| Your
Right to Privacy
Personal information of any kind, such as information regarding your medical care or health status, is protected by Blue Cross' confidentially policies and procedures. While we require such information to process your claims, we do not liberate information that identifies you, as well as your diagnosis or medical condition without your consent.
Grievances
Each and every complaints and disputes relating
to your coverage must be determined in accordance with Blue Cross’
grievance procedure. Grievances may be made by the telephone or
in writing to the phone number or address positioned on the back
of your Blue Cross Identification Card. All grievances received
by Blue Cross that cannot be resolved by phone to the mutual satisfaction
of the Member and Blue Cross will be recognized in writing, together
with a description of how Blue Cross offers to determine the grievance.
We will not react in writing following a regular telephone inquiry
unless and until it is specifically requested to do the same by
the Member. Grievances that cannot be resolved by these procedures
shall be resolved as indicated under Arbitration.
Department of Corporations
The California Department of Corporations is
in charge for regulating health care services plans. The department’s
Health Plan Division has a toll-free telephone number (1-800-400-0815)
for receiving complaints concerning health plans. Both hearing
and speech impaired may use the California Relay Service’s toll-free
telephone numbers (1-800-735-2929 (TTY) or 1-888-877-5378 (TTY))
to make contact with the department. The department’s Internet
web site (http://www.CORP.CA.GOV) has complaint forms along with
instructions online.
You should telephone us and use our grievance
process before contacting the Health Plan Division if you have
a grievance against us. Also if you need help with a grievance
linking an emergency, a grievance that has not been satisfactorily
resolved by your plan, or a grievance that has remained unresolved
for more than 30 days, you may call the Health Plan Division for
assistance. The plan’s grievance process and the Health Plan Division’s
complaint review process are in addition to any other dispute
resolution procedures that may be accessible to you, and your
failure to use these processes does not preclude your use of any
other remedy provided by law.
Binding Arbitration
Any dispute between the employer or covered persons
and Blue Cross must be resolved by binding arbitration, if the
amount in dispute goes above the jurisdictional limit of the Small
Claims Court. Under this coverage, both you and Blue Cross are
giving up the right to take part in class arbitration or have
any dispute decided in the court of law before a jury.
Medicare
Medicare is the primary coverage for groups of
less than 20 employees under TEFRA/DEFRA. Blue Cross is considered
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 only a supplement to Medicare,
but also 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 affiliate is Medicare eligible, even if the member did not sign up or claim Medicare benefits, the Blue Cross plan would pay only in accordance with the benefits of the plan less any amount that would have been payable by Medicare. If Medicare is the member's primary coverage, it is momentous that the member enrolls in both Medicare Parts A and B.
NOTE: Medicare-eligible employees enrolled in plans where Medicare is primary may attain an Individual Blue Cross of California Medicare Supplement with preexisting circumstances waved.
Coordination of Benefits
The advantages of a member’s plan may get condensed
if the member has some other group health, dental, drug or vision
coverage, so that benefits and services the member receives from
all group coverage's do not go beyond 100 percent of the Covered
Expense.
Third Party Liability
If a member is injured, the party in charge may
be legally obligated to reimburse for medical expenses associated
to that injury. If the member recovers damages from a legally
liable third party Blue Cross may recuperate benefits paid for
medical expenses. 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 present
any requisite 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 precise information
been equipped. Benefits will not 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 recommending you that
Blue Cross of California’s incurred loss ratio for 1998 was 79.4
percent. This particular loss ratio was intended after all the
provider discounts were applied.
Enrollment Guidelines |
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