Frequently Asked Questions
Online Member Services
How do I register for an account on bcbswny.com?
Registering for an account is an easy process! Make sure you have your member ID card on hand to complete the steps. Click here to register.
Can I register my account when I have not yet received my insurance card?
You can contact member services at 1-800-544-2583 to obtain your member ID information over the phone.
I forgot my username, how can I get that information?
Forgot your username? Don't worry. Click here to retrieve it.
I forgot my password, how can I reset it?
Forgot your password? Don't worry. Click here to create a new one.
How can I check my deductible/out-of-pocket maximum?
Deductible and out-of-pocket maximum amounts are listed on the home page of your member portal. You can also contact member services to see what amounts have tallied to your account for the plan year.
How can I access my member or my dependents account information?
Login to your online account to view and manage your account information. If your dependent is over the age of 18, they will need to create their own account to view and manage their information.
How do I add a dependent(s)?
Depending on your contract, you may need to contact your employer to add a dependent(s). Contact member services for instructions specific to your plan.
Can I still access my account if my coverage has been cancelled?
You will still be able to access your online account to view claims and explanation of benefits (EOBs) information after your coverage has been cancelled. In time, your account will be archived and claims information will no longer be accessible online. You can contact member services to review past claim and provider information, obtain copies of EOBs, or request a claims history report.
How can I see my member benefits?
Basic benefit information such as copay amounts and deductible amounts can be viewed online through the member portal under the 'My Plan and Perks' section. You can also utilize the 'Treatment Cost Advisor' tool to forecast an approximate cost-share for doctor office visits and specific procedures. This tool is located in the 'My Plan and Perks' section as well.
How can I check my wellness debit card balance?
To check your wellness debit card balance, you'll need to login to your member account first.
What vendors accept the wellness debit card?
Click here to search our wellness debit card vendors.
How do I sign up for paperless?
Going paperless is fast, convenient and secure. Through your online account, you can view all your information any time you want, paper-free. Sign up here.
How can I enroll in a new plan online?
To find out what plan options are available to you, contact our member services. We will ensure you are provided with the information to make an informed choice in a plan that will best fit your needs.
My Coverage and Benefits
Do I have access to any fitness or nutrition programs?
We offer a variety of health and wellness programs throughout the community. Program topics range from lifestyle issues, such as exercise, nutrition, weight management, and smoking cessation as well as health management issues such as diabetes and asthma management. For more information, call us at the number listed on the back of your member ID card.
Can I get my prescription(s) mailed to me?
Yes. We offer a mail order option that provides convenient home delivery of your prescription drugs, and may also help save you money. For information on how to enroll, contact us by calling the number listed on the back of your member ID card.
What is the role of my primary care physician (PCP)?
A primary care physician is usually a doctor in general practice, family practice, internal medicine, or pediatrics. Your PCP is your personal doctor, and can coordinate all of your care. If you haven't seen your PCP, set up an appointment for a routine physical. This will allow you and your doctor to get to know one another. Be sure to tell your doctor about all of your relevant medical history so that he or she is able to properly and appropriately manage your care.
What if I am out of my home service area and need medical attention?
Our BlueCard Program covers you for urgent care when you are away from home. Urgent care must be coordinated by your PCP BEFORE you obtain services. If your PCP recommends treatment, call 1-800-810-2583 to locate a participating Blue doctor.
What if I or one of my dependents will be living outside the area?
If you (or a covered dependent) will be temporarily residing outside the Western New York area, in a participating location for at least 90 days, you may be eligible to become a Guest Member at a Blue Cross and Blue Shield Association-affiliated HMO. Under the Away From Home Care® program's Guest Membership benefit you retain your coverage under Blue Cross Blue Shield.
With our Away From Home Care® program's Guest Membership benefit, you can join another HMO and receive the full range of benefits offered by the HMO in that area.
Guest memberships can be used for students away at school, extended business trips, families living apart or long-term travel. Residency eligibility requirements must be met for any long-term traveler requesting Guest Membership for one year or more.
When you return to the Highmark Blue Cross Blue Shield of Western New York service area, you will use your PCP and receive your Highmark Blue Cross Blue Shield of Western New York benefits. For more information and to verify that this benefit is available to you, contact customer service.
What if I need non-emergency medical attention?
Medical problems that require prompt attention, but are not life-threatening (i.e. ear ache, rash,etc.) are considered urgent or non-emergent. These conditions may include:
- Cold or flu
- Sore throat
- Ear ache
- Burning/frequency of urination
- Skin rash
- Pink eye
- Body/head lice or worms
If you have any of these conditions, call your primary care doctor. Your PCP is accessible 24 hours, 7 days a week. If your doctor is not available, another physician on call will be covering and will help you.
Are there services that require referrals?
Most members do not need a referral from a PCP to see a specialist that is participating in our network. If you are not sure if you need a referral, call us at number on the back of your member ID card.
What benefits are included under Mental Health/Federal Parity and Timothy's Law?
On January 1, 2007, the New York State Mental Health Parity law, called Timothy’s Law – became effective. This law mandated that Plans could not place restrictions on the mental health benefits any differently than on the medical benefits in a member’s policy.
Copayments, coinsurance and deductibles, for mental health services had to match the medical benefits.
On October 3, 2009, the Federal Mental Health parity regulations became effective. The Federal law broadened Timothy’s Law to include substance abuse services and added specific requirements that changed the way member benefit limits, liabilities and pre-authorization requirements were structured.
How do I know if my plan includes coverage for these behavioral health benefits?
While most of these changes apply to large group plans, and many small employer groups, other employer groups have the option to include the full federal parity benefits in their plans. You can check what your benefits cover by calling the number on the back of your member card.
What health care services are available to me? (Health coaching, case management, disease management, etc.)
There is a wide range of services available to our members when it comes to managing chronic and complex health conditions and changing your lifestyle to improve your overall health. Contact member services so we can best direct you to the resource(s) that is appropriate for your needs.
What is the Good Life Program?
The Good Life Program consists of three steps - a health screening, a health assessment, and possibly health coaching, if deemed necessary. Your screening and assessment results will be used to determine if you need to work with a health coach (step 3) to meet your health goals. To learn more about the Good Life Program, click here.
How do I take the health assessment?
After you receive your health screening results, you'll need to take the health assessment. Your health assessment will take approximately 10-15 minutes to complete. Learn more
What do I need to know about 3D mammograms?
3D mammograms are now insurable under preventive guidelines. For members enrolled in a commercial, direct pay, Healthy NY, New York State of Health, or ASO plan, please be aware that some of these services may have a copay, annual limits, or may only be covered in certain age ranges. Contact member services to verify your specific coverage and ensure your provider of service is in-network.
Is a breast pump covered by my plan?
Breast-feeding support, supplies, and counseling are insurable under many commercial plans under preventive measures. Contact member services to verify what products you may be eligible for and where you can obtain them.
What do I need to know about coverage decisions?
We base medical necessity decisions on the appropriateness of care and services. Coverage decisions are based on the benefits and provisions contained in your health plan contract. We do not reward or offer incentives to practitioners, providers, or staff members for issuing denials or for encouraging inappropriate underutilization of care.
Claims and Billing
What if I receive a bill?
If you receive care from a non-participating doctor, you may be asked to pay for services when you receive them or you may receive a bill. Submit any bills or receipts to:
P.O. Box 80
Buffalo, NY 14240-0080
Be sure that your itemized receipt or bill includes the patient's name, ID number, a description of the service, date of service, diagnosis, dollar amount, doctor's name and address, and your signature.
You may also submit a claim electronically through our secure member website.
- Go to bcbswny.com
- Login using your username and password. First time? Click Register Now.
- Click Manage My Account.
- Scroll down and click Claims Submission.
What do I need to know to protect from unplanned costs?
If you have coverage through a fully insured commercial, Article 47 ASO group, Medicaid, or Child Health Plus:
New York State has established a new process to resolve disputes on surprise bills. Health plans, doctors, facilities, and patients have the right to request an independent review from New York State if they do not believe a bill or its payment was reasonable.
What is a surprise bill?
When you receive services from a non-participating doctor at a participating hospital or ambulatory surgical center, the bill you receive for those services will be a surprise bill if:
- A participating doctor was not available; or
- A non-participating doctor provided services without your knowledge; or
- Unexpected medical circumstances occurred at the time the health care services were provides.
It will not be a surprise bill if you chose to receive services from a non-participating doctor instead of from an available participating doctor.
When you are referred by your participating doctor to a non-participating doctor, the bill you receive for those services will be a surprise bill if you did not sign a written consent form stating that you knew the services would be out-of-network and would result in costs not covered by your health plan.
A referral to a non-participating provider occurs when:
- During a visit with your participating doctor, a non-participating doctor treats you; or
- Your participating doctor takes a specimen from you in the office (for example, blood) and sends it to a non-participating laboratory or pathologist; or
- A referral is required under your plan for any other health care services.
Protect yourself from a surprise bill.
You can protect yourself from receiving a surprise bill and only be responsible for your in-network copay, coinsurance, or deductible if you:
- Call the customer service number on the back of your member ID card and ask for an Assignment of Benefits (AOB) form to fill out; and
- Send the form and a copy of the bill(s) you do not think you should pay to both your doctor and us.
- If you don’t complete an AOB, you can also submit your disputed bill directly to New York State’s Independent Dispute Resolution Entity (IDRE) for review. For more information on submitting a dispute for review, visit the New York State Department of Financial Services website at dfs.ny.gov, call 1-800-342-3736, or email IDRquestions@dfs.ny.gov.
How do I submit a claim online?
A member can submit claims in a number of ways. To do this online, the member first must log in to their member portal, click on 'My Account' and scroll down to 'Claims Submission' to submit a paper claim. You will be able to upload your documents that you have saved on your computer.
How do I pay my bill online?
As a member of Highmark Blue Cross Blue Shield of Western New York, you have access to online bill payment. It's a quick and easy way to manage your health plan and pay your premiums. Click here.
What is the difference between in-network and out-of-network?
In-network doctors are medical professionals who have agreed to provide services to our members. When you receive care from an in-network doctor, you pay a small copay and don’t need to file a claim.
Out-of-network doctors do not have a working agreement with us to provide services to our members. If you have an out-of-network benefit, you can seek care from out-of-network doctors or hospitals. You will have a higher out-of-pocket expense.
What is a health care proxy?
A health care proxy is a legal document that allows you to appoint someone you trust, such as a family member or close friend, as your health care agent, to make health-related decisions for you if you lose the ability to make decisions for yourself.
Appointing a health care proxy ensures that your health care wishes are followed. You may give the person you select as your health care proxy as little or as much authority as you want. With a health care proxy in place, important decisions about medical treatment, such as nourishment and water by feeding tubes, as well as instructions like requesting or stopping treatment will be carried out as you have requested.
For more information, call us at number listed on the back of your member ID card.
What is Health Advocate?
Health Advocate is a personal health care coaching and patient advocacy service you can call any time you need help navigating the health care system.
A Health Advocate can help you:
- Find the best doctors and hospitals for complex needs
- Make appointments with hard-to-reach specialists
- Locate and research treatments for a medical condition
- Provide unbiased information
- Assist with administrative, billing, and claims issues
- Help with eldercare issues
Call Health Advocate toll-free at 1-800-359-5465.
What is an Explanation of Benefits (EOB)?
Your Explanation of Benefits (EOB) is an outline of the costs for services you received. An EOB is not a bill. You do not need to respond to this document; it is simply for your records. Learn more about EOBs.
What is a formulary?
A drug formulary is a list of prescription drugs covered by a prescription drug plan.
What is a deductible?
To help keep premium costs lower, some health care plans have a deductible. A deductible is the amount of money a member pays out-of-pocket before paying a copay or coinsurance. To learn more, visit our deductible page.
Doctors and Facilities
I need to have lab services performed. How do I find the nearest network laboratory?
Read important information about our lab services and search for a network laboratory location. Find a Lab.
How does Blue Cross Blue Shield support doctors and hospitals?
We support doctors and hospitals in several ways, including sharing information about health care treatments, helping to coordinate quality care, and reimbursing them for the care they provide. We have many different ways to pay doctors and hospitals for the care they provide our members.
- The resource-based relative value scale (RBRVS) - The RBRVS considers the time a doctor spends on a procedure, how much it costs to run a medical practice, and the cost of medical malpractice insurance. RBRVS also adjusts reimbursement based on how costs vary among different geographic locations. The federal government uses this method to pay doctors across the nation.
- Fee for service – This is the traditional health care payment method under which doctors and hospitals receive a payment that does not exceed their billed charge for each service they provide. This method of payment can also be used in conjunction with an established fee schedule for our managed care and indemnity plans of coverage.
- BlueCard® Program (ITS) – The Blue Cross Blue Shield Association, a national association of independent Blue plans, of which our company is a member, developed this program to help pay your claims when you receive care from an out-of-area doctor or hospital who participates with his or her local Blue Cross and Blue Shield Plan. The BlueCard Program processes your claims using the payment agreement the physician has with his or her local plan. The local plan pays the doctor directly for the services you received.
- Agreed-upon amount – This is a negotiated rate agreed to by our company and a medical facility.
- Capitation – Capitation means we pay doctors a fixed dollar amount in advance, regardless of the number of services they provide to a member. We establish this payment on a per-month basis.
- Diagnosis-Related Grouping (DRG) – A method of reimbursing hospitals for providing inpatient hospital care. It takes into account both your diagnosis and the length of time a patient usually stays in the hospital for that particular diagnosis.
How do I select or change my Primary Care Physician (PCP)?
A member can elect to select or change their PCP from the online member portal. Upon logging in, click on 'Select my Doctor (PCP)' on the homepage. Members will be asked to enter their doctor's information by searching with their Provider ID number or Provider's name and address. If you need assistance finding a doctor near you, use our online provider search tool, Find a Doctor. Member Services can also email, mail, or fax you a directory upon request.
Do I need a referral to see a specialist?
A referral is the recommendation by a physician and/or health plan for a member to receive care from a different physician or facility. Most members do not need a referral from a PCP to see a specialist. If you and your PCP agree that you need to see a specialist, you can select one from our network. You will then be responsible only for your specialist copay.
Can my current specialist refer me to another specialist?
In most cases, your specialist must contact your PCP to request a referral to another specialist. We recommend that you confirm with your PCP that he or she will request the referral.
Can I get a referral to a non-participating doctor or hospital?
Yes, but only if we have determined that there is not a participating network doctor or hospital that can treat your illness or condition. Your PCP must request prior approval for this type of out-of-network referral and needs to provide medical information to explain why the services of a non-participating doctor or hospital are necessary to treat your illness or condition. If prior approval is granted, services will be paid at the in-network benefit level.
How does Highmark BCBSWNY reimburse health care providers?
We use several nationally accepted methods to pay doctors, hospitals, and urgent care centers both in-network and out-of-network.
This is a negotiated rate between Highmark Blue Cross Blue Shield of Western New York and a doctor, hospital, or urgent care center.
This program was developed by the Blue Cross Blue Shield Association, a national organization of independent Blue Cross and/or Blue Shield plans, to make paying claims easy when you visit a doctor, hospital, or urgent care center outside of your coverage area. You pay your normal copay, deductible, or coinsurance, and the local Blue plan pays the rest.
Resource-Based Relative Value Scale (RBRVS)
This scale was created by the federal government to help insurers determine pricing for medical procedures. This scale uses information such as the length of the procedure, general costs of running a practice, and geographic location to determine how much each medical procedure should cost.
Out-of-network reimbursement compared to Usual, Customary and Reasonable (UCR) Cost
Our general out-of-network reimbursement to doctors for services received using out-of-network benefits is approximately 71 percent of UCR. UCR is the amount providers typically charge for a service.
What is prior authorization?
Prior authorization means that certain services or medications have to be pre-approved by Highmark BCBSWNY before you can receive them. We review medical information provided by your doctor, specialist, or provider to determine if these services or medications are deemed to be medically necessary based on certain clinical guidelines. You can find out what services may require pre-authorization by calling the member service number on the back of your member card. Prescription drugs which require prior authorization are noted on our Medication Guide as such, and most injectable products require prior authorization.
I was told I needed prior authorization to obtain a service. What does this mean?
Prior authorization is the process of obtaining approval from your health insurance company for a service or medication. Without a prior authorization, the service or medication is not covered. Your physician is responsible for obtaining a prior authorization when required. In addition to medical services, certain medications are subject to pre-approval to be eligible for coverage under your pharmacy benefit. We review medical information provided by physicians to determine if clinical guidelines have been met and that the medication is being used appropriately. In addition to those drugs noted on the drug list as requiring prior authorization, most injectable products are subject to prior authorization.
I was told I need prior authorization to obtain a service. What's the difference between prior authorization and a referral?
Prior authorization is the process of obtaining coverage approval from Blue Cross Blue Shield for a service or medication before you receive a service or medication. Without prior authorization, the service or medication is not covered under your health plan benefits. Your doctor or service provider is responsible for obtaining the prior authorization when required.
A referral is a recommendation by a doctor or a health plan for a member to receive care from a different doctor or facility.
How do I find out if a prescription drug requires prior authorization?
Your doctor needs to complete and fax a Prior Authorization Request form to us. We have provided copies of this form to our doctors’ offices, or you can call us at number on the back of your member ID card.
How does my doctor obtain prior authorization?
Your doctor needs to complete and fax a Prior Authorization Request form to us. We have provided copies of this form to our doctors’ offices, or you can call us at number on the back of your member ID card.
How long does it take to get prior authorization?
Decisions on requests are typically made within 1-3 business days and communicated to your doctor within three business days of the date your doctor submits the prior authorization request. If, however, additional medical information is required from the doctor in order to make a decision, it may take additional time for us to respond to your doctor’s request.
What if the medication or service the doctor requested is denied?
When a request is denied, alternative treatment options which are covered under the benefit plan are suggested to the doctor. Each request is reviewed individually and decisions are made based on medically sound clinical criteria developed and/or approved by one of our physician committees.
If the prior authorization request for a specific medication is denied, the drug is considered a non-covered benefit. It is not available as a third-tier medication. You have the right to appeal denials and your appeal rights will be contained in the denial letter that you and your doctor will receive.
As a member, you have rights and responsibilities that will help you make the most of your health benefits. These rights range from being treated with respect and dignity, to confidentiality of your medical records and having the chance to voice complaints or appeals about the Plan or your care. For a full list of rights and responsibilities, please see section below
How do we determine what new technology will be covered?
To continue to provide our members with the most up-to-date treatment methods possible, we continually monitor scientific data and literature about new technology, new uses for existing treatment methods and new drugs. A team of medical experts then uses this information to assist them in updating covered benefits.
It's also important to note that a decision to exclude a new treatment method or drug from the list of covered benefits may change as new scientific literature supporting safe and effective outcomes is documented. Any time new information becomes available, the decision will be re-evaluated. Our members' health is our main concern. We're dedicated to being informed about innovations that may benefit our members with safe and cost-effective treatment alternatives.
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