How Our Health Insurance Works
To help you find that information quickly and easily, we put together this summary1explaining how our health insurance works, with additional information about Blue Cross NC Quality Improvement programs.
The Member's Rights and Responsibilities
Notice of Mastectomy Benefits
As required by the Women's Health and Cancer Rights Act of 1998, your health insurance policy provides benefits for mastectomyrelated services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses and complications resulting from a mastectomy, including lymphedema. This coverage is subject to the same deductibles, copayments, coinsurance or limitations as applied to other medical and surgical benefits provided under your policy. If you have questions, please check your benefit booklet or call the Customer Service number on your ID card for more information.
Continuity of Care
At Blue Cross NC, when you change health plans or your doctor* is no longer part of the Blue Cross NC network, you may be eligible to get continued care from your doctor for a short time. During that time, you and your doctor should look for a new, in-network doctor for your care. Blue Cross NC will help its members who need continued care during a change in coverage. This process is called "continuity of care."
To be eligible for continuity of care, one of these four conditions must apply:
- You have a short-term health problem that is life-threatening and needs continued care from your doctor to prevent a chance of death or permanent harm.
- You have a long-term health problem that is life-threatening, degenerative or disabling and need continued care over a longer time.
- You are pregnant or completing post-partum care.
- You have a terminal illness, which means a medical prognosis that puts your life expectancy at six months or less.
You must send a request to Blue Cross NC for continuity of care. A Blue Cross NC nurse will review your request. You can call Customer Service at the phone number on the back of your ID card and ask for a continuity of care request form. Your doctor also has to agree to Blue Cross NC's rules for continued care.
If you are new to Blue Cross NC, you must send the form in within 45 days of your effective date.
If you are not a new member and have learned that your doctor is not in the Blue Cross NC network, you must send the form in within 45 days from when you found out your doctor was out of Blue Cross NC's network.
* Doctor may also mean a nurse practitioner, physician assistant or other health care expert that you have seen for health care.
Transitioning from Pediatric to Adult Care
For teenagers and young adults, it can be tough to know when to switch from their childhood doctor to one who specializes adult care. Most choose to make this transition around 18 to 21 years of age. Blue Cross NC can help members find an in-network doctor near them who is qualified to care for adults. If you are a pediatrician, you can also help your teenage and young adult patients transition to a primary care provider for adults.
- Online: Blue Connect
- Access to utilization management review staff:
1-800-672-7897 (toll free)
- Blue Cross NC Customer Service:
8 a.m. – 9 p.m., Monday – Friday
- Join our provider email registry to get the latest news from Blue Cross NC.
- In the event of any inconsistency between information contained in this summary and the member's Benefit Booklet, the Benefit Booklet shall govern.
- 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.