OPL
OPL be located
What is FEPDirect Special Information?
Standard option PT/OT/ST limit
Benefits are limited to 75 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three.
Catastrophic amount for FEP Blue Focus
Preferred Provider maximum – For a Self Only enrollment, your out-of-pocket maximum for your deductible, and for eligible coinsurance and copayment amounts, is $7,500 when you use Preferred providers. For a Self Plus One or a Self and Family enrollment, your out-of-pocket maximum for these types of expenses is $15,000 for Preferred provider services. Only eligible expenses for Preferred provider services count toward these limits.
What is telehealth benefit Basic option?
Professional services for: Minor acute conditions, Dermatology, Behavioral Health counseling, and Substance use disorder counseling.
PPO: Nothing for the first 2 visits per calendar year for any covered telehealth service; $15 copayment per visit after the 2nd visit PAR/NON-PPO: Patient pays all charges.
When $150 copay applies for basic at Facility
when other dx services are done as same days as services In OP ambulatory surg ctr
Medicare is primary Standard Option PPO provider quote benefit
What is
PRECERT: Not required (Unless Member has Medicare “A” and patient has exhausted Medicare days and always for Gender Reassignment Surgery and RTC)
PPO/PAR/NON-PPO: Plan provides benefits for Medicare coinsurance and deductible for all eligible services. Benefit limitations still apply.
Speech generating device limit
Speech-generating devices, limited to $1250 per calendar year
Catastrophic amount Standard
Preferred Maximum: For a Self Only enrollment, your out-of-pocket maximum for your deductible, and for eligible coinsurance and copayment amounts, is $5,000 when you use Preferred providers. For a Self Plus One or Self and Family enrollment, your out-of-pocket maximum for these types of expenses is $10,000 for Preferred provider services. Only eligible expenses for Preferred provider services count toward these limits. Non-preferred Provider maximum: For a Self Only enrollment, your out-of-pocket maximum for your deductible, and for eligible coinsurance and copayment amounts, is $7,000 when you use Non-preferred providers. For a Self Pluse One or Self and Family enrollment, your out-of-pocket maximum for these types of expenses is $14,000 for Non-preferred provider services. For either enrollment type, eligible expenses for the services of Preferred providers also count toward these limits.
What is BCBSAZ mailing address for claims?
PO BOX 2924 PHX AZ 85062
Inpatient Facility Maternity PPO benefit FEP Blue Focus
Precert: You do not need precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for precertification of additional days for your baby.
PPO: Patient is responsible for $1,500 copay per pregnancy (no deductible). Benefits are provided at 100% of plan allowance.
How does BCBS FEP process as secondary?
When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance
Basic option Home nursing limit
Benefits are available for home nursing care for two (2) hours per day, up to 25 visits per person, per calendar year.
Catastrophic amount Basic
Preferred Provider maximum- For a Self Only enrollment, your out-of pocket-maximum for eligible coinsurance and copayment amounts is $5,500 when you use Preferred providers. For a Self Plus One or a Self and Family enrollment, your out-of-pocket maximum for these types of expenses is $11,000 when you use Preferred providers. Only eligible expenses for Preferred providers services count towards these limits.
Are nurse midwives covered providers?
yes as long as practicing within the scope of their license.
Skilled Nursing Facility (SNF) benefit Basic Option
PPO: No benefits available under Basic Option.
Always payor of last resort
Tricare/ AHCCCS/ Medicaid/ IHS/ FEP Dental
Where can office visit count be located for FEP Blue Focus?
FEPDirect Accumulators under patient level medical accumulators on Professional Provider Visits
Does the $500 penalty for failing to obtain a precert count towards Catastrophic amount
No
Who are the provider under RAPER?
R radiologists
A anesthesiologists
P pathologists
E emergency physicians
R registered nurse anesthetists
Extended Active Rehab (EAR) benefit Standard option PPO provider
PRECERT: Is Required and must be obtained within 72 hours or 3 business days of initial admit. Failure to obtain pre-certification will result in a $500 penalty. Effective 7/1/2014 penalty will be applied to member responsibility for Non Member facilities or provider responsibility for Preferred facilities. Standard Option: Facility must be PPO and an EAR approved facility. Initial approval is based on Medical necessity. Length of stay is also based on medical necessity. The benefit is paid on a per diem rate. If the patient is transferred from another facility, no additional admit copayment will apply and reimbursement will be at 100% of the Plan allowance.
When is a patient eligiblity for Medicare
1st of the month of their 65th birthday. If their birthday is on the 1st, they are eligible the 1st of the month of the month prior.
What is limit for ABA therapy on FEP Blue Focus?
Applied behavior analysis (ABA) for an autism spectrum disorder performed and billed by a facility limited to 200 hours per person per calendar year.
True or False: Pharmacy copays apply toward catastrophic amount
True
What is benefit for Standard option Smoking and Tobacco cessation?
Smoking and tobacco cessation treatment and classes; Individual counseling for smoking and tobacco use cessation
PPO: Benefits are provided at 100% of plan allowance. (no deductible)
NON-PPO: Subject to $350 individual /$700 family calendar year deductible. Patient is responsible for 35% of plan allowance, plus any difference between our allowance and the billed amount.
Inpatient Mental Health Facility benefit FEP Blue Focus
PRECERT: Is Required and must be obtained within 72 hours or 3 business days of initial admit. Failure to obtain pre-certification will result in a $500 penalty. Effective 7/1/2014 penalty will be applied to member responsibility for Non Member facilities or provider responsibility for Preferred facilities.
PPO: Patient is responsible for 30% of plan allowance, after deductible of $500 individual /$1,000 Self Plus One or Family NON-PPO(Participating/ Non-participating): No benefits available.