|
Frequently Asked Questions:
Federal Employee Program (FEP)
For additional information on FEP, visit the Blue Cross and Blue Shield
http://www.fepblue.org site.
Medical Benefits
-
Are preventive physical examinations for adults covered?
-
What would be my out-of-pocket expense when I am admitted to the
hospital for a medical condition?
-
What is precertification and when
is it needed?
-
Can I get a prior approval for a surgery?
-
The provider is billing me for the difference between the total bill
and what I owe on the explanation of benefits (EOB). What should I do?
-
What are my ambulance benefits for an accident or medical
emergency?
-
What is my catastrophic-protection, out-of-pocket maximum?
-
What are my benefits for physical, speech and occupational therapy?
-
What are my benefits for durable medical equipment (DME)?
-
Do I have benefits to quit smoking?
-
Are chiropractors covered?
-
What is Blue Health Connection?
Dental Benefits
-
Is a root canal or a crown covered by dental benefits?
Vision Benefits
-
Are routine eye exams covered under the Federal Employee Service
Benefit Plan?
Pharmacy Benefits
-
What type of drug coverage do I have?
-
Do some prescriptions require prior approval?
-
Do I have to use the Mail-Order Program?
General
-
If I have questions about claim status or benefits, whom do
I contact?
-
If I have questions about the Explanation of Benefits (EOB), whom do
I contact?
-
Why didn't I get my premium statement this month?
-
Why do you want to know if I have other coverage?
Medical Benefits
1. Are preventive physical examinations for adults
covered?
Routine screening examinations performed based on the schedule below and performed by a preferred provider
with a routine diagnosis can be paid in full after the associated office-visit copayment. The covered routine
screening exams are: history and risk assessment, chest X-ray, electrocardiogram (EKG), urinalysis, basic metabolic
or comprehensive metabolic panel test, complete blood count (CBC), cholesterol tests and chlamydial infection
test. They are covered for members as follows:
Once every calendar year.
Basic Option
and Standard Option require a copayment for the office visit.
Note: When the above services are billed with a medical diagnosis, benefits would be eligible under "Other Medical Benefits."
top
2. What would be my out-of-pocket expense when I am
admitted to the hospital for a medical condition?
When you are admitted to the hospital, you will have several different providers that could bill for
services (hospital, physician, anesthesiologist, radiologist or pathologist). Claims are processed as
received and payments are considered based on your specific service plan benefits. Out of pocket expenses
could include deductible, coinsurance and/or any charges not covered by your benefit plan. For more specific
information, please refer to the Service Benefit Plan Brochure, page 68-70.
top
3. What is precertification or prenotification, and when
is it needed?
Consult your benefit booklet or contact the customer service number on your ID card to determine if you are
subject to precertification prior to certain medical services.
Precertification is the requirement to contact the local Blue Cross and Blue Shield plan serving the area where
the services will be rendered before being admitted to a hospital for inpatient care or within two business days
following an emergency hospital admission. It is your responsibility to ensure that precertification is obtained. You,
your physician or the hospital must contact our precertification vendor (Health Integrated) at 1-800-451-7302. If
precertification is not obtained and benefits are otherwise payable, benefits for the admission will be reduced
by $500.
Precertification is not needed for maternity admissions unless your medical condition requires you to stay more
than 48 hours after a vaginal delivery or 96 hours after a cesarean section. Then, you, your physician or the
hospital must contact Health Integrated, the precertification vendor for Arkansas Blue Cross and Blue Shield.
top
4. Can I get a prior approval for a surgery?
Prior approval is given only for services specifically listed in Section 3 and
Section 10 of the Service Benefit Plan brochure.
top
5. The provider is billing me for the difference between
the total bill and what I owe on the explanation of benefits (EOB). What should
I do?
Contact the provider's office and inquire why you received a bill. Give
the information from the EOB, which indicates what you owe. If there is no
resolution between you and the provider, contact FEP Customer
Service at 1-800-482-6655 or 501-378-2531.
top
6. What are my ambulance benefits for an accident or medical
emergency?
Local professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically appropriate, and:
-
Associated with covered hospital inpatient care
-
Related to medical emergency
-
Associated with covered hospice care
Note: We also cover medically necessary emergency care provided at the scene when transport services are not required.
Note: See Section 5(c) for specific benefits.
top
7. What is my catastrophic-protection, out-of-pocket
maximum?
If the total amount of eligible* out-of-pocket expenses in a calendar year for you and your covered family members
meets the following limits, you and any covered family members will not have to continue paying them for the remainder
of the calendar year.
Standard Option:
If the total amount of these out-of-pocket expenses from using preferred providers for you and your covered family
members exceeds $5,000 in a calendar year, you and any covered family members will not have to pay these expenses
for the remainder of the calendar year when you continue to use preferred providers. You will, however, have to pay
them when you use non-preferred providers until your out-of-pocket expense for the services of both preferred and
non-preferred providers reaches $7,000 under Standard Option.
Basic Option:
If the total amount of these eligible* out-of-pocket expenses from using preferred providers for you and your
covered family members exceeds $5,000 in a calendar year under Basic Option, you and any covered family members
will not have to pay these expenses for the remainder of the calendar year.
*There are some expenses that do not count toward the catastrophic-protection,
out-of-pocket maximum, and you must continue to pay them even after your
expenses exceed the limits described above. For additional information,
refer to the Blue Cross and Blue Shield Service Benefit Plan Web site at
http://www.fepblue.org.
top
8. What are my benefits for physical, speech and occupational therapy?
Physical therapy, occupational therapy, and speech therapy when performed by a licensed therapist or
physician are covered as described below. Refer to Section 5(a) of the service brochure.
Cognitive rehabilitation therapy when performed by a licensed therapist or physician is covered.
Note: When billed by a skilled nursing facility, nursing home, or extended care facility, we pay
benefits as shown here for professional care, according to the contracting status of the facility.
Standard Option:
-
Preferred primary care provider or other health care professional: $20 copayment per visit (No deductible)
-
Preferred specialist: $30 copayment per visit (No deductible)
-
Participating: 35% of the Plan allowance
-
Non-participating: 35% of the Plan allowance, plus any difference between our allowance and the billed amount
Note: Benefits are limited to 75 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three.
Note: Visits that you pay for while meeting your calendar year deductible count toward the limit cited above.
Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.
Basic Option:
Benefits are limited to 50 visits per person, per calendar year for physical, occupational or speech therapy, or a
combination of all three. To receive benefits you must use a Preferred provider.
top
9. What are my benefits for durable medical equipment
(DME)?
Standard Option:
Benefits are based on the provider you choose. The highest benefits available are preferred. If you choose to go
to a durable medical equipment company that is not preferred, your out-of-pocket expense will be more. Refer to
Section 5a in the Service Benefit Plan brochure for additional information.
Basic Option:
Benefits must be provided by a preferred provider. Refer to Section 5a in the Service Benefit Plan brochure for additional information.
top
10. Do I have benefits to quit smoking?
Standard Option:
-
Preferred primary care provider or other health care professional: $20 copayment for the office visit
charge (No deductible); You pay 15% of the Plan allowance for all other services (deductible applies)
-
Preferred specialist: $30 copayment for the office visit charge (No deductible); You pay 15% of the Plan allowance for all other services (deductible applies)
-
Participating: You pay 35% of the Plan allowance
-
Non-participating: You pay 35% of the Plan allowance, plus any difference between our allowance and the billed amount.
Basic Option:
-
Preferred primary care provider or other health care professional: $25 copayment per visit
-
Preferred specialist: $35 copayment per visit
-
Participating/Non-participating: You pay all charges
top
11. Are chiropractors covered?
Services for a chiropractor are limited to one office visit per calendar year, one set of X-rays per calendar year and spinal manipulations.
Standard Option:
-
Preferred: $20 copayment per visit (No deductible)
-
Participating: You pay 35% of the Plan allowance
-
Non-participating: You pay 35% of the Plan allowance, plus any difference between our allowance and the billed amount
Note: Benefits are limited to 12 manipulations per calendar year.
Note: Office visits, X-rays and spinal manipulations that you pay for while meeting your calendar year deductible count toward the
appropriate benefit limit.
Basic Option:
Benefits are available for covered services provided by network chiropractors. Covered services include the initial office
visit, spinal manipulations and the initial set of X-rays. A $25 copayment applies for each visit. Benefits are limited
to 20 manipulations per year.
top
12. What is Blue Health Connection?
Blue Health Connection is a 24-hour nurse telephone service that is available
365 days a year by calling a toll-free telephone number 1-888-258-3432 or
accessing our Internet site at http://www.fepblue.org.
The service features health advice or health information and counseling by
registered nurses. Also available is the Audio Health Library with hundreds of
topics, ranging from first aid to infectious diseases to general health issues.
top
Dental Benefits
1. Is a root canal or a crown covered by dental
benefits?
Basic and Standard options offer basic preventive dental coverage. Eligible
services are paid on a fee schedule. Major dental work, such as orthodontics,
root canals or crowns, is not covered. For more information, refer to the Blue
Cross and Blue Shield Service Benefit Plan brochure, Section 5g.
top
Vision Benefits
1. Are routine eye exams covered under the Federal
Employee Service Benefit Plan?
Routine eye exams are not eligible for benefits. However, Service Benefit Plan
members may obtain substantial savings from Davis Vision providers for eye
exams and eyewear through a non-FEHB benefit. The names, addresses and
telephone numbers of Davis Vision providers are available by calling
1-800-551-3337. Refer to Section 5J in the Blue Cross and Blue Shield Service Benefit Plan brochure.
There are no enrollment fees and no additional paperwork or claim forms to be filed in this program. All charges
for eye exams and eyewear are handled directly between you and Davis Vision provider.
top
Pharmacy Benefits
1. What type of drug coverage do I have?
Standard Option:
If you have Standard Option coverage, you can choose to use the Mail Service or
the Retail Pharmacy programs. You may reach the Mail Service Prescription Drug Program
at 1-800-262-7890 or http://www.fepblue.org. For benefits
refer to section 7 of the service plan brochure.
Prescription benefits are available at a preferred retail pharmacy. For a list of the preferred pharmacies, you
may call the Retail Pharmacy Program at 1-800-624-5060 or visit http://www.fepblue.org. For benefits refer to
section 7 of the service plan brochure.
Basic Option:
If you have Basic Option coverage, the Mail Service Program is not available. Basic Option uses preferred
retail pharmacies. For a list of the Basic Option preferred pharmacies, you may call the Retail Pharmacy
Program at 1-800-624-5060 or visit http://www.fepblue.org. For benefits refer to section 7 of the service
plan brochure.
top
2. Do some prescriptions require prior approval?
Certain prescription drugs require prior approval. Contact the Retail Pharmacy
Program at 1-800-624-5060 to request prior approval or to obtain an updated
list of prescription drugs that require prior approval.
top
3. Do I have to use the Mail-Order Program?
Standard Option:
It is your choice to use the Mail-Order Program or a local retail pharmacy.
Basic Option:
Does not offer mail-order.
top
General
1. If I have questions about claim status or benefits,
whom do I contact?
Call the customer service number that appears on your ID card.
top
2. If I have questions about the Explanation of Benefits (EOB),
whom do I contact?
Consult your ID card
for the customer service telephone number or the mailing address.
top
3. Why didn't I get my premium statement this month?
If you have not received your statement by the end of the month, call Customer
Service at the number noted on the back of your member ID card.
top
4. Why do you want to know if I have other coverage?
A decision must be made as to which coverage is responsible for primary
payment.
top
|