Claims Payment Policies and Practices
Qualified Health Plan Issuers have provided information to help you understand what is needed for a claim to be paid, or why a claim was denied.
Click the links below to see the information the issuers have provided.
Anthem Blue Cross
Blue Shield of California
CCHP Health Plan
LA Care Health Plan
Sharp Health Plan
Valley Health Plan
Western Health Advantage
Out-of-network liability, balance billing, and enrollee claim submission
A claim is a request to apply benefits for your health care coverage. Claims are submitted to Anthem Blue Cross for health care services, supplies, drugs, and/or equipment that are provided to you. In most cases, In Network Providers will send claims to Anthem Blue Cross for you. But if you received care from an Out of Network Provider that does not send the claim to Anthem Blue Cross on your behalf, it may be your responsibility to do so. If you are sending a claim to Anthem Blue Cross, we must receive the Claim Form within fifteen (15) months from the date of service in order for Anthem Blue Cross to determine benefits. Anthem Blue Cross will determine if benefits are due in a timely manner. This is typically within thirty (30) days of receiving the claim. You may obtain a copy of the Claim Form by contacting Anthem Blue Cross Customer Service at 855-634-3381 or at the links below.
|Links to Claim Form||Medical||Pharmacy - Express Scripts Thru 12/31/19||Pharmacy - IngenioRx Effective 1/1/20|
|The physical address
to mail your Claim Form to is
|Anthem Blue Cross
P.O. Box 60007
Los Angeles, CA
ATTN: Commercial Claims
P.O. Box 14711
Lexington, KY 40512-4711
P.O. Box 52065
Phoenix, AZ 85072-2065
In Network Providers have an agreement with Anthem Blue Cross. Out of Network Providers do not have an agreement with Anthem Blue Cross. Your personal financial costs when using Out of Network Providers may be considerably higher than when you use In Network Providers. Services provided by Out of Network Providers for non-emergency, non-urgent, and/or non-authorized services are not a covered benefit. This means you will be responsible for all charges performed by an Out of Network Provider. For care obtained from an out of network provider that is an emergency, urgent, and/or authorized service, you are responsible for any deductible, coinsurance, or copayment responsibility that we determine you may. In addition, you will also be responsible for any balance of a Provider’s bill that is above the Maximum Allowed Amount determined by Anthem Blue Cross. Covered Services performed at an In Network Facility at which, or as a result of which, you receive services provided by an Out of Network Provider, you will pay no more than the same cost sharing that you would pay for the same Covered Services received from an In Network Provider.
Anthem Blue Cross wants you to understand the benefits of your health care coverage so you can maximize your health care coverage with us. Anthem Blue Cross offers a variety of ways to assist and educate you to be a more informed consumer. For detailed information regarding the benefits of your plan, please refer to your Combined Evidence of Coverage and Disclosure Form. When logged in to www.anthem.com/ca you can also send messages to us electronically. Anthem Blue Cross is also available to answer any questions you have by contacting our Customer Service at 855-634-3381.
Grace periods and claims pending
If you are getting financial help from the government to pay for your health coverage, once you have paid at least one monthly payment, you can get a grace period of up to three months if you fall behind on payments.
We will continue to consider services you receive during the first month of this grace period according to plan benefits. If you receive services after the first month of this grace period, we will hold (also called "pend") claims — meaning, we won’t pay them yet, but we’ll keep them and will process them after receipt of your premium payments.
If you pay all the missed monthly payments before your grace period ends, we will then go back and consider any claims for covered services we were holding (also called “pending”) according to plan benefits.
Reminder: Not all grace periods are three months — you are entitled to three months if you are getting financial help from the government for your monthly payment.
If you don’t pay for all the missed monthly premiums, we have to deny any claims that we are holding or pending. And you will be responsible to pay all charges for those services.
It is best to pay your monthly payment on time every month, to avoid any chance of getting into your grace period.
If you are interested in setting up automatic payments, contact us at 855-634-3381.
Retroactive claim denials
Retroactive denial means going back and denying claims that were paid in the past. One way that could happen is if we paid a claim after we got your monthly payment; but then your bank says there is not enough money in your account and we never get a new payment from you. We will then go back and retroactively deny that claim, and we will need to get the money back that we paid for it.
If a claim was not paid yet, but we were just holding it (or pending it) as described in the previous section, Grace periods and claims pending — it can also be denied if you run out your grace period. But since we did not pay the claim yet, we wouldn’t call it a retroactive denial. It is just called a denial.
One way you can avoid having your claims denied is by always paying your monthly payment on time. If you are late, be sure to pay before your grace period runs out. Contact us at 855-634-3381 to ask us about setting up automatic payments if you think that can help you prevent you from missing your premium payment.
Getting money back if you pay us more than you owe
If you pay more than what you owe for your premium, we will either refund or credit the extra amount to you or your account. Hopefully, our processes will identify any overpayment automatically. But if you believe you have paid more than you needed to, please contact us at 855-634-3381 or log in to your online account at wwww.anthem.com/ca and send us a message. Some health plans will describe this by the official terms "recoupment of overpayments," which means the same thing — getting your money back if you have overpaid.
Medical necessity and prior authorization
Medical necessity is a standard that doctors and health plans use to determine if the care you are getting, or are looking to get, is right for you. It means, is the care reasonable and necessary to protect your life, prevent significant illness or significant disability — or to alleviate severe pain through treatment of diseases, illnesses or injuries? What your plan covers depends on whether the care is medically necessary and right for the situation, and also the details of your plan.
Sometimes, in order to help us figure out ahead of time (before you get the care) if a health service or device is medically necessary and covered by your plan, you or your doctor may need to contact us. This is called getting "prior authorization (preservice review).”
When you go to a doctor or hospital in your plan, they will work with us to see if any of the care you are getting needs prior authorization. If you go to a doctor or hospital that is not in your plan, it's a good idea to check with us first — especially if it's more involved care, for example, surgery. If you are admitted to the hospital, contact us as soon as you can — ideally within 24 hours of admission. That's not necessary for childbirth admissions unless there's a complication and/or mother and baby are not discharged at the same time.
If you or your doctor do not get prior authorization for something that needs it, you could be responsible for more of the cost as stated in your Combined Evidence of Coverage and Disclosure Form.
We will review requests for prior authorization (preservice review) benefits according to the timeframes listed below.
|Five (5) business days from the receipt of the request||Seventy-two (72) hours from the receipt of the request|
When you need a prescription drug that’s not on your plan’s drug list
If you and your doctor feel you need a prescription drug that's not on your plan's drug list, please have your doctor or pharmacist get in touch with us. We will make a decision within 72 hours of getting the request. We will look at whether it is medically necessary and appropriate compared to the other drugs on our list.
If we deny coverage of the drug, you have the right to request an External Review by an Independent Review Organization (IRO). The IRO will make a coverage decision within 72 hours of receiving your request.
You or your doctor may also submit a request for a prescription drug that is not on your plan's drug list based on what's called "exigent circumstances". For example, if you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or if you are undergoing a current course of treatment using a drug not covered by your plan. In that case, we will make a decision within 24 hours of getting your request.
If we deny coverage for exigent circumstances, you can request an external review by an IRO, similar to above. But a decision will be made more quickly, within 24 hours of getting your request.
Explanation of Benefits (EOB)
After you get care and you or your doctor submits a claim to us for it, we'll send you an Explanation of Benefits (also called EOB for short). It's like recap of your claim. It explains what service you got, the amount the doctor charged, the amount we paid and why — and more. It also tells you how to appeal a claim.
Coordination of Benefits
When you or anybody else on your plan, like your spouse or kids, is covered by two different health plans — both plans may need to know about it. If your plan has coordination of benefits, we will work together to make sure you are getting the right benefits. From time to time, you may get a notice asking if anybody is covered by another plan. Not getting this info back to us may delay claim payments. So if you are asked for this information, be sure to let us know as soon as possible.
- Information on Cost-Sharing and Payments With Respect To Out-of-Network Coverage
- Enrollee Rights Information Under Title I of the Affordable Care Act
Data and Enrollment
- Data on Enrollment
- Data on Disenrollment
- Data on Rating Practices
- Data on Denied Claims
- Data on Appeals
- 2020 Health Plan Rate Booklet
- 2019 Health Plan Rate Booklet
- 2021 Family Dental Rate Booklet
- 2020 Family Dental Rate Booklet
- QHP Model Contract for 2017-2020 – Amended for 2020
- QDP Model Contract for 2017-2020 – Amended for 2020
- CCSB Model Contract for 2017-2020 – Amended for 2020
- Attachment 7 for 2017-2020 – Amended for 2020
- Attachment 14 for 2017-2020 – Amended for 2020
- QHP Model Contract for 2017-2019 – Amended for 2019
- QDP Model Contract for 2017-2019 – Amended for 2019
- CCSB Model Contract for 2017-2019 – Amended for 2019
- Attachment 7 for 2017-2019 - Amended for 2019
- Attachment 14 for 2017-2019 – Amended for 2019
- QHP Model Contract 2017-2019 – Amended for 2017 and 2018
- QDP Model Contract 2017-2019 – Amended for 2017 and 2018
- CCSB Model Contract 2017-2019 – Amended for 2017 and 2018
- Attachment 7 – Amended for 2017 and 2018
- QHP Model Contract for 2017-2019
- QDP Model Contract for 2017-2019
- CCSB Model Contract for 2017-2019