Customer Service Prior Authorization
Resume:
YOUR CLAIM SUMMARY
Subscriber ID: WKQ****1642300
Plan: Blue Local Silver $0 Deductible-III with
Wake Forest Baptist Health
Name: TAMMIE M MOORE
Subscriber Details
This Explanation of Benefits (EOB) shows how
claims were processed by your plan. It is NOT
a bill. It’s a way to check that the care you
received and the amount billed by your
providers are accurate. Keep this for your
records.
July 11, 2022
Group Number:B0000002
Visit BlueConnectNC.com - where you can
also send us a Secure Inbox message
Customer Service (Monday - Friday, 8 a.m. - 7 p.m.) 1-888-***-****
Servicio al Cliente (Lunes - Viernes, 8 a.m. - 7 p.m.) 1-888-***-****
TTY/TDD: 1-800-***-****
Contact Us Need More Information?
What You May Owe:
The total amount you saved as a Blue Cross NC member using in- network providers. (Always use providers in your plan’s network for the best savings.)
4
The original amount charged by the provider(s) you visited before any
$6,669.40 in-network discounts or plan payments were applied. Total Blue Cross
NC Paid:
Processed by Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Below is a total of those claims. You’ll find information on each claim in the “Claim Details" section.
OVERVIEW
$3,373.01
$664.66
Total Amount
Provider(s) Charged:
The total amount your Blue Cross NC health plan paid towards the claims in this summary. (If the number is zero, it’s often because your deductible has not been met yet — or the claims have been adjusted or denied.)
The remaining amount after your discount and what your plan paid in benefits. (It may not reflect payments already made by you or another insurance company.) Your provider(s) may bill you directly for this amount.
Claims
Total Member Savings: $2,782.73
There are 3 alert codes
(look for the icon in the "Claim Details" section). TAKE NOTE:
Find tools and resources at BlueConnectNC.com.
Go Paperless
Get information faster with less clutter on the kitchen counter. You’ll have instant access to EOBs, your member booklet and more in your document library on Blue
Connect . Go paperless by visiting BlueCrossNC.com/ PaperlessDelivery and changing your delivery
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COVID-19: For information about the COVID-19 vaccine, visit BlueCrossNC.com/Vaccine.
Blue Cross and Blue Shield of North Carolina
PO Box 2291
Durham NC 27702-2291
Forwarding Service Requested
ALL FOR AADC 270
TTFDDTADTTADTAFATTADFTADFFDTAADAAAFFDDTADATATDAFFTDTTTFFAAFTTDFAA PB-DSM-25-ENV 23227
TAMMIE M MOORE
603 SHARING TER
GREENSBORO NC 27405-8669
69
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OUT-OF-POCKET LIMIT
(OUT-OF-NETWORK)
DEDUCTIBLE
(IN-NETWORK)
OUT-OF-POCKET LIMIT
(IN-NETWORK)
DEDUCTIBLE
(OUT-OF-NETWORK)
For policy starting: January 01, 2022
Plan's
Limit
Amount
Satisfied
Plan's
Limit
Amount
Satisfied
Plan's
Limit
Amount
Satisfied
Plan's
Limit
Amount
Satisfied
YOUR PLAN AT A GLANCE
Blue Local Silver $0
Deductible-III with
Wake Forest Baptist
Health
TAMMIE M MOORE $0.00 $0.00 $650.00 $650.00 $1,000.00 $163.79 No Maximum $163.79 THIS IS NOT A BILL
CLAIM DETAILS
Service: Reason Code:
(See table at the end)
Not Covered /
Other Liability:
Allowed
Amount:
Member
Savings: Deductible: Copayment or
Coinsurance:
Blue Cross
NC Paid:
Your Provider
Billed:
May 30, 2022
MOSES H CONE MEMORIAL HOSPITAL
Claim Number: 22157S427100
Provider Name:
Date of Care:
Claim for TAMMIE M ID #:WKQ10381642300
Facility Services $1,670.00
(70450)
05/30/2022-05/30/2022 $1,554.05 $115.95 $1,149.39 $0.00 $404.66 $0.00 X00 Facility Services $310.00
(96372XU)
05/30/2022-05/30/2022 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 f63 Facility Services $2,407.00
(9928525)
05/30/2022-05/30/2022 $1,034.81 $1,372.19 $1,034.81 $0.00 $0.00 $0.00 X00 Facility Services $80.40
(J0780)
05/30/2022-05/30/2022 $6.46 $73.94 $6.46 $0.00 $0.00 $0.00 X00 Facility Services $17.80
(J1885)
05/30/2022-05/30/2022 $12.92 $4.88 $12.92 $0.00 $0.00 $0.00 X00
(Does not include any payments you've already made.) Total Amount Provider(s)
Charged: $ 4485.20
You Saved:
$4,080.54
What You May Owe: $404.66
Service: Reason Code:
(See table at the end)
Not Covered /
Other Liability:
Allowed
Amount:
Member
Savings: Deductible: Copayment or
Coinsurance:
Blue Cross
NC Paid:
Your Provider
Billed:
June 10, 2022
DILLINGHAM, CLAIRE S.
Claim Number: 22164G544700
Provider Name:
Date of Care:
Claim for TAMMIE M ID #:WKQ10381642300
Office Visits $260.00
(99203)
06/10/2022-06/10/2022 $109.00 $151.00 $0.00 $109.00 $0.00 $151.00 DST2
(Does not include any payments you've already made.) Total Amount Provider(s)
Charged: $ 260.00
You Saved:
$151.00
What You May Owe: $260.00
Service: Reason Code:
(See table at the end)
Not Covered /
Other Liability:
Allowed
Amount:
Member
Savings: Deductible: Copayment or
Coinsurance:
Blue Cross
NC Paid:
Your Provider
Billed:
June 2, 2022
MOSES H CONE MEMORIAL HOSPITAL
Claim Number: 22159C842100
Provider Name:
Date of Care:
Claim for TAMMIE M ID #:WKQ10381642300
Facility Services $7.00
(J3490)
06/02/2022-06/02/2022 $7.00 $0.00 $7.00 $0.00 $0.00 $0.00 Facility Services $1.40
(J3490)
06/02/2022-06/02/2022 $1.40 $0.00 $1.40 $0.00 $0.00 $0.00 Facility Services $155.00
(96372)
06/02/2022-06/02/2022 $0.00 $155.00 $0.00 $0.00 $0.00 $0.00 f63 Facility Services $1,499.00
(9928425)
06/02/2022-06/02/2022 $1,034.81 $464.19 $1,034.81 $0.00 $0.00 $0.00 X00 Facility Services $17.80
(J1885)
06/02/2022-06/02/2022 $17.80 $0.00 $17.80 $0.00 $0.00 $0.00
(You do not need to pay anything on this claim.)
Total Amount Provider(s)
Charged: $ 1680.20
You Saved:
$1,680.20
What You May Owe: $0.00
3 of 3
Service: Reason Code:
(See table at the end)
Not Covered /
Other Liability:
Allowed
Amount:
Member
Savings: Deductible: Copayment or
Coinsurance:
Blue Cross
NC Paid:
Your Provider
Billed:
June 2, 2022
GREEN, GARRETT L.
Claim Number: 22165G045300
Provider Name:
Date of Care:
Claim for TAMMIE M ID #:WKQ10381642300
Medical Care $244.00
(99283)
06/02/2022-06/02/2022 $108.42 $135.58 $108.42 $0.00 $0.00 $0.00
(You do not need to pay anything on this claim.)
Total Amount Provider(s)
Charged: $ 244.00
You Saved:
$244.00
What You May Owe: $0.00
What our codes mean:
BCBSNC makes payment directly to you for services rendered by non-participating providers. You are responsible for paying the non-participating provider's bills. Non-participating providers may bill you for the difference in what BCBSNC allows and their actual charge.
DST2
"This claim is subject to Surprise Billing Legislation Protections, so the provider is not allowed to balance bill you. See ""Your Rights X00 and Protections Against Surprise Medical Bills"" enclosed for details." Incidental to primary procedure. Service does not warrant separate reimbursement. Member is not responsible for paying for this f63 service.
Please save this form for your tax records. Your balance may not reflect any prior payments made by you or another insurance company.
Additional Information
The information listed in the "Benefit Year Summary" section indicates the most current benefit period information on your plan as of the date of this notice. The "Amount Satisfied" will reflect the total amount satisfied throughout the current benefit period on the plan, which may include all applied before and after any changes in benefits or dependents covered throughout the benefit period. Claims information from a previous benefit period that appear on this notice are not included in the "Amount Satisfied" amounts on this notice. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) provides free aids to service people with disabilities as well as free language services for people whose primary language is not English. Please contact the Customer Service number on the back of your ID card for assistance.
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) proporciona asistencia gratuita a las personas con discapacidades, así como servicios lingüísticos gratuitos para las personas cuyo idioma principal no es el inglés. Comuníquese con el número para servicio al cliente que aparece en el reverso de su tarjeta del seguro para obtener ayuda. Please note, for members who are part of an ERISA employer group plan, deadlines have been extended by federal law during the COVID-19 national emergency. Please see https://www.bluecrossnc.com/covid-19/covid-19-resources-member or contact customer service for the most up to date information.
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1
YOUR APPEAL RIGHTS
Don’t agree with a claim decision? You or someone you name to act on your behalf (an authorized representative) have the right to appeal it. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will then review the decision. How to appeal
First, download the forms needed. You’ll find appeal forms and authorization forms (naming someone to act on your behalf) in the Claims section of BlueConnectNC.com.
Send the completed forms to Blue Cross NC. We must receive your written appeal request within 180 days of the date on this Explanation of Benefits (EOB). Be sure to include your name, subscriber ID number, the date of care and the name of the doctor or hospital. Attach any other documents that are relevant to the claim, too. You can then send it by mail or fax. Mail your appeal to:
Blue Cross NC
Appeals Department, Level 1
PO Box 30055
Durham, NC 27702-3055
Fax your appeal to:
If your appeal is denied, you may be able to ask for an external review by an independent third party. After reviewing the denial, this independent third party will then issue a final decision. For more details on a claim
You can request copies of all documents related to a claim at no cost to you. This may include internal rules or protocols used to make this decision. If our decision is based on medical necessity, experimental treatment or a similar exclusion, it may also include an explanation of the scientific/clinical judgment for the decision based on your medical situation. You can mail this request to: Blue Cross NC; PO Box 2291; Durham, NC 27702. You can also visit BlueCrossNC.com/MedicalPolicies or call Customer Service at 1-888-***-****. Privacy protection
Detailed service descriptions aren’t on EOBs for privacy reasons. But you have the right to know which codes your provider submitted — and what they mean. You can get them directly from the provider or by calling Customer Service at 1-888- 206-4697.
If your plan is provided by your employer
You and your plan may have other voluntary dispute resolution options — such as mediation. You may also have the right to bring an action under section 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA). Contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272) to learn more about these rights. North Carolina Department of Insurance (NCDOI)
The NCDOI can answer your health insurance questions. For help with an appeal, call Health Insurance Smart NC at 1-855-***-****; visit www.ncdoi.com/Smart for the External Review and Request form; or write to them at: NCDOI; Health Insurance Smart NC; 1201 Mail Service Center; Raleigh, NC 27699-1201. To visit in person, you’ll find Health Insurance Smart NC’s physical address at www.ncdoi.com/Smart. Help us prevent fraud
Please review this EOB carefully. If you suspect fraud, abuse, a mistake or improper billing, let Blue Cross NC know! Call our confidential toll-free hotline at 800-***-****. Learn more at BlueCrossNC.com/PreventFraud. BLUE CROSS®, BLUE SHIELD®, the Cross and Shield symbols, registered marks and service marks are marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. All other marks and trade names are the property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. U14446, 6/20 Have a question about
your claims or benefits?
Refer to the “Covered Services” and
“What Is Not Covered?” sections of your
benefit booklet. You can also send us a
secure Blue Connect Inbox message at
BlueCrossNC.com/SecureInbox or call
Customer Service at 1-888-***-****.
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What is “balance billing” (sometimes called “surprise billing”)? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care — like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. You are protected from balance billing for:
Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services. Certain services at an in-network hospital or ambulatory surgical center When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
Your Rights and Protections Against Surprise Medical Bill When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. Continued on back
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When balance billing isn’t allowed, you also have the following protections:
• You are only responsible for paying your share of the cost (like the copayments, coinsurance and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
Cover emergency services without requiring you to get approval for services in advance (prior authorization).
Cover emergency services by out-of-network providers.
Base what you owe the provider or facility (cost sharing) on what it would pay an in-network provider or facility, and show that amount in your explanation of benefits.
Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit. If you believe you’ve been wrongly billed, you may contact 1-800-***-****. Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law. You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
® Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. U39738, 12/21 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) provides free aids to service people with disabilities as well as free language services for people whose primary language is not English. Please contact the Customer Service number on the back of your ID card for assistance. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) proporciona asistencia gratuita a las personas con discapacidades, así como servicios lingüísticos gratuitos para las personas cuyo idioma principal no es el inglés. Comuníquese con el número para servicio al cliente que aparece en el reverso de su tarjeta del seguro para obtener ayuda.
Blue Cross and Blue Shield of North Carolina offers several decision support tools, such as Find a Doctor and Find a Cost, to aid members in making decisions around their health care experience. These tools are offered for member convenience and should be used only as reference tools. Members should consult their own legal counsel, tax advisor or personal physician as applicable throughout their health care experience. BLUE CROSS®, BLUE SHIELD®, and the Cross and Shield symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association. U38905, 9/21 Recently, you visited an out-of-network provider or hospital. The enclosed Explanation of Benefits (EOB) includes a claim for a provider or facility not included in your health plan. We want to make sure you’re getting the most out of your health plan. When you receive care outside of your plan’s network, you will pay more than if you stayed in-network. To stay in-network or find an in-network provider or facility near you:
• Visit BlueCrossNC.com/InNetworkDoc to use our Find a Doctor tool to compare in-network providers and facilities
• Call the number on the back of your Blue Cross and Blue Shield of North Carolina (Blue Cross NC) ID card
• Scan the QR code to search on the Blue Cross NC mobile app IMPORTANT
Thank you for choosing Blue Cross NC. We value your business, and we’re honored to continue serving you. Scan for our mobile app
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Blue Cross and Blue Shield of North Carolina (Blue Cross NC) proporciona asistencia gratuita a las personas con discapacidades, así como servicios lingüísticos gratuitos para las personas cuyo idioma principal no es el inglés. Comuníquese con el número para servicio al cliente que aparece en el reverso de su tarjeta del seguro para obtener ayuda.
Blue Cross and Blue Shield of North Carolina ofrece varias herramientas de apoyo para la toma de decisiones, como “Buscar un médico” (Find a Doctor) y “Consultar el costo” (Find a Cost), para ayudar a los afiliados a tomar decisiones sobre su experiencia de atención médica. Estas herramientas se ofrecen para la comodidad de los afiliados y deben utilizarse únicamente como herramientas de referencia. Los afiliados deben consultar a su propio asesor legal, fiscal o médico personal, según corresponda, a lo largo de su experiencia de atención médica. BLUE CROSS®, BLUE SHIELD®, y los símbolos de la cruz y el escudo son marcas registradas de Blue Cross and Blue Shield Association, una asociación de planes independientes de Blue Cross and Blue Shield. Blue Cross NC es un concesionario independiente de Blue Cross and Blue Shield Association. U38905_sp, 9/21 Recientemente usted acudió a un proveedor u hospital fuera de la red. La explicación de beneficios (EOB) adjunta incluye una reclamación por un proveedor o establecimiento que no está incluido en su plan de seguro médico.
Queremos asegurarnos de que aprovecha al máximo su plan de seguro médico. Cuando reciba atención fuera de la red de su plan, pagará más que si acudiera a proveedores dentro de la red. Para permanecer dentro de la red o encontrar un proveedor o establecimiento dentro de la red cerca de usted:
• Visite BlueCrossNC.com/InNetworkDoc para utilizar nuestra herramienta de búsqueda de médicos para comparar los proveedores y establecimientos dentro de la red
• Llame al número que aparece en el reverso de su tarjeta del seguro de Blue Cross and Blue Shield of North Carolina (Blue Cross NC)
• Escanee el código QR para buscar en la aplicación móvil de Blue Cross NC IMPORTANTE
Gracias por elegir Blue Cross NC. Apreciamos su confianza y nos sentimos honrados de seguir sirviéndole. Escanee para descargar nuestra aplicación móvil
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