Member Notices

Verify Benefit Coverage

We strongly encourage members to ask their provider to check Regence's website or call us to verify benefit coverage before services are provided. Members may also call Regence for any questions about whether a service is a covered benefit.

Health Care Quality Concerns Form

Complete and submit this online fillable form. Your concerns and comments are important to us. If you have concerns about a clinic, doctor or other health care professional, we’d like to hear from you.

 

Fraud Alert: caller targets Regence members

Regence offers advice for protecting yourself
October 22, 2007, updated November 2, 2007

We recently learned that several of our members have received suspicious phone calls from a caller claiming to be from Regence. Members were asked for either their bank account or credit card information.  

Regence is committed to protecting our members' privacy. As such, we never call members to request this type of financial information over the phone in a "cold call" style.

However, members would receive this type of call from Regence if they have elected to deduct their premium from their bank account and we require information to complete their application. In this case, the interaction would have been initiated by the member. In addition, members are also offered the opportunity to send in a new form, should they not wish to provide financial information over the phone.

Members should contact Regence or their benefits administrator if they suspect they have received a questionable phone call. In the meantime, there are things you can do to protect yourself if you receive these types of calls:

• Do not provide credit card or bank account information to the caller.
• If you have received a call and provided financial information, we recommend that you cancel the credit card(s) immediately or contact your bank to flag your bank accounts to monitor suspicious activity. You can also request free credit reports online to monitor your credit for possible identity theft. Be sure to use the official, centralized web site: www.annualcreditreport.com.
• You can also contact your local police department. Regence will fully cooperate with any law enforcement agency to assist in their investigation.

Questions?
If you have any questions or concerns, please contact us.
 

Agent Bonus/Commission Notice

If you have a broker or agent, they may receive bonuses, commissions, administrative services, or other compensation, from Regence. Incentives may be based on any of several factors, including the size of group business, the products you buy, your broker or agent's volume of business with Regence and the other services your agent or broker provides to you. These incentives may have an indirect impact on your rates. For more information, please contact your broker or agent.
 

Traditional and Managed Care Appeal and Grievance Process

What is an Appeal?
An “Appeal” is a written or oral request from a Member or, if authorized by the Member, the Member’s Representative, to change a previous decision made by Regence BlueShield of Idaho concerning:

• Access to health care benefits, including an adverse determination made pursuant to utilization review,
• Claims payment, handling or reimbursement for health care services, or
• Matters pertaining to the contractual relationship between a Member and the plan, or
• Other matters as specifically required by State law or regulation.

Who is a "Member"?
“Member” is the enrolled employee or contract holder or his/her enrolled dependent.

Who is a "Member Representative"?
"Member Representative" is any authorized representative of the Member.

For most appeals there are two Levels of review. In some cases there is available a third level appeal for determination of medical necessity and experimental/investigational procedures.

Level 1 – Appeal (Complaint/Grievance/Reconsideration)

1. Regence BlueShield of Idaho must receive an appeal (complaint/grievance) within 180 days of the member's receipt of the initial claims denial. If received an acknowledgment receipt is sent within five (5) business days or seven (7) calendar days
2. Regence BlueShield of Idaho staff will investigate the issue, including all aspects of the clinical case.
3. The member receives a written decision within 30 days of receipt of the appeal (complaint/grievance).  The exceptions to this time frame will be:
   1. If the appeal involves denial of care as investigational, this will be decided with 20 working days, and
   2. Appeals involving denial of pre-authorization of care will be decided within 14 days.
4. If the decision is not in the member’s favor, Regence BlueShield of Idaho will let the member know that a further appeal (the second level of the process) may be submitted and must be received within one hundred and eighty (180) days of the first level decision.

Level 2 – Appeal (Internal Appeal)

1. Regence BlueShield of Idaho receives the appeal and acknowledges receipt within five (5) business or seven (7) calendar days.
2. Regence BlueShield of Idaho staff gathers documentation related to the case and the case is reviewed by the health plan’s three-member Internal Appeal Panel.
3. The member receives a written decision within thirty (30) days of submission of the appeal. The exceptions to this time frame will be:
   1. If the appeal involves denial of care as investigational, this will be decided within 20 working days, and
   2. Appeals involving denial of pre-authorization of care will be decided within 14 days
4. If the decision is not in the member’s favor, Regence BlueShield of Idaho will let the member know if a third level appeal is available. When available the appeal must be received within four months of the second-level decision.
   

Level 3 – Appeal (External Appeal) This level is only for medical necessity and experimental/investigational procedures.

Standard External Review Request: You must file your written external review request with the Department of Insurance within four months after the date we issue a final notice of denial.

1. Within 7 days after the department receives your request, the department will send a copy to us.
2. Within 14 days after we receive your request from the department, we will review you request for eligibility. Within 5 business days after we complete that review, we will notify you and the department in writing if you request is eligible or what, if any, additional information is needed.  If we deny your eligibility for review, you may appeal that determination to the department.
3. If your request is eligible for review, the department will assign an independent review organization to your review within 7 days of receipt of our notice. The department will also notify you in writing.
4. Within 14 days of the assignment, Regence will provide the independent review organization with the documents and any information considered in making the previous adverse benefit determinations.
5. The independent review organization must provide written notice of its decision to you, to us and the department within 42 days after the receipt of an external review request.

Expedited External Review Request: You may file a written "urgent care request" with the Department of Insurance for an expedited external review of a pre-service or concurrent service denial.

"Urgent care request" means any pre-service or concurrent care claim for medical care or treatment for which application of the time periods for making a regular external review determination:

1. Could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function;
2. In the opinion of the treating health care professional with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the disputed care or treatment; or
3. The treatment would be significantly less effective if not promptly initiated.

The Department will send your request to us.  We will determine, no later than the 2nd full business day, if your request is eligible for review. We will notify you and the Department no later than 1 business day after our decision if your request is eligible. If we deny your eligibility for review, you may appeal that determination to the department.

If your request is eligible for review, the department will assign an independent review organization to your review upon receipt of our notice. The department will also notify you. Upon receipt of notice of the assignment, Regence will provide the independent review organization with the documents and any information considered in making the previous adverse benefit determinations.

The independent review organization must provide notice of its decision to you, to us and to the department within 72 hours after the date of receipt of the external review request. The independent review organization must provide written confirmation of its decision within 48 hours of notice of its decision. If the decision reverses our denial, we will notify you and the department of your eligibility for urgent care within 1 business day after the decision.

For Level 1 and Level 2 appeals, fill out the appeals form (PDF) and mail to the address below.

Regence BlueShield of Idaho
Attn: Appeal Coordinator
P O Box 1106
Lewiston, ID 83501

For members requesting to have their physician appeal on their behalf at the third level, the member must complete the following form(s):

• Authorization for Use and Disclosure of Protected Health Information - Medical Records (PDF)
• Authorization for Use and Disclosure of Protected Health Information - Drug/Alcohol/Psychotherapy Records (PDF)

For Level 3 (External Appeals), fill out the appeals form (PDF) and mail to the Department of Insurance at the address below:

Idaho Department of Insurance
Attn: External Review
700 W. State St., 3rd Floor
Boise, ID 83720-0043

The Department of Insurance can be contacted at (208) 334-4250, or toll-free at 1 (800) 721-3272. Their web address is www.doi.idaho.gov

In order to verify requests for information made by Regence BlueShield of Idaho, please contact our Customer Service department at (208) 746-2671 or toll-free at 1 (800) 632-2022. If you want additional information regarding privacy at Regence BlueShield of Idaho, please refer to our Notice of Privacy Practices at www.regence.com/legal/notice-of-privacy-practices.jsp.

How to Protect Yourself from Identity Theft

Fraudulent Telephone Calls and E-mails Seek to Capture Consumer Information

Consumers should stay alert for telephone calls or spam e-mails that claim to come from well-known companies. The exact scam may vary, but usually the telephone call or e-mail will claim that there is a problem with the consumer’s account and that they need to confirm the consumer’s personal information

Do not give out personal information on the phone, through the mail or over the Internet unless you have initiated the contact or are sure you know who you're dealing with. Identity thieves may pose as representatives of insurance companies, banks, Internet service providers (ISPs) and even government agencies to get you to reveal your Social Security Number, mother's maiden name, account numbers and other identifying information. Before you share any personal information, confirm that you are dealing with a legitimate representative of the organization. You can check the organization's Web site as many companies post scam alerts when their name is used improperly.