Blue Cross Blue Shield TN Personal Dental Coverage | OpenPayer
Currentblue cross blue shield - tennesseePolicy N/A
Personal Dental Coverage Policy
Governs terms, conditions, eligibility, enrollment, premiums, and termination for individual dental insurance issued by BlueCross BlueShield of Tennessee for residents of Tennessee and their eligible dependents.
Policy Summary
Payerblue cross blue shield - tennessee
PolicyPersonal Dental Coverage Policy
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionProviders, members or dependents must submit claims to be reimbursed; obtain prior authorization when required.
No material clinical or coverage changes in this revision.
31 daystimeframe to enroll new dependents after qualifying event
1 yr 90 daystimeframe to submit claims
31 daysgrace period to pay premium
60 daystime to request policy reinstatement
$50individual deductible amount
Dental implants
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explicitly excluded service
Coverage, Enrollment, Claims, and Appeals Rules
Coverage and Administrative Criteria
Key coverage and administrative criteria:
Subscriber eligibility: enrolled under Personal Health Coverage; resident of Tennessee (not outside U.S. >6 months/year); if not a U.S. citizen maintain valid immigration status (student/work visa or green card); complete and submit signed Application; pay required premium as condition of enrollment.
From eligibility and enrollment provisions.
Dependent eligibility: dependents must be listed on the Application and may include spouse (as recognized under Tennessee law) and children (natural, legally adopted or placed for adoption, stepchildren, wards/guardianship, or covered by a Qualified Medical Child Support Order) who are age 25 or younger.
Enrollment rules: insurer determines eligibility after Application; family coverage requires enrolling all eligible dependents; applicant must pay required premium when enrolling; re-enrollment not permitted if prior coverage was terminated for reasons other than non-payment.
Adding dependents (newborns/adoptions/other qualifying events): newborns covered from birth; adopted/placed children covered from physical custody; must enroll new child within 31 days of acquisition or additional premium-related limits may apply; other new dependents (e.g., marriage) must be enrolled within 31 days of eligibility.
Effective date: if eligible, applied and premium paid, insurer will notify Subscriber of the Effective Date; qualifying-event enrollments effective as of the event date if enrolled within 31 days and premium received.
Premiums and payment: premiums due as stated on policy face page; payment must be received at insurer office in Chattanooga, Tennessee; policy term equals premium payment period; premiums must be paid in full on or before due date.
ANY of the following
Insurer may change Premium or rate basis on any Premium due date or when Policy terms change; must notify Subscriber at least 30 days before change.
Premium may change automatically when benefits change, Covered Dependents are added/deleted, or as dependents age per rating rules.
Scope and limitations: policy pays only for services specifically listed as Covered in Attachment C; services not listed are excluded even if ordered by a provider.
Residency and jurisdiction: Subscriber must be a resident of Tennessee; policy references Tennessee law for spouse recognition and requires payments to be received in Chattanooga, Tennessee.
Consent and release: Member signature on the Application authorizes insurer to receive, use and release personal and dental records for policy administration; consent provisions apply to covered services and survive termination for services rendered while insured.
Termination, grace, reinstatement
Rules determining termination, exceptions, grace, and reinstatement of coverage.
Policy termination events: policy renewable until first of: nonpayment of premium; Subscriber request to terminate (effective first day of month after receipt of notice unless otherwise requested); failure to cooperate; move outside Tennessee; material misrepresentation or fraud; insurer decision to terminate the coverage type for a class; insurer ceases to offer this coverage in the individual market.
Dependent termination: Covered Dependent's coverage ends on earliest of: Subscriber's coverage termination; last day of month for which dependent premium was paid; date dependent is no longer eligible (e.g., reaches specified age); date dependent enters active duty in armed forces.
Exceptions for disabled dependents: coverage for mentally retarded or physically handicapped dependents will not terminate due to age if dependent is incapable of self-support and mainly dependent on Subscriber, provided required proof is furnished within 31 days and premiums are paid; insurer may request proof no more than once per year.
Grace period: Subscriber has a 31-day grace period to pay premium. If premium paid during grace period, coverage continues and claims incurred during grace period are honored. If not paid in full during grace period, coverage terminates retroactive to the premium due date. Insurer may suspend payments to Providers rendering services during the grace period; Subscriber is liable for provider charges for services rendered during the grace period.
Claims and payment
Claims submission, billing responsibilities, payment timing, assignment, and required information.
Claim types defined: pre-service claim (requires approval before care), post-service claim (services already provided), and urgent care claim (care that if delayed could jeopardize life/health/function or cause severe unmanaged pain). A denied urgent care claim is treated as a pre-service claim.
Billing responsibility and claim submission deadlines: Members or Covered Dependents are responsible for difference between Provider billed charges and the Maximum Allowable Charge; Provider, Subscriber or Covered Dependent must submit a claim to be reimbursed. Claims must be submitted within 1 year and 90 days from the date the Covered Service was received; if not timely submitted it will not be paid unless it was not reasonably possible to submit within that period.
Payment timing and basis: insurer will reimburse Subscriber or pay Provider according to Maximum Allowable Charges in Attachment C; insurer will pay benefits within 30 days after receipt of a complete claim form; termination of policy does not change the 1 year and 90 day claim submission requirement for prior services.
Assignment of benefits: if Subscriber assigns payment to a Provider, insurer must honor the assignment and pay the Provider; if Subscriber has already paid the Provider and also assigned payment, insurer must still pay the Provider.
Subrogation / Right of recovery
Subrogation and right of recovery provisions.
Subrogation/right of recovery: insurer is subrogated to and has the right to recover amounts paid for Covered Services related to dental illness or injury caused by third parties; insurer has first lien against payments, judgments or settlements that Subscriber receives for dental expenses; Subscriber must promptly notify insurer if third party caused the illness/injury, cooperate, and execute documents necessary to protect insurer rights. Insurer may recover attorneys' fees and enforce rights against tortfeasors, other responsible third parties or available insurance (including underinsured/uninsured motorist coverages). If Subscriber settles a claim, insurer may collect present value of its rights immediately from settlement proceeds, which Subscriber shall hold in trust for insurer.
Grievance and appeals
Grievance procedure and appeals for adverse benefit determinations or other disputes with the insurer.
Scope: grievance procedure covers disputes subject to insurer control, including adverse benefit determinations (denial, reduction, termination or failure to provide/make payment for a service). Procedure cannot resolve provider negligence/quality-of-care claims. Subscriber may authorize others to act on their behalf.
Informal inquiry: an Inquiry is an informal customer service contact that may resolve issues but does not toll grievance filing deadlines and is not required before filing a Grievance.
Filing deadline: Grievances must be initiated in writing within 180 days from the date the insurer issues notice of an adverse benefit determination or from the date of the event causing dissatisfaction.
First-level grievance and hearing: after receipt, first level grievance committee (or qualified reviewers for urgent/pre-service claims) will meet to consider the grievance; individuals involved in prior determinations cannot be voting members; committee has discretionary authority to make eligibility/benefit/claim determinations.
Covered Services and Limitations
Covered services and rules for eligible expenses and providers
Definition of covered services: insurer pays the Maximum Allowable Charge for Covered dental services rendered while the Policy is in force and Member is covered; only services listed in Attachment C are Covered.
Provider and eligible expense requirements: services must be performed by a Practitioner and within the practitioner's specialty or degree to be an eligible expense.
When expense is incurred: defines dates for incurrence - dentures on date of delivery; fixed bridges/crowns/onlays on date teeth are seated; root canal on date pulp chamber opened; periodontal surgery on surgery date; all other services on service date.
Coordination and administrative rules: this individual policy does not coordinate with other insurance (pays secondary to group plan when applicable); insurer may change policy terms only by written agreement with an authorized officer and will notify at least 30 days before renewal changes; notices must be written and sent to insurer address; members must keep address updated.
Coverage criteria and limits
Covered services, limits and exclusions
Covered service categories: Diagnostic & preventive; restorative; major restorative; endodontic; periodontic; removable and fixed prosthetic; oral surgery; and listed miscellaneous services — only services in Attachment C are covered.
Diagnostic and preventive limits: exams limited to 2 per 12 months; intraoral complete series X-rays limited to 1 per 36 months; bitewings limited to 4 films per 12 months; panoramic X-ray 1 per 36 months; prophylaxis limited to 2 per 12 months; fluoride limited to 1 per 12 months for members up to age 18; sealants limited for first and second permanent molars up to age 19; periodontal maintenance limited to 2 per 12 months when following active therapy.
Prosthetic replacement and crown replacement intervals: replacement of prosthetic appliances (including crowns, bridges, dentures, onlays) covered only after the probationary period shown in Attachment C and 5 years have elapsed since existing appliance was supplied; crowns covered only when required for restorative reasons and not restorable by filling materials; replacement eligible after probationary period and 5 years since prior installation.
Least expensive alternative: when multiple professionally acceptable treatments exist, insurer may pay for the least expensive Covered Service alternative; Member is responsible for any cost difference.
Schedule of Benefits criteria
Procedure-level allowable charges and service groupings included in Attachment C (partial list):
Sample CDT entries and example allowable charges: includes numerous CDT codes with Maximum Allowable Charges such as D4273 (Subepithelial Connective Tissue Graft) $231/$254, periodontal codes D4341 $68/D4342 $34, removable prosthetic codes D5110/D5120 Complete Denture $360, D5130/D5140 Immediate Denture $393, partial denture entries D5211–D5226 with listed charges, repair/adjustment entries (D5410–D5751) and overdenture examples D5863–D5866 with charges (e.g., $360).
Financial limits and cost-sharing: Deductible: Individual $50, Family $150; diagnostic and preventive services are exempt from the deductible (as noted in Attachment C).
Probationary period and annual maximum: Probationary Period of 12 months applies to Major Restorative, Periodontic, Removable and Fixed Prosthetic Services as shown in Attachment C; a Calendar year Annual Maximum per subscriber and each covered dependent is specified in Attachment C (specific amount not included in this extract).
ANY of the following
D3310 Root Canal-Anterior — Maximum Allowable Charge = $216.
Privacy notice summary
Privacy and PHI handling rules (informational):
Permitted uses and disclosures: health plan information may be used/disclosed for treatment, payment, and health care operations (including premium rating, quality assessment, care coordination, fraud prevention). Underwriting uses permitted with GINA restriction. Marketing, research and other disclosures allowed as described in the notice, subject to opt-in/opt-out rules for certain marketing.
Authorizations and restrictions: written authorization required for uses/disclosures not described in the notice (e.g., psychotherapy notes, marketing unrelated to health, sale of PHI); authorizations may be revoked prospectively; personal representative disclosures and plan sponsor disclosures described.
Military and federal disclosures: health plan information of Armed Forces personnel may be disclosed to Military authorities and authorized federal officials as required for lawful intelligence, counterintelligence, and national security activities.
Individual rights summary: Members have rights to access designated record sets (fees apply: $0.25 per page, $10 per hour staff time, postage), accounting of disclosures for the past six years, and to request restrictions on uses/disclosures (company not required to agree).
Member privacy rights and company obligations
Member rights and company responses for handling health plan information
Access to records: Member may request access or copies of health plan information by written request using forms from the Privacy Office; company may charge $0.25 per page, $10 per hour staff time, postage, and requires advance payment; alternative formats or summaries may incur fees.
Accounting of disclosures: Member may request an accounting of disclosures for the past six years (excluding treatment/payment/health care operations); repeated requests in a 12-month period may incur reasonable cost-based charges; contact Privacy Office for details.
Restrictions and confidential communications: Member may request restrictions on uses/disclosures (company not required to agree; only binding if in writing signed by Privacy Office representative). Member may request confidential communications by alternate methods/addresses if normal delivery may endanger them; immediate requests by phone permitted with written follow-up.
Breach notice: company will notify Members following a breach of unsecured protected health information including date, type of data, parties involved, and corrective actions taken.
Code Lists, Fee Schedule, Deductibles, and Claim Deadlines
Payment basismixed
Reimbursements are made according to Maximum Allowable Charges in Attachment C
Dental procedure codesmixed
ADA Code
The American Dental Association Code assigned to a particular dental procedure.
Partial CDT fee schedule (Attachment C excerpt)CPTCovered
D0120
Periodic Oral Evaluation
D0210
Intraoral-Complete Series Including Bitewings
D1110
Prophylaxis-Adult
D3310
Root Canal-Anterior (Excluding Final Restoration)
D5110
Complete Denture-Maxillary
Sample CDT codes with allowable chargesmixedCovered
Claim filing deadlineClaims must be submitted within 1 year and 90 days from the date a Covered Service was received; claims for services rendered prior to policy termination must also be submitted within 1 year and 90 days.
Exception if not reasonably possibleIf it is not reasonably possible to submit within 1 year and 90 days, the claim will not be invalidated or reduced (company will consider circumstances).
Provider/patient responsibilityThe Provider, Subscriber or Covered Dependent must submit the claim to BlueCross to be reimbursed; claim forms available from customer service (sent within 15 days on request).
inv-16: Family Deductible satisfaction rule
Family Deductible definition
What Providers and Members Must Do
Documentation Required
Release of Information Authorization
You authorize and consent to Our receipt, use and release of personal information for Yourself and all Covered Dependents. This consent includes any and all dental records, obtained, used or released in connection with administration of the Policy, subject to applicable laws. Such consent is deemed given by Your signature on the Application. Additional consent may be required whenever You or Your Covered Dependents obtain Covered Services under this Policy. This authorization and consent remains in effect throughout the period You and Your Dependents are Covered under this Policy. This consent survives the termination of the Coverage to the extent that such information or records relate to services rendered while You and Your Dependents were insured under the Policy.
You may also be required to consent to the release of personally identifiable health information in connection with the administration of the Policy.
Billing Rule
Claims submission and prior authorization responsibility
Key Definitions and Terms
inv-27: Member / Subscriber / Coverage
MemberAny person enrolled as a Subscriber or Covered Dependent under this Policy; defined term 'Member' includes Subscriber and Covered Dependents.
SubscriberAn individual to whom the Policy is issued, who has applied for Coverage and for whom applicable Premium has been received (referred to as 'You' or 'Your').
CoverageThe insurance benefits the Subscriber is entitled to under this Policy (the Policy describes terms, conditions, exclusions and limitations).
inv-28: pre-service claim — definition
Pre-service claim — definitionA pre-service claim is any claim that requires approval of a Covered Service in advance of obtaining dental care as a condition of receipt of a Covered Service in whole or in part.
Use case
Policy Summary
Payerblue cross blue shield - tennessee
PolicyPersonal Dental Coverage Policy
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionProviders, members or dependents must submit claims to be reimbursed; obtain prior authorization when required.
Reinstatement: Subscriber may request reinstatement in writing within 60 days of the last paid day; insurer will notify within 45 days whether it will reinstate. If reinstated, there is no gap in coverage; Subscriber must pay a reinstatement fee and required premium for the lapsed period. Requests after 60 days require a new Application, insurer will notify within 45 days and a gap in coverage and new Effective Date will occur.
Complete information and claim forms: Subscriber or Provider should complete claim forms (available from customer service) to ensure efficient processing; insurer will send a claim form within 15 days upon request; proof of payment acceptable to insurer must be submitted with the claim form; mail claim forms to address on dental ID card.
First-level decision timelines: written decisions are sent as follows: pre-service within 30 days of receipt; post-service within 60 days; pre-service urgent care within 72 hours. Decision includes statement of understanding, basis for decision, and reference to documentation (copies provided upon written request).
Second-level grievance: Subscriber may request reconsideration within 90 days of first-level decision; second-level committee members not involved in first-level decision; Subscriber may request in-person or telephonic hearing, present new information and question witnesses. Second-level written decision timelines and further appeal rights described in policy.
Independent external review and legal timing: insurer will provide for independent review for certain medical necessity or rescission determinations; independent reviewer deadlines include 45 days for standard determinations and 72 hours for life-threatening urgent matters; insurer will pay reviewer fee and submit information within 5 business days; no legal action may be brought until 60 days after proof of loss furnished and no action after 3 years.
Grievance and independent review references: first and second level grievance procedures, timelines for decisions, rights to hearings and independent external review for medical necessity or coverage rescission determinations are provided per the Grievance section.
Legal limits and recovery: no action may be brought until 60 days after proof of loss furnished; no action after 3 years; insurer may recover administrative overpayments within specified timeframes except in cases of fraud or incomplete information.
Exclusions (non-covered services): list includes any procedure not in Attachment C; services not deemed Necessary Dental Care or not authorized; charges over Maximum Allowable Charge; overdentures; cosmetic procedures; dental implants; replacement of lost/stolen appliances; athletic mouth guards; denture duplication; oral hygiene instruction; prescription/take-home fluoride; diagnostic photographs; services not completed by coverage termination; experimental/investigational services; services related to felony or work-related injuries; services before effective date; telephone/email consultations; charges for completing claim forms; services by certain relatives; pharmaceuticals except as specified; and other exclusions listed in Attachment B.
Provider eligibility rule reiterated: services must be performed by a Practitioner within his/her specialty or degree to be eligible expenses.
Expense timing reiterated: defines incurrence dates for dentures, crowns/bridges, root canals, periodontal surgery and other services.
Fee schedule reference: Attachment C contains detailed CDT codes with Maximum Allowable Charges for diagnostic, preventive, restorative, major restorative, endodontic, periodontic, and removable prosthetic codes (partial schedule included in this extract).
D5110 Complete Denture-Maxillary — Maximum Allowable Charge = $360.
Attachment C is the authoritative Schedule of Benefits containing the full fee schedule and allowable charges for covered CDT codes; providers should reference Attachment C for exact allowable amounts per code.
Amendments and complaints: Member may request amendment of health plan information in writing; company will respond and may deny for permitted reasons with written explanation; Members may contact the Privacy Office for questions or complaints or file with HHS; no retaliation for filing complaints.
Privacy Office contact: Members may contact the Privacy Office for more information or to file complaints; contact information is provided in the notice.
Family Deductible is the maximum dollar amount a Subscriber and Covered Dependents must incur and pay during a Calendar Year as specified in Attachment C.
Satisfaction ruleOnce the Family Deductible amount has been satisfied by 3 or more Covered Family Members during a Calendar Year, the Deductible will be considered satisfied for all Covered Family Members for the remainder of that Calendar Year.
Charge basis exclusionAny balance of charges between Billed Charges and the Maximum Allowable Charge will not be considered when determining if the Family Deductible has been satisfied.
inv-17: Example maximum allowable charge entries present
D1110 - Prophylaxis-AdultAllowable Charge example entries shown in Attachment C (Prophylaxis entries include $48 for D1120 child; D1110 continuation in schedule).
inv-18: Deductible — individual and family deductible amounts and applicability
Individual Deductible$50 per Calendar Year (Attachment C).
Family Deductible$150 per Calendar Year (Attachment C).
Deductible exemptionDeductible does not apply to Diagnostic and Preventive Services.
inv-19: Annual maximum — calendar year maximum per subscriber and dependent (value not in excerpt)
Calendar year maximum (scope)There is a Calendar Year Maximum payable per Subscriber and each Covered Dependent (specified in Attachment C).
Specific amount not shownThe exact dollar amount for the Calendar Year Maximum is not included in the provided excerpt of Attachment C.
Applies per memberThe Calendar Year Maximum applies to each Member under this Policy (Attachment C definition).
You or Your Covered Dependents may be charged or billed by a Provider for Covered Services rendered by that Provider. You or Your Covered Dependents are responsible for the difference between Billed Charges and the Maximum Allowable Charge for a Covered Service. The Provider, You or Your Covered Dependents must submit a claim to Us to be reimbursed. Claims must be submitted within 1 year and 90 days from the date a Covered Service was received; if not submitted within that time frame, the claim will not be paid unless it was not reasonably possible to submit on time. A Provider, You or Your Covered Dependents are also responsible for complying with Our policies or procedures, including obtaining Prior Authorization when necessary. Providers, You or Your Covered Dependents may request claim forms from customer service; we will send a form within 15 days. We may request additional information or documentation reasonably necessary to make a coverage decision.
Claims must be submitted within 1 year and 90 days of service.
Providers, Subscribers or Dependents may request a claim form; we will send it within 15 days.
Prior Authorization required when specified by Us.
Denial Risk
Payment suspension during Grace Period
You have a 31-day Grace Period in which to pay your Premium. If You pay the Premium during the Grace Period, Your Coverage will continue and claims for Covered Services incurred during the Grace Period will be honored. If You do not pay the Premium due, in full, during the Grace Period, Your Coverage will terminate retroactive to the Premium due date. We may suspend payments to Providers rendering services to You during the Grace Period. You will be liable for Providers' charges for services rendered during the Grace Period.
Grace Period = 31 days.
We may suspend payments to Providers during the Grace Period.
Prior Authorization
Prior Authorization
Prior Authorization is a review conducted by Us, prior to the delivery of certain services, to determine if such services will be considered Covered Services. Providers and Members must obtain Prior Authorization for services when required by Us; failure to obtain required Prior Authorization may result in denial of coverage.
Prior Authorization is required for certain services as determined by the Plan.
Prior Authorization decisions are made before services are delivered and affect coverage determination.
Note
Covered services list requirement
Personal Dental Coverage provides a wide range of benefits to cover most services associated with dental care. Only the services listed in Attachment C will be Covered. Services include diagnostic and preventive, restorative, major restorative, endodontic, periodontic, removable prosthetic, fixed prosthetic, oral surgical services, and listed miscellaneous services.
Only services listed in Attachment C are Covered.
Covered categories include Diagnostic & Preventive; Restorative; Major Restorative; Endodontic; Periodontic; Removable & Fixed Prosthetic; Oral Surgery; Miscellaneous.
Note
Probationary Period note
The Probationary Period applies to Major Restorative Services, Periodontic Services, Removable Prosthetic Services and Fixed Prosthetic Services as shown in Attachment C. The Probationary Period for applicable classes of benefits is 12 months where indicated.
Probationary Period for specified services = 12 months (see Attachment C).
Note
Military and federal authority disclosures
Health Plan information of Armed Forces personnel may be disclosed to Military authorities under certain circumstances. Health Plan information may also be disclosed to authorized federal officials as required for lawful intelligence, counterintelligence, and other national security activities. Providers and Members should be aware these disclosures are permitted by law and may occur without additional authorization when applicable.
Disclosures to Military authorities permitted for Armed Forces personnel.
Disclosures to authorized federal officials permitted for lawful intelligence, counterintelligence, and national security activities.
Pre-service claims are required when Prior Authorization is needed before services are provided.
Relation to Urgent CareA denied Urgent Care claim is always treated as a pre-service claim.
inv-29: post-service claim — definition (claim for services already provided)
Post-service claim — definitionA post-service claim is a claim for a Covered Service that is not a pre-service claim; the dental care has already been provided to the Member.
BillingOnly post-service claims can be billed to the Member or the insurer under this Policy.
Submission timeframePost-service claims must be submitted within the standard claim filing deadline (1 year and 90 days) to be paid.
inv-30: Urgent Care — definition and criteria for urgent care designation
Urgent Care — definitionUrgent Care is dental care or treatment that, if delayed or denied, could seriously jeopardize the Member's life or health or ability to regain maximum function, or would subject the Member to severe unmanaged pain that cannot be adequately controlled without the care.
Clinical determinationUrgent Care designation may be made by a dentist or physician with knowledge of the Member's dental condition.
Claims handling noteA claim for denied Urgent Care is always treated as a pre-service claim (special handling in grievance procedures).
inv-31: Maximum Allowable Charge — definition of insurer-determined maximum payable amount
DefinitionMaximum Allowable Charge is the amount that We, at Our sole discretion, have determined to be the maximum amount payable for a Covered Service based on Our fee schedule (Attachment C).
Payment effectBlueCross will reimburse You or pay the Provider according to the Maximum Allowable Charges in Attachment C; Our payment fully discharges Our obligation for that claim.
Billed charges relationAny difference between Billed Charges and the Maximum Allowable Charge is the Member's responsibility and is not considered when determining Deductible satisfaction.
inv-32: Covered Services / Necessary Dental Care — definition of covered and necessary dental services
Covered ServicesCovered Services are those procedures performed by a duly licensed Practitioner, deemed Necessary Dental Care and listed as Covered Services in Attachment C, subject to all Policy terms, exclusions and limitations.
Practitioner requirementServices must be performed by a Practitioner within his or her specialty or degree to be eligible expenses.
Attachment C limitationOnly services listed in Attachment C will be Covered; services not listed are excluded even if recommended by a provider.
inv-33: Prior Authorization — definition of prior authorization process
Prior Authorization — definitionPrior Authorization is a review conducted by Us, prior to the delivery of certain services, to determine if such services will be considered Covered Services.
When requiredMembers and Providers are responsible for obtaining Prior Authorization when necessary as a condition of coverage or reimbursement.
Relation to pre-service claimsPrior Authorization requests are processed as pre-service claims when required before care is provided.
inv-34: Subscriber / Member — restated subscriber/member definitions with pronouns
Subscriber (You, Your)An individual who meets eligibility requirements, has applied for Coverage, paid the applicable Premium, and to whom the Policy was issued; referred to as 'You' or 'Your'.
MemberIncludes the Subscriber and Covered Dependents; 'Member' means a Subscriber or a Covered Dependent.
Pronoun usagePolicy uses 'You' and 'Your' to refer to the Subscriber; defined terms are capitalized throughout the Policy.
inv-35: Practitioner — definition
Practitioner — definitionA Practitioner includes a Dentist acting within the scope of his or her license, a physician performing dental services within the scope of his or her license, or other persons licensed by the State to provide dental services (e.g., licensed dental hygienist under supervision).
Scope requirementServices must be performed by a Practitioner within his/her specialty or degree to be eligible expenses under the Policy.
inv-36: Expenses Incurred — rules for when expenses are considered incurred for various services
General rule — expenses incurredAn eligible expense is considered incurred on the date the service is performed unless otherwise specified for particular services.
DenturesFor full and partial dentures, the eligible expense is considered incurred on the date of delivery.
Fixed prosthetics and othersFor fixed bridges, crowns, inlays and onlays — incurred on the date the teeth are seated; root canal therapy — on the date the pulp chamber is opened; periodontal surgery — on the date the surgery is performed.
inv-37: BlueCross legal obligations to maintain privacy of health plan information and provide notice of privacy practices
Legal obligation to maintain privacyBlueCross is required to maintain the privacy of all health plan information and provide this notice of privacy practices to Members, following applicable laws and regulations.
Notice changesBlueCross may change privacy practices and will notify Members of any changes by issuing a new notice; practices apply to information created or received before the change.
Contact for notice copyMembers may request a copy of the notice of privacy practices at any time by contacting BlueCross at the address on the notice.
inv-38: Permitted uses and disclosures of health plan information
Permitted uses — treatment/payment/operationsHealth plan information may be used and disclosed for Treatment, Payment, and Health Care Operations (e.g., to providers for treatment, to pay claims, and for administrative functions like premium determination and care coordination).
Underwriting & GINA restrictionPHI may be used for underwriting and premium rating, but health plans are prohibited from using or disclosing genetic information for underwriting purposes per GINA.
Other permitted usesUses also include Marketing (with opt-out/opt-in rules), Research, disclosures as required by law, military authorities, court orders, and other legal requirements as described in the notice.
inv-39: Designated Record Set — what members can inspect or obtain
Designated Record Set — right to accessYou have the right to look at or get copies of Your health plan information in the Designated Record Set by written request to the Privacy Office; fees apply ($0.25 per page, $10 per hour staff time) and advance payment is required for copying.
Scope of setThe Designated Record Set includes health plan information maintained by BlueCross, subject to limited exceptions under applicable law.
Request processRequests must be made in writing using a form available from the Privacy Office; alternative formats or summaries may be provided for a fee.
inv-40: Breach Notice — member rights to notification following a breach of unsecured PHI
Breach notice rightsYou have the right to notice following a breach of unsecured protected health information; the notice will include at minimum the date of the breach, type of data disclosed, who accessed and received the disclosure, and corrective actions taken.
Scope of notificationNotice applies to breaches of unsecured PHI and describes actions to prevent further non-permitted disclosures.
Member remediesCompany will provide the required breach notice information to affected Members as described in the policy's Individual Rights section.