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Defined Benefit Plans
To file a Claim, usually all you will have to do is show your ID card to your Hospital or Physician (or other Provider) at the time of service. They will file your Claim for you. Remember however, it is your responsibility to insure that the necessary Claim information has been provided to Blue Cross Blue Shield of Illinois.
In certain situations, you will have to file your own Claims. This is primarily true when you are receiving services or supplies from Providers other than a Hospital or Physician. An example would be when you have had ambulance expenses.
To file your own Claim, follow these instructions:
Complete a Claim Form.
Attach copies of all bills to be considered for benefits. Bills must include:
Provider’s name and address,
the patient’s name,
the diagnosis code,
the date of service and a description of the service, and
the Claim Charge.
Mail the completed Claim Form with attachments to:
Blue Cross and Blue Shield of IllinoisP. O. Box 805107Chicago, Illinois 60680-4112
Claims must be filed no later than twelve months after the date of service is received. Claims not filed within two years from the date a service is received, will not be eligible for payment.
You will receive an Explanation of Benefits (EOB) telling you how much was paid.
If the Claim is denied in whole or in part, you will receive a notice from the Claim Administrator with: (1) the reasons for denial; (2) a reference to the health care plan provisions on which the denial is based; (3) a description of additional information which may be necessary to perfect the appeal, and (4) an explanation of how you may have the Claim reviewed by the Claim Administrator if you do not agree with the denial.
If your Claim has been denied in whole or in part, you may have your Claim reviewed. The Claim Administrator will review its decision in accordance with the following procedure. Within 180 days after you receive notice of a denial or partial denial, write to the Claim Administrator. The Claim Administrator will need to know the reasons why you do not agree with the denial or partial denial. Send your request to:
Claim Review SectionHealth Care Service CorporationP.O. Box 2401
Chicago, Illinois 60690
You may also designate a representative to act for you in the review procedure. Your designation of a representative must be in writing as it is necessary to protect against disclosure of information about you except to your authorized representative. While the Claim Administrator will honor telephone requests for information, such inquiries will not constitute a request for review. You and your authorized representative may ask to see relevant documents and may submit written issues, comments and additional medical information within 180 days after you receive notice of a denial or partial denial. The Claim Administrator will give you a written decision within 60 days after it receives your request for review.
If you have any questions about the Claims procedures or the review procedure, write or call the Claim Administrator Headquarters. The Claim Administrator offices are open from 8:45 A.M. to 4:45 P.M., Monday through Friday.
Blue Cross and Blue Shield of Illinois300 East RandolphChicago, IL 6060
If you have a Claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court.