April 20, 2018
Learn More About Our HMO Emergency Benefit Management Process
Some of our members are using the emergency room (ER) for things like head lice or sprained ankles, for convenience rather than for serious or life-threatening issues. Doing so not only drives up costs for our members, but uses limited ER resources for conditions that are not serious or life threatening. We want to make health care affordable for our members, and to do so, we have to be good stewards of their money.
What You Need to Know:
- Starting June 4, 2018, our fully insured group HMO members may be required to pay for the entire emergency room (ER) bill if they go to an out-of-network ER as a convenience for a condition they don’t think is serious or life-threatening.
- On May 1, 2018, we will send letters to members who have had an out-of-network ER claim letting them know more about their care options (see more details below).
- The review process for claims incurred after June 4, 2018, will be to:
- Request medical records and an itemized bill for the claim. We will review each medical record to ensure the services our members receive are being accurately billed to eliminate inappropriate charges. As part of the review, the member’s symptoms and concerns will be reviewed in connection with their HMO plan.
- Pend – not deny – claims while we review the claim.
- Review each claim using a multi-step process.
- A claim will not be denied without review by a licensed physician. Should the claim be denied, the member will have the same appeal rights that they currently have.
Member Communication Details
The letters being sent on May 1 are going to members who have had an out-of-network ER claim. It will explain the claims review process and their care options.
We want to make sure members receive the right care, at the right place and at the right time for the best health outcomes. We’ve spent the last few years educating members about where to go for the right level of care, and we will continue to do that through SmartER CareSM Education Campaign.
For additional resources, go to:
- The SmartER Care website at smartercaretexas.com to learn more about where members can go when they need care.
- Our website at bcbstx.com. Click on the Find a Doctor link to search for a doctor or urgent care clinic close by.
If you have any additional questions, reach out to your account executive or agent.