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UC2004

Behavioral Health Benefits for Blue Cross PLUS

Unspecified 

A COVERED PERSON MAY WRITE THE CALIFORNIA DEPARTMENT OF

INSURANCE AT:

CALIFORNIA DEPARTMENT OF INSURANCE

CLAIMS SERVICES BUREAU, 11TH FLOOR

300 SOUTH SPRING STREET

LOS ANGELES, CA 90013

Benefit Determinations

Pre-Service Claims

Pre-service claims are those claims that require notification or approval prior to receiving Behavioral Health Services.

If the Covered Person’s claim was a pre-service claim, and was submitted properly with all needed information, the

Covered Person will receive written notice of the claim decision from UBH within 15 days of receipt of the claim. If

the Covered Person filed a pre-service claim improperly, UBH will notify the Covered Person of the improper filing

and how to correct it within five days after the pre-service claim was received. If additional information is needed to

process the pre-service claim, UBH will notify the Covered Person of the information needed within 15 days after the

claim was received, and may request a one-time extension not longer than 15 days and pend the Covered Person’s claim

until all information is received. Once notified of the extension, the Covered Person then has 45 days to provide this

information. If all of the needed information is received within the 45-day time frame, UBH will notify the Covered

Person of the determination within 15 days after the information is received. If the Covered Person does not provide

the needed information within the 45-day period, the claim will be denied. A denial notice will explain the reason for

denial, refer to the part of the plan on which the denial is based, and provide the claim appeal procedures.

Concurrent Care Claims

If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and

the request to extend the treatment is an urgent claim as defined below, the Covered Person’s request will be decided

upon within 24 hours, provided the request is made at least 24 hours prior to the end of the approved treatment. UBH

will make a determination on the request for the extended treatment within 24 hours from receipt of the request. If the

request for extended treatment is not made at least 24 hours prior to the end of the approved treatment, the request will

be treated as an urgent claim and decided according to the timeframes described below.

If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and

the Covered Person’s request to extend treatment is a non-urgent circumstance, the request will be considered a new

claim and decided according to pre-service or post-service timeframes, whichever applies.

Post-service Claims

Post-service claims are those claims that are filed for payment of benefits after Behavioral Health Services have been

received. If the Covered Person’s post-service claim is denied, he or she will receive a written notice from UBH within

30 days of receipt of the claim, as long as all needed information was provided with the claim. UBH will notify the

Covered Person within this 30-day period if additional information is needed to process the claim, and may request a

one-time extension not longer than 15 days and pend the claim until all information is received.

Once notified of the extension, the Covered Person then has 45 days to provide this information. If all of the needed

information is received within the 45-day time frame, and the claim is denied, UBH will notify the Covered Person of

the denial within 15 days after the information is received. If the Covered Person does not provide the needed

information within the 45-day period, his or her claim will be denied.

A denial notice will explain the reason for denial, refer to the part of the plan on which the denial is based, and provide

the claim appeal procedures.

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