Typically, when you receive medical services, your provider will bill your health plan (BCBSIL) before sending a bill to you. BCBSIL then reviews the services you received and determines which services are covered by your plan. Occasionally, claims may be denied after you've received services. This can happen for a variety of reasons, including:
- BCBSIL conducts a medical necessity review and determines that your services did not meet the definition set forth in your benefit plan. For more information, see the When Do I Need Benefit Approval for a Medical Service? section.
- You are no longer covered by your plan or eligible for benefits, or you were not covered at the time that you received medical services.
- You visited an out-of-network provider for non-emergency services and are covered by a plan that does not have out-of-network benefits.
- Another insurer or source should have been billed for your services before or in place of BCBSIL.
Note: This is not a complete list. For more information, please see your benefits booklet.
The following steps may help you to avoid having your claim denied:
- Review your plan's benefit booklet before you seek medical services.
- Verify your benefits by calling customer service at the phone number on the back of your ID card.
- Talk to your provider about BCBSIL's medical policy. You and your provider can access our medical policies online. These policies offer information about medical services that may have limitations based on published clinical research.
In addition to the above, your claims may be denied if you lose coverage after failing to pay your premium. For more information, see the What Happens if I Miss a Premium Payment? section.
If a claim is denied, you may be responsible for the cost of the services received. However, you also have the right to submit an appeal. An appeal is a way to have that decision reviewed. These steps will help get you started:
- Fill out the Appeal Request Form.
- Mail it to BCBSIL at the address provided on the form.
Refer to your benefit plan materials or call the Customer Service number on the back of your ID card with questions about the appeal process and plan benefits available to you.