Your Right to Privacy

Our complete Notice of Privacy Practices provides a comprehensive overview of the policies and practices we enforce to preserve our members’ privacy rights and control use to their health care information, including: the right to authorize release of information; the right to limit access to medical information; protection of oral, written and electronic information; use of data; and information shared with employers. This notice can be downloaded from our Web site by clicking on this link Notice of Privacy Practices or by calling Small Group Customer Service at (800) 627-8797.

Grievances

All complaints and disputes relating to your coverage must be resolved in accordance with Blue Cross' grievance procedure. You can report your grievance by phone or writing; see your Blue Cross ID card for the appropriate contact information. All grievances received by Blue Cross that cannot be resolved by phone (when appropriate) to the mutual satisfaction of the Member and Blue Cross will be acknowledged in writing, together with a description of how Blue Cross proposes to resolve the grievance. Grievances that cannot be resolved as indicated through binding arbitration, or if the plan you are covered under is subject to the Employee Retirement Income Security Act of 1974 (ERISA), in compliance with ERISA rules.

If the group is subject to ERISA, and a member disagrees with Blue Cross’ proposed resolution of a grievance, the member may submit an appeal by phone or in writing, by contracting the phone number or address or address printed on the letterhead of the Blue Cross response letter.

For the purpose of ERISA, there is one level of appeal. For urgent care requests for benefits, Blue Cross will respond within 72 hours from the date the appeal is received. For pre-service requests for benefits, the member will receive a response within 30 calendar days from the date the appeal is received. For Post-service claims, Blue Cross will respond within 60 calendar days from the date the appeal is received.

If the member disagrees with Blue Cross’ decision on the appeal, the member may elect to have the dispute settled through alternative resolution options, such as mediation.

Department of Managed Health Care

The California Department of Managed Health Care (DMHC) is responsible for regulating health care services plans. If you have a grievance against your health plan, you should first telephone your health plan at (800) 627-8797 and use your health plan’s grievance process before contacting the DMHC. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you.

If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the DMHC for assistance.

Your case may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by your health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature, and payment disputes for emergency or urgent medical services.

The DMHC also has a toll-free telephone number (888-HMO-2219), and TDD line (877-688-9891) for the hearing- and speech- impaired. The department’s Internet Web site, www.hmohelp.ca.gov, has complaint forms, IMR application forms and instructions online.

Binding Arbitration

If a plan is subject to ERISA, any dispute involving a request or claim for medical services must be resolved under ERISA claims procedure rules, and is not subject to mandatory binding arbitration. Members may pursue voluntary binding arbitration after they have completed an appeal under ERISA rules.

If a member has another dispute that does not involve a request or claim for medical services, or if the group is not subject to ERISA, the following provisions apply:

Any dispute between the employer and/or the member and Blue Cross must be resolved by binding arbitration (not by lawsuit or trial by jury or other court process, except as California law provides for judicial review of arbitration proceedings), if the amount in dispute exceeds the jurisdictional limit of the Small Claims Court. Under this coverage, both the member and Blue Cross are giving up the right to participate in class arbitration or have any dispute decided in a court of law before a jury.

Medicare

Under TEFRA/DEFRA, Medicare is the primary coverage for groups of less than 20 employees. Blue Cross is considered primary coverage for groups of 20 or more employees. This Blue Cross coverage is NOT a supplement to Medicare, but provides benefits according to Non-Duplication of Medicare Claims.

This means that when Medicare is the primary health coverage, benefits will be provided in accordance with the benefits of the plan less any amount paid by Medicare. If the member is entitled to Part A or B of Medicare, you will be eligible for non-duplicate Medicare coverage, with supplemental coordination of benefits.

However, if you are required to pay the Social Security Administration an additional premium for any part of Medicare, then the above policy will only apply if you are enrolled in that part of Medicare.

NOTE: Medicare-eligible employees/dependents enrolled in plans where Medicare is primary may obtain an Individual Blue Cross of California Medicare Supplement with preexisting conditions waived.

Coordination of Benefits

The benefits of a member's plan may be reduced if the member has other group health, dental, drug or vision coverage, so that benefits and services the member receives from all group coverage’s do not exceed 100 percent of the Covered Expense.

Third Party Liability

If a member is injured, the responsible party may be legally obligated to pay for medical expenses related to that injury. Blue Cross may recover benefits paid for medical expenses if the member recovers damages from a legally liable third party. Examples of third party liability include car accidents and work-related injuries.

Voiding Coverage for False and Misleading Information

False or missing information or failure to submit any required enrollment material may form the basis for voiding coverage from the date a plan was issued or retroactively adjusting premium to what it would have been had the correct information been furnished. No benefits will be paid for any claim submitted if coverage is void. Premiums already paid for the time period for which coverage was rescinded will be refunded, minus claims paid.

Loss Ratio

As required by law, we are advising you that Blue Cross of California and its affiliated companies’ incurred medical care ratio for 2002 was 80.81 percent. This loss ratio was calculated after provider discounts were applied.