. Copayment (copay) — A fixed amount you pay to receive a medical service, usually at the time the service is performed (office visits, emergency room, urgent care). Note that the copayment does not go toward paying the deductible, coinsurance or out-of-pocket maximum. Copays are separate and continue even after your out-of-pocket maximums are met. In-network providers — Providers (i.e., hospitals and doctors, etc.) that sign a contract agreeing to accept the allowed amount for a service as payment in full so that members will not be billed for the balance. Out-of-network providers — Providers (i.e., hospital and doctors, etc.) that have not signed a contract with the Blues to accept the approved amount and may bill for balances. Out-of-network providers may result in higher out-of-pocket costs.
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Who can join
2016 Benefits at a glance Mental health and substance abuse treatment
Leaving the hospital
Questions
DME
Organ transplant Member
You pay
Physicians/Providers
Preventive services Preventive care
Prescription drugs
Deductible, coinsurance and dollar maximums
In network
Out of network
Covered – 100%
Covered – subject to deductible and coinsurance Customer service
Reasons to join
Pap Smear Screening — one per calendar year
Missouri
Mammography Screening Routine and high-risk mammogram screening in accordance with Outpatient guidelines established by the American Physician office services diagnostic services Surgical services hearing Cancer Society – one routine exam per calendar year beginning at age 40. Under age 40, one per calendar year, if high-risk factors are present
Covered – 100%
Prostate Specific Antigen (PSA) Screening Screening test for asymptomatic males age 40 and older whenservices performed in accordance guidelines established Emergency Coping with heart failure or COPD with Facing a complex medical condiWhere am i covered tion by the American Cancer Society – one per calendar year
Covered – 100%
Shot
Covered – subject to deductible and coinsurance Pneumonia
Research monitors
Covered – subject to deductible and coinsurance
Early Detection Screening Tests Early detection screening for colon and rectal cancers when performed in accordance with guidelines established by the American Cancer Society. Barium Enema X-ray — one every 5 years age 50 and over (or at any age if risk factors are present); or Colonoscopy — one every 10 years age 50 and over (or at any age if risk factors are present); or
Covered – 100%
Not covered
Hepatitis C (HCV) Screening For enrollees who are at risk or when signs or symptoms are present which may indicate a Hepatitis C infection
Covered – 100%
Covered – subject to deductible and coinsurance
Well Baby – Six visits up to age 2
Covered – 100%
Not covered
Immunizations — age and frequency limitations for selected medically recognized immunizations at doctor’s office, retail health clinic, and certain immunizations at a pharmacy.
Covered – 100%
Sigmoidoscopy — one every five years age 50 and over (or at any age if risk factors are present) Fecal Occult Blood Test — one per calendar year beginning at age 50 Total serum cholesterol with low density lipoprotein (LDL) — one test every 5 years beginning at age 20
Bone Marrow Screening
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Not covered
Not covered
Not covered
Eye care
Physicians/Providers
Preventive care
Prescription drugs
Deductible, coinsurance and dollar maximums
Reasons to join Eye care
Missouri
You pay
Physician office services Call/nursing telephone support
Hospital and other services Outpatienttodiagnostic services Alternatives hospital care
Physician office services
Plan benefits
Non-Medicare members — Covered with $25 Shot copayment for the first sixPneumonia office visitsWho tocanajoinPrimary Care Physician, per year per member. 100% member Where am i covered copayment for specialists Research monitors and subsequent office visits at a discounted rate hearing
Office Visits — not subject to deductibles or Coping with heart failure or COPD Facing a complex medical condiout-of-pocket maximums Questions tion Leaving the hospital
Out of network
Ready to join
Surgical services
Emergency services
Mental health and substance abuse treatment
In network
Customer service
DME
Maternity care
Not covered Organ transplant
Member
Physicians/Providers Medicare members have coverage through Medicare.
Office Consultation & Outpatient Consultation — not subject to deductibles or out-of-pocket maximums
Covered at a 100% member copayment for Missouriprocedure codes certain Customer service allowed at discounted rate
Not covered
Retail Health Clinics
Covered – $50 copayment
Not covered
Preventive care
Physician office services
Prescription drugs
Outpatient diagnostic services
Deductible, coinsurance and dollar maximums
Surgical services
Reasons to join
Eye care
hearing
Shot
Emergency medical care Hospital Room Emergency services Emergency Coping with heart failure or COPD Facing a complex medical condiWhere am i covered tion Services rendered in the emergency room of a hospital for initial examination and treatment of condition resulting from accidental injury or qualifying medical emergency are covered. Medical emergencies will be considered to exist only if medical treatment is secured within 72 hours after the onset of condition. Physician Qualified Medical Emergency & First Aid Services Initial examination and treatment of a qualifying condition resulting from accidental injury or qualifying medical emergency. Medical emergencies will be considered to exist only if medical treatment is secured within 72 hours after the onset of condition. Urgent Care Centers Ground Ambulance — medically necessary transport Air/Water Ambulance Covers one-way transport from the scene of an emergency incident to the nearest available facility qualified to treat the patient, or transporting a patient one-way or round-trip from home to the nearest available facility qualified to treat the patient. Medical emergency/accidental injury patients are provided one-way transportation from home to the facility. Home bound patients are provided round trip transportation from home to the facility and back when medically necessary and when other means of transportation could not be used without endangering the patient’s health. Medical Emergency/Accidental Injury: Follow-Up Care
Pneumonia
You pay
In network
Out of network
Research monitors
Covered – $125 copayment waived if admitted
Covered – $125 copayment waived if admitted
Covered – 100%
Covered – 100%
Covered – $50 copayment Covered – subject to deductible and coinsurance
Not covered Covered – subject to deductible and coinsurance
Covered – 100% up to the allowed amount
Covered – 100% up to the allowed amount
Not covered
Not covered
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ice
Member
2016 Benefits at a glance
Physicians/Providers
Prescription drugs
Deductible, coinsurance and dollar maximums
Reasons to join
Diagnostic services
Eye care
Missouri
Customer service
Outpatient Magnetic Imaging (MRI), Surgical services Resonance hearing Magnetic Resonance Angiography (MRA) Use of MRI for diagnostic examination for all body Shot parts when ordered by a physician and performed on approved equipment. Must be performed at approved facilities.
You pay
In network
Out of network
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Outpatient diagnostic services
Preauthorization may Facing a complexbe medicalrequired. condiWhere am i covered
Coping with heart failure or COPD
tion
Other Outpatient Diagnostic Tests, X-rays, Laboratory & Pathology, PET, CAT Scans and Nuclear Medicine
Pneumonia
Research monitors
Preauthorization may be required. Radiation Therapy — for the diagnosis of condition, disease or injury. Preauthorization may be required.
Maternity services provided by a physician
You pay In network
Out of network
Pre-Natal and Post-Natal Care
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Delivery and Nursery Care
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Maternity care
Organ transplant
Abortions — must be medically necessary. For medically induced abortion by oral ingestion of medication when medically necessary Certified Nurse Midwife Eye care For a given uncomplicated pregnancy, reimbursement for such care would be to the physician or certified nurse midwife, but not both. Obstetrical services by certified nurse midwives are limited to basic antepartum care, normal vaginal deliveries, and postpartum care. Certified nurse midwives are reimbursed only for deliveries occurring in the inpatient setting or in a birthing center that is hospital affiliated, state licensed and accredited and approved by the carrier. The certified nurse midwife must be legally qualified and registered, certified nurse and/or licensed, as applicable, to perform these health care services.
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port
e abuse
You pay
Hospital care Hospital care
Call/nursing telephone support
Hospital and other services Alternatives to hospital care
In network Plan benefits
Semi-Private Room, General Nursing Services, Meals and Special Diets
Mental health and substance abuse treatment
Leaving the hospital
Who can join
Questions
DME
Inpatient Medical Care
MyBlue Medicare Magazine
Physician office services
Plan benefits
Prescription drugs
Outpatient diagnostic services
Deductible, coinsurance and dollar maximums
Reasons to join
Emergency services
Surgical services
Questions
Coping with heart failure or COPD
Facing a complex medical condition
Covered – subject to deductible and coinsurance Covered — subject to deductible and coinsurance Research monitors
Hospice Care (Provider approval required)
Coping with heart failure or COPD
Surgical services
Facing a complex medical condition
Organ transplant
Member
Out of network Not covered
Limited to 100 days per benefit period. Renewable after 60 days of continuous non-confinement. Covered — subject to deductible and coinsurance
Not covered
Limited to 2 days of hospice care for each remaining inpatient hospital day. Lifetime maximum of 210 days. Covered — subject to deductible and coinsurance
Not covered
Eye care
Missouri
Outpatient diagnostic services
You pay
In network
DME
Reasons to join
Pneumonia
Maternity care
Where am i covered
Physicians/Providers
Deductible, coinsurance and dollar maximums
Eye care
Customer service
Shot
Ready to join
Skilled Nursing Facility (Must be an approved BCBS Skilled Nursing Facility)
Prescription drugs
Covered – subject to deductible and coinsurance
Organ transplant
hearing
Who can join
Leaving the hospital
Covered – subject to deductible and coinsurance Missouri
Ambulatory Surgical Centers (Facility must satisfy Program requirements and be an approved facility)
Tobacco cessation
Covered – subject to deductible and coinsurance
Physicians/Providers
Alternatives to hospital care Hospital and other services Alternatives to hospital care
Covered – subject to deductible and coinsurance Member
Chemotherapy Coverage is provided for treatment of malignant disease and Hodgkins disease, except when the treatment is considered experimental or investigational. Preventive care
Covered — subject to deductible and coinsurance
Maternity care
Maximum 365 days for each continuous period of hospital confinement or for successive periods of confinement separated by less than 60 days.
(Predetermination required for non-Medicare members) Other services
Out of network
Covered – subject to deductible and coinsurance
Ready to join
Customer service
hearing
Where am i covered
Home Health Care (Facility approval required)
Shot
Pneumonia
Research monitors
Limited to 3 home health care visits for each remaining day of the inpatient hospital benefit period as long as the patient is medically eligible.
Not covered
Each visit by member of the home health care team, and each home health aide visit is considered the equivalent of 1 home visit.
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s
Organ transplant
2016 Benefits at a glance Member
Physicians/Providers
Deductible, coinsurance and dollar maximums
Reasons to join
Eye care
Missouri
You pay
Customer service
Outpatient surgical services hearing Surgery — includes materials, supplies, preoperative and postoperative care, and suture removal Shot Pneumonia
Surgical services
Maternity care
OPD
Voluntary Sterilization — excludes reversal sterilization
Facing a complex medical condition
Where am i covered
Research monitors
In network
Out of network
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
You pay
Human organ transplants
In network
Out of network
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Organ transplant
Specified Organ Transplants Preauthorization by Human Organ Transplant Program is required. All members must be enrolled in Case Management. Must be performed in a Blue Distinction Center.
Call/nursing telephone support
Eye care
Hospital and other services Alternatives to hospital care
Plan benefits
Ready to join
Maternity care
Mental health care and substance abuse treatment Mental health and substance abuse treatment
Leaving the hospital
Questions
You pay
Who can join
In network
Out of network
Inpatient: Up to 45 days treatment each for psychiatric and substance abuse covered — 100% up to the allowed amount.
DME
Organ transplant
Member
Physicians/Providers
Preventive care
Prescription drugs
Deductible, coinsurance and dollar maximums
Reasons to join
Eye care
Missouri
Services must be preauthorized by ValueOptions. For preauthorization, call 1-877-228-3912 (not mandatory for Medicare enrollees)
Physician office services
Outpatient diagnostic services
Surgical services
hearing
Shot
Emergency services
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Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Outpatient: Mental Health: Up to 35 visits covered per benefit period — Visits 1-20: 100% up to the allowed amount, Visits 21-35: 75% up to the allowed amount. Customer service
Pneumonia
Substance Abuse: Up to 35 visits per benefit period covered at 100% up to the allowed amount.
Research monitors
Inpatient: Not covered unless medical emergency admission. Outpatient: Mental Health: Up to 35 visits covered per benefit period — Visits 1-20: 100% up to the allowed amount, Visits 21-35: up to 75% of the allowed amount. Substance Abuse: Up to 35 visits per benefit period covered at 100% up to the allowed amount.
e
Hospital care
Call/nursing telephone support
Hospital and other services Alternatives to hospital care
Plan benefits
Ready to join Maternity care
Other services Allergy Testing
Other services
Mental health and substance abuse treatment
Leaving the hospital
In network Questions
DME
Allergy Therapy/Serum
Physician office services
Not covered
Not covered
Covered subject to deductible and coinsurance
Covered subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Covered – subject to deductible and coinsurance
Prescription drugs
Deductible, coinsurance and dollar maximums
Reasons to join
Outpatient diagnostic services
Surgical services
Missouri
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Durable Medical Equipment* Prosthetic and Orthotic Appliances Hair Pieces and Wigs — Wigs and appropriate related supplies (stand and tape) are covered for any age for an individual who is suffering hair loss from the effects of chemotherapy, radiation therapy or other treatments for cancer. For the initial purchase of wig and related supplies, the maximum benefit is $250. Thereafter, the maximum annual benefit is $125. Prosthetic and Orthotic: Jaw Motion Rehabilitation (Jaw motion rehabilitation system and related items) Diabetes Education Covers comprehensive American Diabetes Associationapproved education classes for newly-diagnosed or uncontrolled diabetics. Cardiac Rehabilitation – Only Phases I and II are covered Must begin within 3 months of a cardiac event and be completed within 6 months.
Customer service
Pneumonia
Limited to 60 combined visits per calendar year, per condition.
Where am i covered
Outpatient Physical, Speech and Occupational Therapy (medical necessity required)
Eye care
Covered — subject to deductible and coinsurance
hearing
Shot
Tobacco cessation
Organ transplant
Physicians/Providers
Excludes adjustment manipulation and initial office visit MyBlue Medicare Magazine
Out of network
Member
Chiropractic Care Emergency first aid and diagnostic x-ray of the spine only. Preventive care
You pay
Who can join
Research monitors
Services are covered when performed in the outpatient department of the hospital or approved freestanding facility. Therapy is also covered when provided by an in-network independent physical therapist, an independent occupational therapist, or speech and language pathologist.
Not covered
Covered — 100%
Not covered
Covered — 100%
Prosthetic & Orthotic appliances are not covered with the exception of wigs
Not covered
Not covered
Covered — 100%
Not covered
Up to 36 sessions (3 sessions per week for 12 weeks) covered at 100% up to the allowed amount
Not covered
*Durable Medical Equipment — Subject to deductible and coinsurance when processed as part of inpatient services or office services.
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nd dollar
condi-
2016 Benefits at a glance DME
Organ transplant
Member
Physicians/Providers
Reasons to join Eye care
Hearing care
Missouri
must be a participating provider hearing
Audiometric exam — once every 36 months Shot
Pneumonia
Hearing aid evaluation — once every 36 months
Where am i covered
You pay
Customer service
Research monitors
Maternity care
In network 100% up to the allowed amount 100% up to the allowed amount
Out of network Not covered Not covered
100% up to the standard hearing aid allowance
Not covered
Binaural hearing aids for children 19 and under — once every 36 months
100% up to the allowed amount
Not covered
Hearing Organ transplant aid conformity test — once every 36 months
100% up to the allowed amount
Not covered
Ordering and fitting the hearing aid (one monaural) standard or digital — every 36 months
Vision care Eye care
medical coverage
Routine exam
You pay In network
Out of network
Under the medical coverage, one routine vision exam covered with a $25 copayment, once every 24 months.
Under the medical coverage, one routine vision exam covered with a $25 copayment, once every 24 months.
Routine exams, frames, lenses and additional services -- Contact Davis Vision at 1-888-234-5164.
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use
Questions
Leaving the hospital
DME Organ transplant Member Physicians/Providers
Prescription drugs
You pay
Coverage administered by Express Scripts 866-662-0274 Prescription drugs
Deductible, coinsurance and dollar maximums
Retail (One-Month Supply)
Mail Order Outpatient diagnostic services Surgical services (90-Day Supply)
Tier 1: Generic $12
Reasons to join
Missouri
Customer service
Tier 3: Non-preferred Brand $100 Tier 1: Generic $24 Tier 2: Preferred Brand $80
hearing
Tier 3: Non-preferred Brand $200
Shot
Coping with heart failure or COPD
Facing a complex medical condition
Eye care
Tier 2: Preferred Brand $40
Where am i covered
Prescription Drug Categories
Pneumonia
Research monitors
Tier 1: Generic Medications (Equivalents or Alternatives) Important terms/definitions
Tier (Single Source, Sensitive Drug Classes) Hospital2: care Brand Medications Call/nursing telephone support Hospital and other services Preferred Plan benefitsBrand, andReady to join Alternatives to hospital care
Tier 3: Brand Medications (Multi-Source or Non-Preferred Brand) Who can join
Beyond original medicare
Other services
Mental health and substance abuse treatment
Leaving the hospital
Questions
DME
M Physicians/Providers
SilverSneakers
Preventive care
Prescription drugs
Deductible, coinsurance and dollar maximums
Reasons to join
Missouri
Internet/bcbsm.com/online/live coaching
MyBlue Medicare Magazine
Physician office services
Outpatient diagnostic services
Surgical services
hearing
Shot
Everyday savings
Tobacco cessation
Emergency services
Coping with heart failure or COPD
Facing a complex medical condition
Where am i covered
Pneumonia
Research monitors
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“EOB” stands for Explanation of Benefits As a member of the Traditional Care Network plan, once you have services performed, you will receive an Explanation of Benefits, or EOB. The EOB will show you: • What services you had and what the provider billed • What your Plan paid and any Blue Cross discounts that were applied • The amount you may owe through deductibles, coinsurance or copayments • Any non-covered services that were not payable through your benefit plan Reviewing your EOB statements is a good way to keep track of your medical care.
EOB Statement Details
1
Identifies who this EOB statement is for.
2
Summarizes claims by doctor, hospital, or other health care provider as follows:
A
The amount submitted to Blue Cross on the claim.
B
What you saved by being a Blue Cross member.
C
What Blue Cross paid.
D
Amounts any other insurance(s) paid.
E
What you pay. You may have already paid or may still owe this amount. You should never be asked to pay more than this amount.
3
Shows the balances to date for deductibles and out-ofpocket maximums for your current benefit period.
4
Important information about your coverage, tips to lower health care costs, and ways to improve overall health.
5
Customer Service information if you have questions about something on your statement.
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5
1
2
A
B
C
D
E
3
4
The statement shown is general and for illustrative purposes only. Your actual statement may look slightly different depending on your benefit plan.
6
Detailed information about each claim we processed. The sum of all claims in this section for the same provider should match the numbers in the Claim Summary section.
F
Information your provider puts on the claim to identify the medical service you received.
G
The unique number Blue Cross assigns to a claim. You can reference this number if you need to call us about this claim.
Important terms/definitions
Hospital care
6 F G
Page 2 of your statement shows your appeal rights and what you can do if you disagree with any of the benefit decisions made for a claim. You can also find definitions for terms used on the statement. Call/nursing telephone support
Hospital and other services Alternatives to hospital care
Plan benefits
Ready to join
Who
Beyond original medicare
Other services
Mental health and substance abuse treatment
Leaving the hospital
Questions
DME
Physicians/Provi
SilverSneakers
Preventive care
Prescription drugs
Deductible, coinsurance and dollar maximums
Reasons to join
Online EOBs Internet/bcbsm.com/online/live coaching
Everyday savings
Missouri
Log in at bcbsm.com if you want to view recent claims, deductibles, coinsurance MyBlue Medicare Magazine Physician office services Outpatient diagnostic services Surgical services hearing balances, and other information. It’s easy: 1.
Go to bcbsm.com and follow steps to create a login account.
2.
After logging in, select Claims in the blue bar near the top.
3. Tobacco Click on Explanation of Benefits statements. cessation Emergency services Coping with heart failure or COPD
Facing a complex medical condition
Shot
Where am i covered
Research m
Help us prevent fraud
Call/nursing telephone support
Checking to make sure you actually received services as shown on the EOB helps us prevent error and fraud. Call your customer service number 1-877-832-2829, if you have questions about a claim or EOB. Hospital and other services Alternatives to hospital care
Plan benefits
Ready to join
Maternity care
Who can join
Mental health and substance abuse treatment
Leaving the hospital
Questions
DME
15
Claim questions and appeals
1
To confirm you are paying the right amount, compare the EOB and the provider bill side-by-side. Match the service dates and the amounts. If they match, pay the provider that amount and file the EOB for your records.
16
After your claims are submitted to BCBS by your providers, you will receive an Explanation of Benefits. In addition, you will most likely receive a billing statement from your provider, showing any outstanding balances you may owe.
2
3
If the amounts do not match, or if you have questions, call customer service at 1-877-832-2829, as shown on the back of your BCBS identification card. A BCBS representative will be happy to review the EOB statement and answer your questions.
If you are not satisfied with the response or outcome from customer service, you may file an appeal with BCBS by completing an Auto/Inquiry Appeal form. The BCBS customer service representative can help you obtain the form.
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Once you receive the form, make sure to attach an explanation of your concern and copies of the statements in question. Check the Appeal Box on the form and mail to:
If the issue remains unresolved, you may file an appeal with the UAW Trust. Please see your Summary Plan for details.
Auto National Appeal Unit 600 Lafayette East – Mail Code #2004 Detroit, Michigan 48226-2998
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Contact information Blue Cross Blue Shield of Michigan
ValueOptions – Help Line
Hospital, Surgical/Medical Services For questions on benefits, claims or how to locate providers, 8 a. m. - 8 p.m. Eastern time, Monday – Friday
Precertification — Mental Health and Substance Abuse (required for non-Medicare members only) 1-877-228-3912
1-877-832-2829 Mailing Address (for claim inquiries):
Blue Card Access — National Provider Network
UAW Auto Retiree Service Center
Information on participating network providers at home and while traveling
P.O. Box 311088 Detroit, Michigan 48231
1-800-810-2583
Case Management Coordination of health care
Express Scripts (formerly Medco Health)
1-800-845-5982
Mail Order and Retail (Drug Stores) Prescription drug questions 1-866-662-0274
Retiree Health Care Connect The UAW Trust eligibility and call center Eligibility, membership, address changes, and ID card requests.
Delta Dental 1-800-524-0149
1-866-637-7555
Davis Vision Tobacco Cessation
1-888-234-5164
1-800-775-2583
Medicare
Veterans Health Administration
medicare.gov
va.gov/health
1-800-633-4227
1-877-222-8387
UAW Retiree Medical Benefits Trust uawtrust.org
Blue Cross Blue Shield of Michigan is proudly represented by the UAW R041223
