Claims and Coverage Frequently Asked Questions

To see your claims online, log in to your Blue Access for Members℠ account or use the BCBSTX Mobile App. After you log in, click on "Claims" to view your claims. Using this feature, you can:

• Access up to 18 months of claims.
• Use filters to find the information you need. You can filter information by member, claim type, claim status and provider.
• ​Download or print claim information.

​Want a quick guide to help you better understand your claims information? Each claim comes with an Explanation of Benefits (EOB) statement. Your EOB will break down the services you received, the cost of the services and what you might have to pay. ​

Most often, your provider will submit a claim for reimbursement on your behalf. If your provider does not send the claim for you, you can file it yourself.

To submit a claim for reimbursement, you can fill out or download a Medical Claim Form from Buscador de formularios. You can also log into BAM to download this form from the "Forms and Documents" link. Then, fill out the form completely.

Para enviar su formulario completo, puede hacer lo siguiente:

• Go to the BAM Message Center. Create a new message. Attach the form and the original bill issued by the provider to the message. Select "Claims Submission Attachments" in the subject dropdown. Then, click Send.
• Mail the form and the original bill from your provider to the address at the top of the claim form.

To check the status of a claim, you can log in to your BAM account and check the “Claims” section. You can also sign up to get alerts about your claims in BAM.

Note that BAM and Customer Service agents will not have updates on your claim until it is submitted and processed.

There are only a handful of reasons a health care service may not get approved or a claim may not be paid. 

Most often, the reasons may be:

• La reclamación presenta errores.
• You used a provider not in your health plan’s network (an out-of-network provider). 
• Your care needed approval ahead of time.
• You got care that is not covered by your plan.
• The claim was filed with the wrong insurance company.

Usted tiene derecho a saber por qué se rechazó una reclamación. You can always check your EOB statement for why your claim was denied and to make sure your claim information is correct. Si se rechaza una reclamación, al final de su EOB se indicará el motivo del rechazo.

 Learn more about claim denials.   

Review your EOB first to find out why the claim was denied. If a simple mistake was made on the claim, like the wrong birth date or a different home address, you can give Customer Service a call to easily correct it.

You can also check with your provider. They will have been notified that the claim was denied and may know what mistake needs to be fixed so they can submit it again.

If your claim was denied for another reason, you may need to ask BCBSTX to review the claim. This is called appealing a claim.

You always have the right to know why a claim was denied and to appeal it. Todas las Explicaciones de Beneficios cuentan con instrucciones sobre qué hacer si se rechaza una reclamación. It is also explained in your benefit booklet. Es posible que reciba su Explicación de Beneficios por correo. If you signed up for online access to your account, you can log in to BAM to see your EOB and any information related to the denial.

While some appeals are quicker to review, a standard appeal takes about 30 days. Some appeals may take up to 60 days to review.

Si su vida o salud podría estar en riesgo mientras espera, puede pedir una apelación acelerada. Si es elegible, la revisión se gestionará dentro de las 72 horas. You and your provider will get a phone call from BCBSTX explaining the decision and next steps.

Learn what to do about denied claims.

Not all plans are the same. And there are also different types of plans, like medical, dental, vision and prescription. To find out what is covered under your specific plans, view your benefits booklet. It can be found in the "Coverage and Benefits" section of BAM. You’ll need to be logged in to BAM to see your plan’s details.

You will have up to 60 days to add your infant to your coverage. The plan will be retroactive. This means it will cover your baby's care going back to birth. Refer to your benefits booklet, which can be found in the "Coverage and Benefits" section of BAM, for more details.

Your benefit booklet explains what is covered under your specific health, dental, vision and prescription plans.

You will receive your benefit booklet in the mail shortly after you enroll in a health plan. A digital version of your benefit booklet can also be found in the "Coverage and Benefits" section of BAM. You need to be logged in to BAM to see your plan’s details.

Learn more about benefit booklets.

When you get care from a provider who files a claim on your behalf, we’ll take the information and create an Explanation of Benefit (EOB) statement for you. An EOB shows costs from your provider and if the claim was approved or denied. Costs vary based on what your plan covers and what services you receive. If you have a deductible or coinsurance, the EOB will explain how much of the bill your plan covered and how much you may be responsible for due to a deductible or coinsurance.

Learn more about EOBs.

An SBC is a summary of all the benefits that are covered under your health plan. You can find the SBC for your health plan on BAM. You need to be logged in to BAM to see your document.

If you prefer to get a paper EOB, it will be mailed to you after your claim is finalized. Si está suscrito a las declaraciones digitales, you will get an email or text when your EOB and benefit booklet are ready to view in your BAM cuenta.

When you have a routine visit - also known as preventive care - with an in-network provider, only certain services are 100% covered. If you ask for or choose to have other services performed, or to talk with the provider about other issues that are not routine, you may be charged for them.

Most often, you may be sent a bill after a routine or diagnostic visit because:

• You may have seen an out-of-network provider.
• You may have had lab work done that was sent to an out-of-network provider.
• Es posible que haya solicitado servicios adicionales que no eran de rutina. These services may be considered medical care.

Learn about the difference between preventive care and medical care.   

When you visit an in-network provider, only certain services are 100% covered. Due to this, your health plan may have only covered part of your total bill.

Primero, vuelva a verificar su Explicación de Beneficios para asegurarse de que todos los servicios que recibió tengan cobertura. If you believe you were billed for a service that was covered, call your provider. If you are still having issues, call the customer service number listed on your BCBSTX member ID card.

Cuando recibe atención médica de urgencia o es atendido por un profesional fuera de la red en un hospital o centro quirúrgico para pacientes no hospitalizados de la red, you are protected from surprise billing or balance billing. In these cases, you shouldn’t be charged more than your plan’s copay, coinsurance and/or deductible.

Si usted tiene dos coberturas médicas, su médico puede presentar una reclamación en ambas. Insurance companies then decide which plan covers which costs. Esto se llama Coordinación de Beneficios (COB, en inglés)

You may get a COB questionnaire from your insurer to set up the COB so claims get paid correctly. If you do, be sure to fill it out, even if you do not have other coverage. You may also want to document other coverage you have when your plan renews each year.

Learn more about COB.

Sometimes, you may need care due to an accident that happened at work, while on vacation, or just driving around town. If that happens, BCBSTX will need to determine if you should have to pay the medical bills, or if someone else is responsible. This process is called subrogation. We may send you a subrogation questionnaire to get more details about the accident. But don't worry, BCBSTX will handle subrogation on your behalf.

Learn more about subrogation.