Benefit Determinations

Post-Service Claims

Post-Service Claims are those claims that are filed for payment of benefits after health care has been received. If your Post-Service Claim is denied, you will receive a written notice from Blue Cross Blue Shield of Massachusetts within 30 days of receipt of the claim, so long as all needed information was provided with the claim. Blue Cross Blue Shield of Massachusetts will notify you within the 30-day period if additional information is needed to process the claim and may request a one-time extension not longer than 15 days and pend your claim until all information is received.

Once notified of the extension, you then have 45 days to provide this information. If all of the needed information is received within the 45-day time frame and the claim is denied, Blue Cross Blue Shield of Massachusetts will notify you of a denial within 15 days after the information is received. If you don’t provide the needed information within the 45-day period, your claim will be denied.

Pre-Service Claims

Pre-Service Claims are those claims that require certification or approval prior to receiving health care. If your claim was a Pre-Service Claim, and was submitted properly with all needed information, you will receive written notice of the claim decision from Blue Cross Blue Shield of Massachusetts within 15 days of receipt of the claim. If you filed a Pre-Service Claim improperly, Blue Cross Blue Shield of Massachusetts will notify you of the improper filing and how to correct it within 5 days.

After reviewing the revised Pre-Service Claim, Blue Cross Blue Shield of Massachusetts will notify you of any additional information needed within 15 days and may request a one-time extension not longer than 15 days and pend your claim until all information is received. Once notified of the extension, you then have 45 days to provide this information. If all of the needed information is received within the 45-day time frame, Blue Cross Blue Shield of Massachusetts will notify you of the determination within 15 days after the information is received. If you don’t provide the needed information within the 45-day period, your claim will be denied.

Urgent Care Claims

Urgent Care Claims are those claims that require notification or approval prior to receiving medical care, where a delay in treatment could seriously jeopardize your life or health or the ability to regain maximum function or, in the opinion of a doctor with knowledge of your health condition could cause severe pain. In these situations:

• You will receive notice of the benefit determination in writing or electronically as soon as possible, but not later than 72 hours after Blue Cross Blue Shield of Massachusetts receives all necessary information, or such other timeframe as required under federal law, taking into account the seriousness of your condition.
• Notice of denial may be oral with a written or electronic confirmation to follow within 3 days.
• If you filed an Urgent Care Claim improperly, Blue Cross Blue Shield of Massachusetts will notify you of the improper filing and how to correct it within 24 hours after the Urgent Care Claim was received. If additional information is needed to process the claim, Blue Cross Blue Shield of Massachusetts will notify you of the information needed within 24 hours after the claim was received. You then have 48 hours to provide the requested information.

You will be notified of a determination no later than 48 hours after Blue Cross Blue Shield of Massachusetts’ receipt of the requested information or the end of the 48-hour period within which you were to provide the additional information, if the information is not received within that time.

Concurrent Care Claims

If an on-going course of treatment was previously approved for a specific period or number of treatments, and your request to extend the treatment is an Urgent Care Claim as defined above, your request will be decided as soon as possible, and the Claims Fiduciary will notify you of the determination within 24 hours after receipt of the claim, provided your request is made at least 24 hours prior to the end of the approved treatment. If your request for extended treatment is not made at least 24 hours prior to the end of the approved treatment, the request will be treated as an Urgent Care Claim and decided according to the timeframes described above.