General Information Regarding Georgia Health Insurance

Balance Billing
Participating Physicians are prohibited from balance billing for covered health services. A Participating Physician has signed an agreement with the Claims Administrator to accept the Claims Administrator's determination of the Usual, Customary and Reasonable Fee for Covered Services rendered to a Participant who is his or her patient. A Participant is not liable for any fee in excess of this determination or negotiated fee, except what is due under the Plan, e.g., Copayments or Coinsurance.

Proof of Loss, Payment of Claims
If you incur out-of-area claims, please submit the bill to Blue Cross Blue Shield Healthcare Plan of Georgia. Please include your ID number so the Plan Administrator can verify that you are an active Participant.

Timeliness of Filing and Payment of Claims (Out-of-Area Only)
In the event you submit a claim, to receive benefits, a properly completed claim form with any necessary reports and records must be filed within 24 months from the date of service. Payment of claims will be made as soon as possible following receipt of the claim, unless more time is required because of incomplete or missing information. In this case, the Plan Administrator will notify you of the reason for the delay and you will receive a list of all information needed to continue processing your claim. After this data is received, BCBSHP will complete claims processing.

Network Providers
Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. provides or makes payment for Medically Necessary covered health care services received by the Participant. The health care services are subject to the limitations, exclusions, and Copayments specified in the SPD Booklet. Unless otherwise specified, all services must be coordinated by the Primary Care Physician you have selected from the BlueChoice provider directory.

Unauthorized Use of Identification Card
If you permit a BCBSHP Identification Card to be used by someone else or if you use the card before coverage is in effect or after coverage has ended, you will be liable for payment of any expenses incurred resulting from the unauthorized use. Fraudulent misuse could also result in termination of the coverage. If you know of any unauthorized use, please notify us immediately.

Questions About Coverage or Claims
If you have questions about your coverage, contact your Plan Administrator or the BCBSHP Customer Service Department. Be sure to always give your ID number. If you wish to get a full copy of the Utilization Review program procedures, contact the Customer Service Department.

Write
Customer Service Department
Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.
P.O. Box 7368
Columbus, Georgia 31908

When asking about a claim, give the following information:

• Identification number;
• Patient's name and address;
• Date of service; type of service received; and
• Provider name and address (Hospital or doctor).

Complaints about Service
As a Participant, you have a right to express dissatisfaction and to expect unbiased resolution of issues. The following represents the process established to ensure that the fullest attention is given to your concerns.

• Call the Customer Service Department. The phone number is on your ID Card. Tell BCBSHP your problem and BCBSHP will work to resolve it for you as quickly as possible.
• If you are not satisfied with the answer, you may file a formal complaint, preferably, but not necessarily, in writing. This request for a further review of your concerns should be addressed to the location provided by the Customer Service Representative at the number on your ID Card.
• If, depending on the nature of your complaint, you remain dissatisfied after receiving the response, you will be offered the right to appeal the decision. At the conclusion of this formalized re-review of your specific concerns, a final written response will be generated to you.

Complaints about Provider Service
If your complaint involves care received from a provider, please call the Customer Service number. Your complaint will be resolved in a timely manner.