Member Rights and Responsibilities

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As a Blue Cross and Blue Shield of North Carolina (Blue Cross NC) member, you have certain rights and responsibilities.

Your Rights

As a Blue Cross NC member, you have the right to:

  • Receive information about your coverage and your rights and responsibilities as a member.
  • Receive, upon request, facts about your plan, including a list of doctors and health care services covered.
  • Receive polite service and respect from Blue Cross NC.
  • Receive polite service and respect from the doctors who are part of the Blue Cross NC networks.
  • Receive the reasons why Blue Cross NC denied a request for treatment or health care service, and the rules used to reach those results.
  • Receive, upon request, details on the rules used by Blue Cross NC to decide whether a procedure, treatment, site, equipment, drug or device needs prior approval.
  • Receive, upon request, a copy of Blue Cross NC's list of covered prescription drugs. You can also request updates about when a drug may become covered.
  • Receive clear and correct facts to help you make your own health care choices.
  • Play an active part in your health care and discuss treatment options with your doctor without regard to cost or benefit coverage.
  • Participate with practitioners in making decisions about your health care.
  • Expect that Blue Cross NC will take measures to keep your health information private and protect your health care records.
  • Voice complaints and expect a fair and quick appeals process for addressing any concerns you may have with Blue Cross NC.
  • Make recommendations regarding Blue Cross NC's member rights and responsibilities policies.
  • Receive information about Blue Cross NC, its services, its practitioners and providers and members' rights and responsibilities.
  • Be treated with respect and recognition of your dignity and right to privacy.

Your Responsibilities

As a Blue Cross NC member, you should:

  • Present your Blue Cross NC ID card each time you receive a service.
  • Read your Blue Cross NC benefit booklet and all other Blue Cross NC member materials.
  • Call Blue Cross NC when you have a question or if the material given to you by Blue Cross NC is not clear.
  • Follow the course of treatment prescribed by your doctor. If you choose not to comply, advise your doctor.
  • Provide Blue Cross NC and your doctors with complete information about your illness, accident or health care issues, which may be needed in order to provide care.
  • Understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible.
  • Make appointments for non-emergency medical care and keep your appointments. If it is necessary to cancel an appointment, give the doctor's office at least 24-hours notice.
  • Play an active part in your health care.
  • Be polite to network doctors, their staff and Blue Cross NC staff.
  • Tell your place of work and Blue Cross NC if you have any other group coverage.
  • Tell your place of work about new children under your care or other family changes as soon as you can.
  • Protect your Blue Cross NC ID card from improper use.
  • Comply with the rules outlined in your member benefit guide.
  • 1

    In the event of any inconsistency between information contained in this summary and the member's Benefit Booklet, the Benefit Booklet shall govern.

  • 2

    The Benefit Booklet defines an adverse benefit determination as follows: A denial, reduction or termination of, or failure to provide full or partial payment for, a benefit, including one that results from the application of any utilization review, or a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate. Rescission of coverage is also included as an adverse benefit determination. The National Committee for Quality Assurance (NCQA) is an independent, not-for-profit organization that evaluates and reports on the quality of the nation's managed care plans. NCQA maintains and regularly updates quality standards utilized by the health insurance industry to gauge levels of ongoing quality and improvement. The NCQA accreditation program helps employers and consumers compare health plans based on various quality measures.

     

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