The Primary Plan Pays First

When Medicare is primary submit claims to Medicare first.

Hospitals, physicians and other providers are required to submit your claims directly to Medicare, when Medicare is primary.

Medicare Part B Assignment And The Limiting Charge

If you have both Medicare Part B and Blue Cross and Blue Shield Service Benefit Plan coverage, always ask your physician if he or she accepts Medicare assignment. If your physician does not accept Medicare assignment, he or she may charge more than Medicare's allowance up to a limit set by Medicare called the limiting charge. We will pay for such services up to Medicare's limiting charge. Under Basic Option, the physician must also be a Preferred network provider.

All Providers Must File Claims For You

All physicians and other providers are required to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether they accept Medicare assignment or not and is required by law. In addition, doctors, suppliers and other providers must file Medicare Part B Claims electronically.

Please be sure your Blue Cross and Blue Shield Service Benefit Plan ID number is included on the Medicare claim form. This will help ensure that a claim for any balances remaining after Medicare's payment is forwarded to your Local Blue Cross and Blue Shield Plan for payment.

What Is Medicare Assignment?

When your doctor or supplier agrees to accept the charge approved by Medicare as total payment for services, this is called "accepting Medicare assignment." Medicare pays your doctor or supplier 80 percent of the Medicare-approved charge, after subtracting any part of the $135 annual deductible you have not met. For covered services, the doctor or supplier can charge you only for the amount applied to the deductible and the remaining 20 percent of the approved charge. This 20 percent is your coinsurance amount, which is usually paid by your Blue Cross and Blue Shield Service Benefit Plan coverage, as is the $135 Medicare annual deductible. If Medicare is your primary coverage, in most cases your Medicare and Standard Option coverage together cover the entire amount approved by Medicare for covered services. This is true for Basic Option only when you use Preferred providers for covered care. If you want to find a physician or supplier who accepts Medicare assignment, you can also get a listing of Medicare participating providers online at www.medicare.gov.

All Medicare participating providers agree to accept assignment on all claims. Non-participating Medicare providers can choose whether to accept Medicare assignment on a claim-by-claim basis.

"Limiting Charge"

The limiting charge places a limit on how much Non-participating Medicare physicians who do not accept Medicare assignment can charge their patients.

Physicians who do not accept Medicare assignment are required by law to accept the limiting charge as payment in full. You are not responsible for any difference between the limiting charge and the physician's charge. If this happens, please contact your local Social Security or Medicare office.

If your doctor accepts Medicare assignment, the law does not affect you. Remember, participating Medicare physicians always accept 100 percent of the Medicare approved amount as payment in full.

Private Contracts

Occasionally, a physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by the Original Medicare. If you sign this type of agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. Our payment will be limited to the amount we would have paid after Medicare's payment. You will be responsible for paying the difference between the amount billed and the amount we pay. It's important that you're aware that private contracts can substantially increase your out-of-pocket costs.

If Medicare Is Primary

If you are asked to complete a portion of the claim form, instructions on how to fill out a Medicare claim form are on the back of the form.

Keep these pointers in mind when you need to fill out this form:

• Look at box #2 on the form, labeled "Claim Number from Health Insurance Card." Write your Medicare identification number here — not your Blue Cross and Blue Shield Service Benefit Plan identification number. If you have a spouse with Medicare, remember that you and your spouse have different Medicare identification numbers. Your number includes any suffix or prefix letters that are shown with the number on your card.

• Look at box #5 where you see "Name and Address of Other Insurance, State Agency (Medicaid), or VA Office" followed by "Policy or Medical Assistance Number." Write "Blue Cross and Blue Shield Service Benefit Plan" and your Service Benefit Plan identification number here (it begins with "R"). If you have Self and Family coverage, all of your eligible family members have the same Service Benefit Plan number.

• Look in box #5 at the "Note" that reads: "If you do not want payment information on this claim released, put an (X) here." A small square follows, which you should not mark. Here's why: Your local Blue Cross and Blue Shield Plan needs information from Medicare before it can begin to process your claim. If you leave the square blank, Medicare will be able to send the information to your Local Plan, which will pay benefits for any remaining covered expenses on this claim.

If you include your Service Benefit Plan ID number, Medicare will send it directly to your local Blue Cross and Blue Shield Plan after Medicare has paid all of its benefits.

If you need to file for secondary benefits from the Service Benefit Plan, please take the following steps:

1. Ask your local Blue Cross and Blue Shield Plan for a Federal Employee Program (FEP) Health Benefits Claim Form. You can also access a copy of the claim form online from this web site by clicking here, Health Benefits Claim Form.

2. Fill out the form completely.

Be sure to give your correct Blue Cross and Blue Shield Service Benefit Plan identification number. And don't forget that you or the patient must sign the completed form.

3. Attach copies (not the originals) of the Medicare Summary Notice form.

4. Attach copies of itemized bills.

Keep the originals of all forms and bills in case you need them later.

5. Include a statement.

In some Plan areas, for supplies such as durable medical equipment, your physician must write a statement indicating why the item was obtained and how long it will be needed. Call your local Blue Cross and Blue Shield Plan to find out if this is necessary.

6. Include a special questionnaire.

If you received physical therapy, dental care resulting from an accident, home nursing care or mental health/substance abuse care, call your local Blue Cross and Blue Shield Plan to obtain a special questionnaire. You should have the questionnaire filled out by your physician before mailing your FEP Health Benefits Claim Form.

7. Send your claim to your local Blue Cross and Blue Shield Plan.

The sooner you submit your claims, the sooner you'll receive payment. But always remember that when there is a delay or problem of any kind, or you're not sure what to do:

Write or call your local Blue Cross and Blue Shield Plan! You'll find your local Plan's phone number on the back of your Service Benefit Plan ID card. Or, you can check the white pages of your phone book. You can also send an inquiry online using the Customer eService feature on this web site.

When The Service Benefit Plan Is Primary Submit Claims To Us First

When your Blue Cross and Blue Shield Service Benefit Plan Standard Option or Basic Option coverage is primary, you must pay the applicable Service Benefit Plan deductibles, copayments and coinsurance. These requirements are not waived unless Medicare is primary.

If Medicare is not primary and the Service Benefit Plan pays first, you may be required to submit the Medicare claim after we have paid our benefits. Contact your local Social Security Office or your local Medicare carrier for information on how to get Medicare claim forms and for information on how to file claims.

Don't forget precertification when the Blue Cross and Blue Shield Service Benefit Plan is primary. Whenever a Service Benefit Plan member is scheduled to go into the hospital, or within two business days after an emergency admission, the local Blue Cross and Blue Shield Plan must be contacted.

If you're not sure whether you need precertification, please call a customer service representative at your local Blue Cross and Blue Shield Plan. You'll find the phone number for your local Plan on the back of your Service Benefit Plan ID card, or check the white pages of your phone book. Precertification is important; if correct procedures are not followed, your hospital benefits will be reduced by $500 in those cases where you are responsible for making the call and getting precertification.

In some geographic areas, Preferred network, Participating or Member providers may help you obtain precertification. In other areas, you must ensure that the local Plan is called. You, your representative (for instance, a family member), your doctor or the hospital may make the call, but ultimately it is your responsibility to make sure precertification has been obtained.

If you have Medicare Part A (or other health insurance) as your primary carrier, you don't need precertification. Overseas and maternity admissions are also excluded from the precertification requirement.

Please refer to Section 3 in the 2008 Service Benefit Plan brochure for additional information about precertification for hospital admissions.

Preferred and Member hospitals will file claims for you, as will Preferred and Participating professional providers.

Important Tips

• Carry both your Medicare ID card and your Service Benefit Plan ID card with you at all times. They are your passports to quick service when you visit a hospital or physician. By presenting your cards, you often avoid being asked for a deposit for your care.

• Both your Medicare ID card and your Service Benefit Plan ID card have identification numbers on them that are yours alone. Write these numbers down and keep them in a safe place, in case you ever misplace your cards.

• Services not included in your coverage will be your responsibility to pay, so always refer to official Medicare publications and your Blue Cross and Blue Shield Service Benefit Plan brochure when you have doubts. Remember that these booklets change from year to year. You can get up-to-date copies of Medicare publications by calling 1.800.633.4227 and the 2008 Blue Cross and Blue Shield Service Benefit Plan brochure (RI 71-005) from your local Blue Cross and Blue Shield Plan.

• Be sure to keep a record of all bills you receive for health care. Note payments received or those made to physicians and hospitals on your behalf. That way you will know when something may not be right with a claim, and you'll be able to make an inquiry. If you need to write to your Blue Cross and Blue Shield Plan, always include both your Medicare and your Service Benefit Plan identification numbers. You'll find your local Plan's phone number on the back of your Service Benefit Plan ID card or in your local white pages. You can also contact the local Blue Cross and Blue Shield Plan under Customer eService.

Deadline For Filling Your Claims

If the Service Benefit Plan is the primary payer or you need to send a claim to us after Medicare's payment, you need to submit your claim and any supporting documentation, such as the provider's bill, to us as soon as possible. Your claims need to be submitted to the local Blue Cross and Blue Shield Plan by December 31 of the year after the year you receive the service. There are some exceptions to this timely filing rule, such as legal incapacity, however, you must submit the claim as soon as reasonably possible.

The Disputed Claims Process

If you disagree with our decision about your claim or request for services, supplies, drugs or precertification, you can appeal our decision using the disputed claims process.

First, you need to write to the address on your Blue Cross and Blue Shield Explanation of Benefits (EOB) to reconsider our initial decision or to the Retail Pharmacy Program or Mail Service Pharmacy Program for prescription drugs for the pharmacy to reconsider a decision. You must do this within six months from the date of the initial decision, and include any information about why you think the initial decision was wrong.

We have 30 days from the date we receive your request to pay the claim, maintain our denial or ask you for more information. If we need more information, you or your provider has 60 days to send us the information we requested.

If we maintain our denial of benefits, you may ask OPM to review the decision. You must write to OPM within 90 days after the date of our letter informing you of our decision.

OPM will review your disputed claim request and will use the information it collects from you and from us to determine if we correctly applied the terms of our contract when we denied your claim or request for service. OPM will send you a final decision within 60 days.

For a complete discussion of all of the steps in the disputed claims process, please see Section 8 in the 2008 Service Benefit Plan brochure.

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