Updated July BBBenefenefenefititits Cos Cos ......Updated July 18, 2008 BBBenefenefenefititits Cos...

Updated July 18, 2008

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Group MembershipGroup and Individual OperationsFor Groups with 2-50 employees

www.SouthCarolinaBlues.com

® Registered Marks of the Blue Cross and Blue Shield Association.

BlueCross BlueShield of South Carolina Confidential

2 Benefits Coordinator Guide

This manual is the property of BlueCross BlueShield of South Carolina.The material herein is confidential and is designed for internal and group

Benefits Coordinator use only.

www.SouthCarolinaBlues.com 3



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Purpose ...................................................................................................................................... 5Eligibility.................................................................................................................................... 6

Types of Membership ...................................................................................................... 6Eligible Employees ............................................................................................................ 6Ineligible Employees ......................................................................................................... 6Eligible Dependents .......................................................................................................... 7Participation Requirements ............................................................................................ 7Contribution Requirements ........................................................................................... 7Dental Participation ......................................................................................................... 8Participation Audits.......................................................................................................... 8Renewals .............................................................................................................................. 9

The Membership Application ........................................................................................... 10Adding New Employees ................................................................................................ 10How to Complete the Membership Application..................................................... 11

Life Insurance Coverage ...................................................................................................... 21Attained Reduction Age ................................................................................................ 21Changing Life Insurance Coverage............................................................................. 21Increasing Volume or Amount of Life Insurance ................................................... 21Adding Dependent Life ................................................................................................. 21Decreasing Life Coverage ............................................................................................. 22Personal Health Statement for Change to Life Coverage ...................................... 22Other Requests ................................................................................................................ 22Where to Send Completed Membership Applications ......................................... 23

Cancelling Coverage ............................................................................................................. 24Cancelling Coverage Due to an Employee’s Death ................................................. 24Cancel Dependent Coverage Due to Divorce .......................................................... 24Cancel Dependent Child(ren) ...................................................................................... 25Extension of Liability ...................................................................................................... 25

Incomplete Applications ..................................................................................................... 27Requests for Information .............................................................................................. 27Change of Cancellation Date ........................................................................................ 27

Forms ....................................................................................................................................... 35Ordering Forms or Supplies ......................................................................................... 35




Billing ....................................................................................................................................... 36How to Read Your Bill .................................................................................................... 36Changes/Activity Page ................................................................................................... 37

Continuation of Coverage................................................................................................... 46COBRA.............................................................................................................................. 46State Continuation Coverage ....................................................................................... 49Coordination of Benefits ............................................................................................... 49When Is Medicare Primary? (Grid)............................................................................ 52Subrogation ...................................................................................................................... 53Workers’ Compensation................................................................................................ 53ERISA Information ......................................................................................................... 54Denial of a Claim............................................................................................................. 55

The Health Insurance Portability and Accountability Act (HIPAA)........................ 57Portability and Creditable Coverage .......................................................................... 57Privacy ............................................................................................................................... 57

Customer Service .................................................................................................................. 60Hours of Operation ........................................................................................................ 60Automated Voice Response Unit ................................................................................ 60Benefits Coordinators Instructions for VRU ........................................................... 60Member Instructions for VRU .................................................................................... 63Customer Service Unit .................................................................................................. 65

Contact Lists .......................................................................................................................... 66Contact List for Group Membership, Columbia, SC ............................................. 66Contact List for Group Claims .................................................................................... 67Contact List for Group Membership and Claims ................................................... 68

Frequently Asked Questions .............................................................................................. 69Glossary of Terms ................................................................................................................. 74




PurposeThank you for choosing BlueCross BlueShield of South Carolina as your group healthinsurance provider. We are very happy to have you as part of our BlueCross family. ThisBenefits Coordinator’s Guide provides valuable information and instructions to assist you incommunicating with us. We want your experiences with us to be very positive because weappreciate your business and want to provide “STAR” service (Service That’s Above the Rest)to you and your employees.This guide also will help you become familiar with some of our procedures. Our goal is tomake it easier for you to do business with us. We want it to be a pleasant experience for bothyou and your employees.If you have any questions about this guide, please feel free to contact us.(Link to Customer Service Unit)[email protected]




Eligibility

Types of MembershipThere are four types of coverage available:

• Single• Family• Employee/Spouse• Employee/Child(ren)

Eligible EmployeesAll employees must satisfy the following conditions to be eligible for coverage under a smallgroup contract:

• Be an active, full-time employee of the group• Work at least 30 hours a week and at least 48 weeks a year• Be actively at work on the effective date of coverage

Ineligible Employees• New hires that have not completed their probationary period• Employees covered as a dependent of a spouse on the same group• Part-time or seasonal employees

NotNotNotNotNote:e:e:e:e: To be considered actively-at-work, the employee must: 1) have begun and not beabsent from work because of leave of absence or temporary lay-off, unless the absence isdue to a Health Status Related Factor other than substance abuse or chemicaldependency; and 2) be performing the normal duties of his or her occupation at one ofthe employer’s places of business or at a location to which the employee must travel to dohis or her job.

NotNotNotNotNote:e:e:e:e: Directors, corporate officers, councilmen, owners and partners are not consideredeligible employees unless they work at least 30 hours a week and at least 48 weeks a year.




Eligible Dependents“D“D“D“D“Deeeeepppppendenendenendenendenendenttttt””””” means (1) an employee’s spouse; or (2) an employee’s unmarried child less than19 years of age, or under age 23 if a full-time student enrolled in an accredited, educationalinstitution. This includes a natural child, adopted child or any other child dependent upon theemployee for support. Full-time student determination will be based upon the standards of theaccredited institution.

“Inc“Inc“Inc“Inc“Incaaaaapacpacpacpacpacitititititaaaaattttteeeeed Dd Dd Dd Dd Deeeeepppppendenendenendenendenendenttttt””””” means an unmarried child who is (1) incapable of self-sustainingemployment by reason of mental retardation or physical handicap, and (2) dependent uponthe employee for support. The employee must provide written proof of such a dependency andincapacity within 31 days of the dependent’s 19th or 23rd birthday if a full-time studentenrolled in an accredited, educational institution. We require proof every two years.Written proof of incapacity is an attending physician’s statement with the dependent’s nameand date of birth, along with the named condition causing incapacity and prognosis. Thegroup is responsible for attaching this information to the Membership Application.

Participation Requirements

Contribution Requirements1. When the employer pays 100% of the single coverage premium, all eligible employees

must enroll with at least single coverage.2. When the employer pays less than 100% of the single coverage premium, employees

can waive for:• Coverage through the military• Other group health coverage• Other individual health coverage

A “wwwwwaiveraiveraiveraiveraiver” is considered an employee who chooses not to enroll in the group plan yourcompany offers because he or she is already covered on another policy.

On gOn gOn gOn gOn grrrrroupoupoupoupoups of 15 or mors of 15 or mors of 15 or mors of 15 or mors of 15 or more eme eme eme eme employeployeployeployeployeeeeeesssss:::::At least 75% of the eligible, full-time employees, after waivers, must be enrolled ANDat least 60% of the total eligible, full-time employees must be enrolled.

On gOn gOn gOn gOn grrrrroupoupoupoupoups of les of les of les of les of less tss tss tss tss than 15 Emhan 15 Emhan 15 Emhan 15 Emhan 15 Employeployeployeployeployeeeeeesssss:::::The number of acceptable waivers is determined by group size:

NotNotNotNotNote:e:e:e:e: Failure to comply with participation requirements may result in the cancellation ofyour group’s coverage.




TTTTTotototototal Fal Fal Fal Fal Full-ull-ull-ull-ull-TTTTTime Eligime Eligime Eligime Eligime Eligible Emible Emible Emible Emible Employeployeployeployeployeeeeeesssss WWWWWaiver Alloweaiver Alloweaiver Alloweaiver Alloweaiver AllowedddddLess than 4 none

4 to 7 18 to 11 2

12 to 14 3We consider a “refusal” to be an employee who chooses not to enroll in the group plan yourcompany offers because he or she does not want it. Employees must “refuse” coverage whenthey don’t have other insurance. We accept the following limits:

EligEligEligEligEligible Fible Fible Fible Fible Full-ull-ull-ull-ull-TTTTTime, Afime, Afime, Afime, Afime, Afttttter Wer Wer Wer Wer Waiversaiversaiversaiversaivers RefRefRefRefRefusals Alloweusals Alloweusals Alloweusals Alloweusals Alloweddddd2 to 7 none8 to 9 1

10 to 11 212 to 14 3

More than 15 Minimum of 60%of total full-time must enroll

Dental Participation• Dental Only not available to accounts with fewer than six employees• Dental Only available to accounts with seven to 50 employees — 75% of all full-time

employees must enroll

Enrollment LevelWe must move groups to the proper size category when enrollment levels fall below thenumber of required employees enrolled for its size, assuming the group meets the minimumparticipation requirements. If the group does not meet the minimum requirements, it mustincrease the enrollment to meet the participation standards or we will cancel the group.

Participation Audits

NNNNNOOOOOTE:TE:TE:TE:TE: We periodically review groups to make sure they meet the minimumparticipation requirements. This is called a Participation Audit. We will notify the groupif we are reviewing the participation level. At that time, you must provide proof of yourparticipation level by submitting the completed Participation Audit Form and a copy ofyour most recent Quarterly Wage Report (UCE120).




Eligible Employee Declining Coverage (Refusal)If an eligible employee refuses coverage, he or she must complete a Membership Applicationand indicate that coverage is being refused and why.The employee must sign a Membership Application declining coverage, and you should send itto BlueCross as if it were a regular Membership Application.

RenewalsWe review every group’s rates annually, usually 90 days prior to the group’s anniversary date.We send a “Schedule A,” listing the group’s renewal rates and benefits, to the group and theagent for review at least 30 days prior to the group’s renewal date. This is typically the timegroups elect to make changes to their benefits.

NotNotNotNotNote:e:e:e:e: BlueCross also requires a signed Membership Application waiving coverage fromany employee who has other coverage. An employee who is covered by a spouse in thesame group must also sign a Membership Application waiving coverage.




The Membership ApplicationBlueCross uses only one Membership Application for new enrollees or to make changes toexisting policies. This means that the same application can be used for many differentfunctions such as:

• Enrolling new employees• Making changes to employee coverage• Changing an address• Adding dependents• Cancelling coverage (employer terminates employee or employee death)• Requesting COBRA or six-months continuation (employer terminates employee or

employee death)• Changing beneficiaries• Changing/correcting Social Security numbers• Refusing coverage• Letting us know that there is other health/dental coverage• Requesting Extension of Liability

Please remember, the employee must sign the Membership Application before we can processit. The agent or the group must submit the Membership Application for processing. Wecannot accept applications directly from the employee.At the end of this section, you will find samples of properly completed MembershipApplications. Please refer to them as you read the following instructions that explain how tocomplete each block.

Adding New EmployeesA new enrollee is an employee hired after the initial enrollment and who meets eligibilityrequirements.You must use a BlueCross Membership Application to add new employees or for any othertype or combination of coverage change. Employees who did not enroll when they were firsteligible, but desire to enroll at a later date are lllllate enate enate enate enate enrolrolrolrolrolleleleleleeeeeesssss. . . . . We exclude coverage for them forthe first 12 months; then they are subject to a six-month pre-existing waiting period. Anapplicant is a late enrollee 1) if we do not receive the application within 30 days of the effectivedate, even if the employee is applying within the probationary period, and 2) if the requestedeffective date is not within the group’s probationary period.A ssssspppppeeeeeciciciciciaaaaal enl enl enl enl enrolrolrolrolrolleleleleleeeeee is an employee who did not enroll when first eligible because he or she hadother coverage, but now has lost that other coverage and wants coverage under your grouppolicy. Employee(s) or dependent(s) should have Certificates of Creditable Coverage




confirming their previous insurance coverage (Link to HIPAA – Special Enrollment). . . . . Attachthese and send them in with the Membership Application. If they are not sent in with theapplication, you can mail or fax them to us for processing. A new spouse or a newborn isconsidered a special enrollee. (Link to Customer Service Unit)You may also print a copy of the Membership Application that is located on our Web site,SouthCarolinaBlues.com.

How to Complete the Membership ApplicationTo enrenrenrenrenroll a neoll a neoll a neoll a neoll a new emw emw emw emw employeployeployeployeployeeeeee, the entire form must be completed.

IIIIItttttem 1. Emem 1. Emem 1. Emem 1. Emem 1. Employeployeployeployeployee Namee Namee Namee Namee NamePrint the employee’s last name, first name and middle initial, if any. If the employee is a junior,senior, II, III, etc., that designation should follow the last name (e.g., Smith Sr., Joseph M.).Enter the employee’s home telephone number with the area code (e.g., 803-123-4567).

IIIIItttttem 2. Birem 2. Birem 2. Birem 2. Birem 2. Birttttth dah dah dah dah dattttteeeeeEnter the employee’s date of birth.

IIIIItttttem 3. Sem 3. Sem 3. Sem 3. Sem 3. SeeeeexxxxxEnter the employee’s sex — male or female.

IIIIItttttem 4. Sem 4. Sem 4. Sem 4. Sem 4. Sooooocccccial Sial Sial Sial Sial Seeeeecurcurcurcurcurity Nity Nity Nity Nity NumbumbumbumbumberererererEnter the employee’s Social Security number.

IIIIItttttem 5. Hem 5. Hem 5. Hem 5. Hem 5. Home Pome Pome Pome Pome PhonehonehonehonehoneEnter the employee’s home phone number.

IIIIItttttem 6. Aem 6. Aem 6. Aem 6. Aem 6. AddrddrddrddrddreeeeessssssssssEnter the address where the employee receives his/her mail.

IIIIItttttem 7. Name of Emem 7. Name of Emem 7. Name of Emem 7. Name of Emem 7. Name of EmployerployerployerployerployerEnter the company name exactly the way it is on your company’s application for healthcoverage.

NotNotNotNotNote: e: e: e: e: Initially eligible, full-time employees declining coverage must complete aMembership Application refusing coverage. You must send this completed “refusal”application to BlueCross to remain on file.

http://www.southcarolinablues.com/bcbs/bcbs_redo.nsf




IIIIItttttem 8. Bem 8. Bem 8. Bem 8. Bem 8. BlueCrlueCrlueCrlueCrlueCroooooss Grss Grss Grss Grss Group Noup Noup Noup Noup NumbumbumbumbumberererererEnter the 10-digit group number; Example is 05-12345-00-105 - 12345 - 00 - 1

Check digit: further identifies specific group and/or sub-group.

Suffix: identifies any locations, subsidiaries, sub-group, etc.

Base Number: identifies your group specifically.

Prefix: denotes type and size of group.A group number with 00 as the eighth and ninth digit (e.g., 05-12345-00-1) indicates the maingroup number. If an employer has more than one group number, the eighth and ninth digitsare sequentially numbered (01, 02, etc.). These are called sub-group numbers. Multiple groupnumbers can signify several things. Sub-group numbers can indicate subsidiaries of acompany, different locations or departments, etc. A company may have several levels ofcoverage. Put the group number that corresponds to the employee’s location, level of benefits,etc., in this block. You can find the group number(s) on the cover page of your company’shealth coverage contract(s) and on your bill.

IIIIItttttem 9. Dem 9. Dem 9. Dem 9. Dem 9. Deeeeeparparparparpartmentmentmentmentment Nt Nt Nt Nt NumbumbumbumbumberererererIf your company chose to use department numbers for billing purposes, enter the appropriateone here. A department number must have three digits (e.g., 123). If your company decided touse department numbers, we assigned them to your account when your company originallyenrolled. If your company did not choose to use department numbers, leave this block blank.

IIIIItttttem 10.em 10.em 10.em 10.em 10. EfEfEfEfEffffffeeeeective Dactive Dactive Dactive Dactive Dattttte of Ae of Ae of Ae of Ae of Action Rection Rection Rection Rection ReqqqqqueueueueuestststststeeeeedddddEnter the date the employee’s coverage is to begin using the two-digit format, MMDDYY. Theeffective date must correspond to the date of hire or the eligibility date whichever one meetsyour company’s probationary period requirements.Probationary PeriodA probationary period is the length of time an employee must work for a company before theemployee is eligible for health coverage. For example, employees will be eligible for coveragefollowing date of hire or eligibility date after 30, 60 or 90 days, based on the specificprobationary period your company selects. The probationary period your company selects isincluded in your company’s health coverage contract. You cannot waive any probationaryperiods for any new employees.

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Depending upon your company’s probationary period, coverage may begin on the first billing datefollowing the probationary period. The probationary period is set up on the billing cycle. Billingdates are either the first or the fifteenth day of a month, depending on your company’s cycle.

Reason For ApplicationIIIIItttttem 11. Reem 11. Reem 11. Reem 11. Reem 11. Reaaaaassssson fon fon fon fon for tor tor tor tor the Ahe Ahe Ahe Ahe ApplicpplicpplicpplicpplicaaaaationtiontiontiontionCheck the box next to “New Member” and select either “yes” or “no” if new member is a full-time employee working at least 30 hours per week, 48 weeks per year.Full-Time Date of HireEnter the month, day and year of hire, using two digits for each (MMDDYY)If the employee is on COBRA or State Continuation, check the box indicating COBRA or StateContinuation coverage and enter the qualifying event and the start date.

SSSSSppppponsonsonsonsonsorororororeeeeed Md Md Md Md MembembembembembershipershipershipershipershipIf an employee is a sponsor of a covered spouse in the same group or a COBRA dependent, weconsider the application to be a new addition and we need the ID number of the employeesponsoring coverage to verify the membership. As an example, the employee’s company hires acovered spouse. This spouse/new hire is sponsored by the employee’s coverage and will notserve waiting periods as long as these have been met prior to being sponsored off theemployee’s coverage. Enter the ID number of the employee sponsoring coverage in “SponsoredMember’s Social Security Number.”

Coverage InformationIIIIItttttem 12. Mem 12. Mem 12. Mem 12. Mem 12. Meeeeedicdicdicdicdical Eleal Eleal Eleal Eleal ElectionctionctionctionctionSome employers offer their employees more than one basic health plan. To make sure weprocess the applications correctly, check the correct type of coverage, PPO (Preferred Blue®) orHDHP (High Deductible Health Plan).

CheCheCheCheCheccccck Tk Tk Tk Tk Tyyyyypppppe Me Me Me Me Membembembembembership fership fership fership fership for Eor Eor Eor Eor Eacacacacach Coveragh Coveragh Coveragh Coveragh Coverage De De De De DeeeeesirsirsirsirsireeeeedddddEmployees must select from the health and/or dental benefits offered by your company.Employees must check the type of health membership that best describes their familymembers to be covered.

� Employee Only� Employee/Spouse� Employee/Child(ren)� Family

Please note that dental is an optional stand-alone plan that your company may or may notoffer.

If tIf tIf tIf tIf the emhe emhe emhe emhe employeployeployeployeployee doe doe doe doe doeeeees not ws not ws not ws not ws not wananananant tt tt tt tt to enro enro enro enro enroll in toll in toll in toll in toll in the hehe hehe hehe hehe healtaltaltaltalth plan your ch plan your ch plan your ch plan your ch plan your comomomomompanpanpanpanpany ofy ofy ofy ofy offffffersersersersers, he or she, he or she, he or she, he or she, he or shestill mstill mstill mstill mstill must cust cust cust cust comomomomomplepleplepleplettttte a Me a Me a Me a Me a Membembembembembership Aership Aership Aership Aership Applicpplicpplicpplicpplicaaaaation ttion ttion ttion ttion to ro ro ro ro refefefefefusususususe te te te te the che che che che coveragoveragoveragoveragoverage.e.e.e.e. The employee must




check the refusal reason box – “No Medical Coverage due to:” in this section and check thebox that best explains why he/she is refusing coverage. Depending on your contract, he/shemay or may not be allowed to refuse the health plan.

IIIIItttttem 13. Dem 13. Dem 13. Dem 13. Dem 13. Denenenenentttttal Eleal Eleal Eleal Eleal ElectionctionctionctionctionEmployees must check the type of dental membership that best describes their familymembers to be covered. If your cIf your cIf your cIf your cIf your comomomomompanpanpanpanpany ofy ofy ofy ofy offffffers ters ters ters ters this optional bhis optional bhis optional bhis optional bhis optional benefenefenefenefenefit and hait and hait and hait and hait and has les les les les less tss tss tss tss thanhanhanhanhanssssseeeeeven emven emven emven emven employeployeployeployeployeeeeees enrs enrs enrs enrs enrolleolleolleolleolled, emd, emd, emd, emd, employeployeployeployeployeeeeees who cs who cs who cs who cs who chohohohohoooooossssse dene dene dene dene dentttttal mal mal mal mal must tust tust tust tust takakakakake te te te te the same tyhe same tyhe same tyhe same tyhe same typppppe ofe ofe ofe ofe ofmembmembmembmembmembership aership aership aership aership as ts ts ts ts their heheir heheir heheir heheir healtaltaltaltalth ch ch ch ch coveragoveragoveragoveragoverage — single, fe — single, fe — single, fe — single, fe — single, familyamilyamilyamilyamily, e, e, e, e, etttttccccc.....

� Employee Only� Employee/Spouse� Employee/Child(ren)� Family

IIIIItttttem 14. Lem 14. Lem 14. Lem 14. Lem 14. Lififififife Insurance Insurance Insurance Insurance InsuranceeeeeWhen the employer is paying the full cost (100%) 100%) 100%) 100%) 100%) for a type of coverage, all eligible employeesmust enroll in that type. If the employer’s contribution is less than 100%, the coverage may beoptional with approval. Please refer to the Companion Life Application included in yourgroup’s contract for your group’s contribution percentage.For example, your employer offers basic life, accidental death and dismemberment, and short-term disability coverage. Your employer pays 100% of the cost for each of these. Every eligibleemployee must enroll in those coverages.AD&D is always required along with basic life coverage. It is never optional.

TTTTTyyyyypppppeeeees and Amouns and Amouns and Amouns and Amouns and Amounttttts of Ls of Ls of Ls of Ls of Lififififife Insurance Insurance Insurance Insurance Insurance Coverage Coverage Coverage Coverage Coverage De De De De DeeeeesirsirsirsirsireeeeedddddThe categories listed below show the only types of life insurance coverage available.

Life and AD&DDependent LifeSTDLTDLife only

LLLLLififififife Amoune Amoune Amoune Amoune AmountttttEnter the Life Amount on the line provided and select the type of Life coverage the employeedesires as indicated above.

LLLLLififififife Clae Clae Clae Clae ClassssssssssA life class code has two digits. The code assigned is based on the benefits purchased by youremployer.




Some groups have more than one classification of employees. For example, Code 01 may meanexempt employees and Code 02 may mean non-exempt. Enter the Code for the class that fitsthe employee applying for coverage.

EEEEEarararararningningningningningsssssComplete this block only if the amount of life insurance coverage is based on the employee’syearly earnings.Enter the employee’s hourly, weekly, bi-weekly, monthly or annual salary on the line next to“Earnings” and check the box that describes the correct pay cycle based on what your companyselected.If the amount is not based on earnings, leave it blank.

BBBBBenefenefenefenefeneficiciciciciariariariariaryyyyyEnter the name of the employee’s life insurance bbbbbenefenefenefenefeneficiciciciciariariariariaryyyyy. The employee may list a primarybeneficiary and a contingent beneficiary. A contingent beneficiary is one who would receivethe life benefit should the primary beneficiary be deceased at the time of the employee’s death.If the information is blank, we will enter “To the estate of…”Print the first name, last name and the relationship of the beneficiary to the employee (e.g.,son, daughter, spouse, mother, father, etc).

EnrEnrEnrEnrEnrollmenollmenollmenollmenollment Inft Inft Inft Inft Infororororormamamamamationtiontiontiontion

LLLLList All Fist All Fist All Fist All Fist All Family Mamily Mamily Mamily Mamily Membembembembembers ters ters ters ters to Bo Bo Bo Bo Be Covere Covere Covere Covere Covereeeeed or Afd or Afd or Afd or Afd or Affffffeeeeectctctctcteeeeed by a Changd by a Changd by a Changd by a Changd by a ChangeeeeePrint the spouse’s full name, Social Security number, sex and date of birth, if covered. Use twodigits each for month, day and year. For each covered dependent child, print the last name,first name, middle initial, Social Security number, sex and date of birth. (Link to Eligible Dependents)For more than four dependent children, print the information described above for eachadditional child on a separate piece of paper and attach it to the Membership Application.Indicate on the application that additional dependent information is attached.If a dependent is age 19 and enrolled in an accredited, educational institution, the employeemust attach proof of full-time student status from the institution. Without thisdocumentation, the dependent cannot enroll for coverage.

Other Insurance InformationDo you or any member of your family have any other health, dental or drug coverage?If neither the employee nor any family members are covered by any other group healthcoverage, the employee should check the “No” box. Otherwise, he or she should check the“Yes” box and provide the Policyholder’s ID number if the coverage is BlueCross BlueShield ofSouth Carolina. If this block is not completed accurately, it may delay payment of claims andprescription drugs. (Link to Coordination of Benefits (COB))




EmEmEmEmEmployeployeployeployeployee Cere Cere Cere Cere CertiftiftiftiftificicicicicaaaaationtiontiontiontionIt is important that employees read and fully understand each and every part of theMembership Application. The Group Plan Benefits Coordinator cannot sign for the employeeto enroll in the group policy. The employee must sign and date the application. We cannotaccept an application that the employee who is applying for coverage has not signed.Where to Send Completed Membership ApplicationsWhen applications are complete, please mail them to:

BlueCross BlueShield of South CarolinaGroup Membership, AX-G10P.O. Box 100177Columbia, SC 29202

You may fax the membership applications to BlueCross at (803) 264-0143. If you fax theapplication you do notdo notdo notdo notdo not need to mail the hard copy.(Link to Customer Service Unit)If Thomas Cooper & Company Inc. administers your group; please send your applications to:

Thomas Cooper & Co. Inc.P.O. Box 22557Charleston, SC 29414Fax (803) 264-9283

Changing Coverage and Other RequestsTo make changes to an employee’s coverage, you must use a Membership Application. Pleasedo not do not do not do not do not make changes on your bill.Several situations require changes to an employee’s coverage, including adding and removingdependents. The most common reasons are on the Membership Application in Block 1. Spaceis provided for you to explain any reason for a coverage change not listed.In addition to changing coverage, this section of the guide provides information on makingcorrections and instructions for requesting name changes, ID cards, transfers within yourgroup, etc.

NotNotNotNotNote:e:e:e:e: We must receive Membership Applications within 31 days of any change (birth,adoption, marriage, death or divorce). Otherwise we will process the application as a lateenrollee. We will exclude coverage for the first 12 months, then the member will have a six-month pre-existing waiting period. If the employee or dependents have creditable coveragethrough previous insurance, they should attach the Certificate of Coverage to the applicationand mail or fax them to BlueCross.When you are changing an employee’s coverage, the employee must complete all blocks on theMembership Application otherwise indicated in these instructions.




Making A ChangeEmEmEmEmEmployeployeployeployeployee infe infe infe infe infororororormamamamamation – Comtion – Comtion – Comtion – Comtion – Complepleplepleplettttte Ie Ie Ie Ie Itttttems 1, 4 and 8ems 1, 4 and 8ems 1, 4 and 8ems 1, 4 and 8ems 1, 4 and 8Complete name, employee’s Social Security number and 10-digit BlueCross group number.Enter department number only when changing the department number.

ReReReReReaaaaassssson fon fon fon fon for Aor Aor Aor Aor ApplicpplicpplicpplicpplicaaaaationtiontiontiontionCheck the box next to “Coverage Change” in Item 11 and write the reason for the change onthe line provided. In addition, provide the Date of Occurrence for the change.

ReReReReReaaaaasssssons Fons Fons Fons Fons For Coveragor Coveragor Coveragor Coveragor Coverage Change Change Change Change ChangeeeeeAdd Dependents Because of Birth or Adoption

(1) An employee may change from single to employee/children or family coverage on thedate of birth, adoption or assumption of legal custody. Dependent children includenatural children, as well as a child legally adopted, a stepchild, foster child or a childunder the legal guardianship of the employee or spouse. The child must be dependenton the employee for at least 51 percent of support.For adopted children, the 31 days in which to add the child to the employee’s coveragebegins when the child is born, or when the employee or spouse takes temporarycustody of the newborn child and begins adoption proceedings within 31 days. Forolder children not adopted at birth, the child must be added to the employee’s coveragewithin 31 days of the date temporary custody begins.

(2) When upgrading coverage due to birth, adoption or assumption of legal custody, theeffective date in Item 10 may be the actual date of the event or the next billing date. Inaddition to all other required items, check “Coverage Change” in Item 11 and enter thedate of occurrence on the line provided. BlueCross BlueShield of South Carolina mustreceive Membership Applications within 31 days after birth, adoption or assumption oflegal custody. Proof of a child’s legal status is required. Employees may establisheligibility with copies of a Qualified Medical Child Support Order (QMCSO) oradoption papers.

(3) Check the appropriate box for the type of medical, dental and life elections wanted.Remember that drug and dental coverage are optional stand-alone plans that yourgroup may not offer.

(4) Print the full name, sex and birth date of newborns and/or dependent children in Item15. It is not necessary to list members again who are already enrolled.

(5) If BlueCross receives a coverage change request later than 31 days from the date ofbirth, adoption or legal custody, the dependent will be a Late Enrollee and will besubject to pre-existing condition limitations.

(6) In all situations, the appropriate premium must be paid in order for coverage tobecome effective.




DDDDDeeeeeaaaaattttth (h (h (h (h (of an Emof an Emof an Emof an Emof an Employeployeployeployeployeeeeee’’’’’s Ss Ss Ss Ss Spppppousousousousouse)e)e)e)e)� An employee may need to change from single to employee/child(ren) to add dependent

children due to the death of a spouse. The effective date of the coverage change may beeither the day following the date of the spouse’s death or the next billing date.

� Check “Coverage Change” in Item 11, indicate the reason for the change on the lineprovided and enter date of death in “Date of Occurrence.”

� Check the appropriate boxes for medical, dental and life coverage elections.

MarMarMarMarMarrrrrriagiagiagiagiageeeee� An employee who marries may want to change to employee/spouse or family coverage.

The Membership Application must be received within 31 days of the date of themarriage.

� If the spouse is not enrolled when the member enrolls, he or she will be treated as aLate Enrollee with coverage excluded for 12 months, then subject to a six-month pre-existing waiting period.

� Check “Coverage Change” in Item 11 and write “marriage” on the line beside “Reasonfor Change.” If there is a former spouse to be excluded, write the former spouse’s nameon that line as well. Enter the date of the marriage in “Date of Occurrence.”

� Check the appropriate boxes for medical, dental and life coverage elections.� Print the new spouse’s full name, Social Security number, sex and date of birth in the

spaces provided under “Enrollment Information.”� The effective date can either be the date of marriage or the next billing date.

DivorDivorDivorDivorDivorccccceeeeeWhen an employee gets divorced or legally separated, coverage must be downgraded to singleor employee/child(ren). The effective date will be the next billing date after the date of thedivorce. Check the box next to “Coverage Change” in Item 11 and print the name of the spouseto be excluded on the line next to “Reason for Change.” Check the appropriate boxes formedical, dental and life coverage elections.When upgrading coverage due to a divorce, follow the instructions under “Add DependentsBecause of Birth or Adoption.”

OOOOOttttther Reher Reher Reher Reher ReaaaaasssssonsonsonsonsonsEmployees may wish to change coverage for reasons not listed above (e.g., reinstatement ofcoverage, attained reduction age). Complete items 1, 4 and 8. Check “Coverage Change” inItem 11 and provide a brief description of the reason for the change on the line provided. Enterthe Date of Occurrence and select the desired medical, dental and life coverage elections.Make sure the employee signs the application.




RefRefRefRefRefusing Coveragusing Coveragusing Coveragusing Coveragusing CoverageeeeeAn employee may or may not be allowed to refuse health coverage and retain dental and/or lifecoverage depending on your group’s participation requirements. However, if the employer ispaying 100% of the cost of coverage, no employee can decline coverage.For example, an employee may decide to drop your company’s health coverage because thespouse has family health coverage at no cost from his/her employer. The other employer’s plan,however, does not include dental or life coverage, and your employee wants to keep both.

� The effective date should be the first billing date following the event causing the changeprovided the date is not retroactive; otherwise, the effective date will be a current date.

� Check the box next to “No Medical Coverage Due To:” and select the box that bestdescribes why health coverage is being refused.

� Enter the date the spouse’s policy became effective on the line beside “Date ofOccurrence.” Check the appropriate boxes for medical, dental and life coverageelections.

� If the amount of life insurance is based on his or her salary, enter the earnings on theline provided and check the appropriate box, (hourly, weekly, etc.).

� Enter the two-digit life class code, if known.

UUUUUpppppgggggrading Coveragrading Coveragrading Coveragrading Coveragrading Coverageeeee(Example Changing from Single to Family Coverage)We have already covered most reasons for upgrading coverage. However, employees may wantto upgrade coverage for other reasons.For example, an employee’s spouse changes jobs and loses group coverage. Your employee mayadd the spouse and/or eligible dependent children to your company’s coverage:

� Check the box next to “Coverage Change “ in Item 11 and print “Spouse lost coverage”on the line next to “Reason for Change.” Enter the date the spouse’s health coverageended in “Date of Occurrence.”

� Check the appropriate boxes for medical, dental and life coverage elections.� Sign the application.

We must receive the Membership Application within 31 days of the effective date in Item 10. Ifnot, we will process the application as a late enrollee.

WherWherWherWherWhere te te te te to So So So So Send Comend Comend Comend Comend Complepleplepleplettttteeeeed Md Md Md Md Membembembembembership Aership Aership Aership Aership ApplicpplicpplicpplicpplicaaaaationstionstionstionstionsWhen applications are complete, please mail them to:





You may fax the membership applications to BlueCross at (803) 264-0143. If you fax theapplication you do notdo notdo notdo notdo not need to mail the hard copy.(Link to Customer Service Unit)If Thomas Cooper & Company Inc. administers your group; please send your applications to:





Life Insurance CoverageWhen the employer pays 100% of the cost for life insurance for eligible employees, coveragemust be made effective immediately after an employee’s probationary period ends.To change life insurance coverage, you must always complete Items 1, 4, 7, 8, 10 and 14. Theemployee must sign the application. The instructions below are for completing additionalrequired sections of a Membership Application:

• Check “Coverage Change” in Item 11 and print “Life volume increase” on the linebeside “Reason for Change.”

• If the volume change involves a salary increase, put the new salary on the line next to“Earnings” in Item 14 and check the appropriate box. Put the life class code on the linenext to “Life Class,” even if the code isn’t changing.

• Sign the application.

Attained Reduction AgeLife insurance coverage decreases by 35% at age 65 and by 50% at age 70 and 0% at retirement.Your Companion Life group contract shows the reduction age for your company. You mustsubmit a Membership Application indicating the employee should be changed to theappropriate reduction class because of his/her attained age.Check “Coverage Change” in Item 11 and print “Life Reduction” on the line beside “Reason forChange.” The effective date in Item 10 should be the billing date following the month in whichthe reduction age is attained. Enter the date of the employee’s 65th (or 70th) birthday on the linenext to “Date of Occurrence.” We will change the code to reflect the appropriate reductionamount. The new code will appear beside the employee’s name on the Roster of Membershippage of your bill.

Changing Life Insurance CoverageTo notify us of life insurance changes, check the box entitled “Coverage Change” and print abrief description of the desired change (e.g., drop dependent life or add short-term disability)on the line next to “Reason for Change.”

Increasing Volume or Amount of Life InsuranceIf the amount of life insurance is based on an employee’s salary, coverage can increase whenemployee’s salary increases. If an employee receives a promotion and the amount of life insurance isbased on position, coverage can increase to the amount appropriate for the new life class.

Adding Dependent LifeAn employee can add dependent life coverage when he or she marries or acquires children(birth, adoption or legal custody of minor children). Check “Coverage Change” in Item 11.Check the box beside “Dependent Life.” Enter the date of marriage, birth, adoption or legalcustody in the “Date of Occurrence.”




Decreasing Life CoverageIf your company pays less than 100% of the cost of an employee’s coverage, we will acceptdecreases in life insurance. Check “Coverage Change” in Item 11 and print the reason for thechange on the line beside “Reason for Change” (for example a decrease in salary or position)and enter the date of the event in “Date of Occurrence.”

Personal Health Statement for Change to Life CoverageIf an employee declines coverage when initially eligible and decides to take coverage at a laterdate, we require a Personal Health Statement.Here are examples of when we require a Personal Health Statement to change life coverage.

� When employees pay part or all of the cost of life insurance or disability insurance, theymust complete Personal Health Statements if they want coverage after their initialeligibility period has passed. This is required even if they choose coverage on a futureanniversary date.

� An employee’s dependents are eligible for dependent life coverage on the employee’soriginal effective date or when marriage, birth, etc., occur. If the employee does notelect to take the coverage within 30 days of becoming eligible, a Personal HealthStatement is required for each dependent that wants coverage.

� A Personal Health Statement is required when an employee elects to take short term orlong-term disability coverage later than 30 days after the original effective date.

Send us notification of life insurance coverage changes within 31 days of the requestedeffective date. Otherwise, if approved, we will change the effective date to the next billing date.

Other RequestsTo make other changes such as name, address, Social Security number, etc., simply write thetype of change on the very top of the Membership Application and complete the necessaryitems to provide all the information needed for the action.It is important to keep employees’ records accurate and current. When changes take place, youmust send in a completed Membership Application. This will help ensure prompt delivery ofExplanations of Benefits (EOB) and other pertinent claims correspondence from us to youremployees.You may make multiple changes for the same employee on one form if you mark all changes:

� You can change the employee’s name and address at the same time by writing “NameChange and Address Correction” on the top of the Membership Application andcompleting the necessary items to provide all the information needed for those actions.




Where to Send Completed Membership ApplicationsWhen applications are complete, please mail them to:


You may fax the membership applications to BlueCross at (803) 264-0143. If you fax theapplication you do notdo notdo notdo notdo not need to mail the hard copy. Please complete and return only oneapplication.(Link to Customer Service Unit)If Thomas Cooper & Company Inc. administers your group; please send your applications to:





Cancelling CoverageWhen your group terminates an employee, the company will still be liable for premiums untilyou notify us to cancel that employee’s coverage.We must receive a Membership Application terminating coverage for the employee within 24hours after the employee leaves the company, or coverage may be extended an additional 31days. The cancellation will be effective on the first billing date following notice to us that theemployee should no longer be covered. We do not cancel employees except on the next billingdate. You must also send a Membership Application to remove employees who were on file asa refusal/waiver. These employees will appear on your bill roster with a status of “R.”To request a Certificate of Creditable Coverage from BlueCross, members should callCustomer Service.Employees and/or their covered dependents may be eligible to continue their coverage for 18to 36 months under COBRA or six months under State Continuation. (Link to Continuation ofCoverage) If employees select Continuation, their coverage is changed, not cancelled.Employees or dependents eligible for Continuation who do not elect coverage underContinuation or COBRA may not take conversion coverage instead. For example, when anemployee is terminated for gross misconduct,,,,, the employee is not eligible for COBRA. He orshe may apply for conversion coverage.

Cancelling Coverage Due to an Employee’s Death

If the status is single, we will cancel the coverage on the day following the date of death. If thestatus is family, we will cancel the coverage effective on the next billing date following the dateof death.Check “Coverage Change” in Item 11 and print the reason for the change on the line beside“Reason for Change” (for example, deceased).Check the box next to “Cancellation of Coverage,” enter date of death in “Date of Occurrence.”Complete Items 1, 4, 8 and 10.

Cancel Dependent Coverage Due to DivorceThe effective date should be no later than the date of the divorce.

Important Note: The employee/member must notify us of his or her wish to exerciseExtension of Liability rights. It is not automatic! He or she must submit a MembershipApplication requesting Extension of Liability and complete the following blocks:




Check “Coverage Change” in Item 11 and print the reason for the change on the line beside“Reason for Change” (for example, divorce). To exclude the former spouse, print the name ofthe former spouse on the line as well.Check the box next to “Coverage Change” in Item 11 and write “divorce” on the line provided.Enter the date of divorce in “Date of Occurrence.” Check the appropriate boxes for medical,dental and life coverage elections.In the case of divorce, often there will be a beneficiary change for the life insurance benefits.Enter the new beneficiary (ies) in Item 14.

Cancel Dependent Child(ren)(Example: Changing from Family to Single Coverage)An employee may or may not be allowed to downgrade coverage (based on the group’scontribution). Your company’s Group Request for Coverage Form shows your group’scontribution. The effective date of all downgrades should be the first billing date following thedate of occurrence. It should not be a retroactive date.An example of downgrading is an employee who can no longer afford family coverage. Checkthe box next to “Coverage Change” in Item 11 and give an explanation (e.g., can’t afford familycoverage) on the line next to the box.

Extension of LiabilityIf a member’s coverage under this contract ends and, at the time coverage ends, the member iseither confined in a hospital or totally disabled, that member retains coverage for the disablingcondition only. BlueCross will continue to pay health claims related to the disabling conditionuntil one of the following occurs:

(1) The condition ends or is no longer disabling.(2) The member receives benefits under this section for 365 days after coverage ends.(3) The member reaches the maximum contract benefit.(4) The date your group contract with BlueCross is replaced by another group health plan

with similar benefits.“Disabled” means the patient is receiving ongoing medical care by a physician and is not ableto perform the usual and customary duties or activities of a person in good health of the sameage. Claims must be accompanied by a physician’s statement of disability.

IIIIItttttem 1: Emem 1: Emem 1: Emem 1: Emem 1: Employeployeployeployeployee Namee Namee Namee Namee NamePrint the employee’s last name, first name and middle initial, if any.

NotNotNotNotNote:e:e:e:e: A complete physician’s statement must accompany the Extension of Liabilityrequest.




IIIIItttttem 4: Sem 4: Sem 4: Sem 4: Sem 4: Sooooocccccial Sial Sial Sial Sial Seeeeecurcurcurcurcurity Nity Nity Nity Nity NumbumbumbumbumberererererEnter the employee’s Social Security number.

IIIIItttttem 7: Name of Emem 7: Name of Emem 7: Name of Emem 7: Name of Emem 7: Name of EmployerployerployerployerployerPrint the company’s name

IIIIItttttem 8: Bem 8: Bem 8: Bem 8: Bem 8: BlueCrlueCrlueCrlueCrlueCroooooss Grss Grss Grss Grss Group Noup Noup Noup Noup NumbumbumbumbumberererererEnter the 10-digit group number.

IIIIItttttem 11: Pem 11: Pem 11: Pem 11: Pem 11: Pleleleleleaaaaassssse Indice Indice Indice Indice Indicaaaaattttte Ree Ree Ree Ree Reaaaaassssson fon fon fon fon for Aor Aor Aor Aor ApplicpplicpplicpplicpplicaaaaationtiontiontiontionCheck the box beside “Coverage Change” and write “Extension of Liability” on the line next to“Reason for Change.”The employee must sign and date the application.




Incomplete Applications

Requests for InformationAn incomplete Membership Application can cause a delay in the action (add, change, cancel,etc.) we take for a particular employee. We can reject the application and return it for furtherinformation.We may contact you by mail or phone to provide the missing information for an incompleteMembership Application.

Change of Cancellation DateIf we receive a request to cancel an employee or dependent’s coverage and there is a paidclaim for a date of service after the requested cancellation date, the date will be moved tothe next billing date after the date of service of the claim. For example: The requesteddate of cancellation is 09/01/04. Before BlueCross received the cancellation, it paid aclaim for services rendered on 09/02/04. We will change the cancellation date to 10/01/04and premiums will be due for the corresponding month. We will mail a letter to thegroup to inform you that we have made a change to the cancellation date.




Adding a New Employee 30-Day Probationary Period with Lifeby Earning




Health Statment – 2-24 Enrolled Employees




Adding a New Employee 30-Day Probationary Period/RefusingHealth Coverage with Dantal and Life only




Extension of Group Coverage Under COBRA




Coverage Change Due to Marriage




Canceling Coverage




Forms

Ordering Forms or SuppliesIf you need forms or supplies, you may order them by using our Web site.

• Go to our Web site at www.SouthCarolinaBlues.com.• Select “I am a Benefits Coordinator.”• Under “Information Center,” select “Forms.”• Choose the forms you need.





BillingPremium due dates are either the 1st or the 15th of the month; whichever a company selectedwhen it initially enrolled. If your payment is 15 days past due, your account is delinquent. Ifyour payment is 30 days past due, we will cancel your account for nonpayment of premiums.We will not process claims on delinquent accounts.If you do not send payment or make payment arrangements prior to cancellation fordelinquency, collection proceedings will begin. We will forward the account to our collectionsrepresentative at Vengroff, Williams & Associates.Bills usually consist of four parts:

� Changes/Activity page(s)� Please Pay page(s)� Return Stub page(s)� Roster of Membership

You will receive a separate bill for each group number.

How to Read Your Bill1. When you submit a Membership Application, be sure to keep the third copy to compare

to your bill.� For a requested action to appear on your bill, you must adhere to the following

guidelines: For groups on a 1st of the month billing cycle, we must receiveapplications on or before the 5th of each month. For example, if the next billing cycleis 8/01/06, then we must receive the Membership Application by 7/05/06.

� For groups on a 15th of the month billing cycle, we must receive applications on orbefore the 1st of each month. For example, if the next billing cycle is 8/15/06, thenwe must receive the Membership Application by 8/01/06.

2. When you receive your bill, compare the copies of your pending application to theChanges/Activity page and the Roster of Membership. Actions requested on incompleteapplications submitted on or before the appropriate deadline may not be on your nextbill. We may not have received the additional information in time to process it.

3. If an action does not appear on your bill and you sent it prior to the deadline but wehave not informed you that we returned the application for additional information,notify BlueCross immediately. Otherwise, you should pay the amount billed and thechanges should appear on your next bill.

4. You should report any discrepancies to BlueCross immediately.To better understand the type of billing your group has, carefully review the followingexplanation of the different parts of a bill, and how we calculate it. (We will include a samplebill at the end of this section. Please refer to it as you read the following information).




Changes/Activity PageWe include this page when we receive a request to add, change or cancel an employee’scoverage or when we process an application that is not in probationary period. It also appearswhen we process a change that is not within the allotted time. It will also appear if thesubscriber transfers to another group.The following information explains the contents of various blocks and columns on theChanges/Activity page, some of which will be carried over to the other pages of your bill: DueDate, Group Number, etc.

DDDDDue Daue Daue Daue Daue Dattttteeeee (lololololocccccaaaaattttteeeeed under td under td under td under td under the Grhe Grhe Grhe Grhe Group Noup Noup Noup Noup Numbumbumbumbumbererererer)The month and day in which the next payment is due.

PrPrPrPrPrininininint dat dat dat dat dattttte line (loe line (loe line (loe line (loe line (locccccaaaaattttteeeeed under td under td under td under td under the Dhe Dhe Dhe Dhe Due Daue Daue Daue Daue Dattttte)e)e)e)e)The date BlueCross printed the bill. It is important to consider this date when questioning whyan action you requested does not show on your current bill. An action will not appear on a billif BlueCross did not receive the request in time to process it before the date the bill is printed.

AAAAAction Coction Coction Coction Coction CodededededeBeginning here, read across the page for information regarding each employee.For each type of action you request on an application, a code identifies the action yourequested. It appears in the “Action Code” column at the extreme left of this page. You shouldcompare this part of your bill to your pending applications.An action code explaining the nature of each action appears to the left of the name of eachemployee on whom you have requested action. The meaning of each code is given below andcan also be found at the bottom of each page of a bill:

� ADD — — — — — Adding a new employee or an employee’s coverage. There is one line ofinformation for each employee being added. A debit always appears in the “Premium”column.

� CHG — — — — — Making a change to an employee’s coverage. There are two lines ofinformation for each employee making a change. The only exceptions are the “ActionCode” and “Identification Number” columns of the bill. The first line applies to theformer coverage and a credit always appears in the “Premium.” The second line appliesto the new coverage and a debit always appears in the “Premium” column.

� LE — Cancelling an employee’s coverage because he or she left employment ortransferred to another subgroup.

� DEC — Cancelling an employee’s coverage because of death.� REJ — Coverage is rejected. The reason may appear on the bill.� ADJ — A debit or a credit caused by a correction to a previously processed action.� TRN — This indicates the employee has two group health coverage policies with

BlueCross BlueShield of South Carolina. (1) If the employee has left employment (LE),complete a Membership Application advising BlueCross to terminate his or her




coverage. This will prevent us from paying claims. (2) If the employee has not leftemployment, please notify us so we can coordinate benefits between the two plans.(Link to Coordination of Benefits)

BBBBBlueCrlueCrlueCrlueCrlueCroooooss Iss Iss Iss Iss Idendendendendentiftiftiftiftificicicicicaaaaation Ntion Ntion Ntion Ntion NumbumbumbumbumberererererAn ID number is a 12-digit number beginning with ZCY (health) or ZCR (dental only).

NameNameNameNameNameThe employee’s last name and first initial appear here.

EfEfEfEfEffffffeeeeective Dactive Dactive Dactive Dactive DattttteeeeeThe effective date of the action you requested for this employee and the date billing for his orher new premium began.

TTTTTyyyyypppppeeeeeA single digit appears here:

� S ===== single coverage (employee only)� F = family coverage� D = employee/children coverage� 8 ===== employee/spouse coverage� L = life insurance only for the employee� A ===== dental coverage only� R = the employee refused health coverage

BBBBBCCCCC::::: Not Applicable

BBBBBS:S:S:S:S:Not Applicable

EEEEEB:B:B:B:B: When a “5” appears here, the employee has Major Medical coverage which includeshospital and physician coverage.

DDDDDG:G:G:G:G: A “1” means the employee has stand-alone drug coverage. The type membership status isalways the same for drug coverage as it is for EB.

DN:DN:DN:DN:DN: DN signifies stand-alone dental coverage.� S = single coverage (employee only)� F = = = = = family coverage or employee/children coverage� 8 = employee/spouse coverage

The type of membership should be the same as the employee’s health coverage unless yourcontract allows different dental coverage than health.

LLLLLififififife Clae Clae Clae Clae ClassssssssssThe two-digit life class code indicates the type and amount of life insurance selected.




LLLLLififififife, AD & De, AD & De, AD & De, AD & De, AD & D, D, D, D, D, Deeeeep, Sp, Sp, Sp, Sp, STDTDTDTDTD, L, L, L, L, LTDTDTDTDTDWhen a “1” appears under any of these headings, it means the employee has that type ofinsurance coverage: life, accidental death and dismemberment, dependent life, short termdisability, or long term disability. If a “1” does not appear under a heading, the employee doesnot have that coverage.

PrPrPrPrPremiumemiumemiumemiumemiumThis is the premium due for the employee in question for the current month and any previousmonth’s premium.

BBBBBalancalancalancalancalance De De De De Due Sue Sue Sue Sue Showhowhowhowhown on Ln on Ln on Ln on Ln on Laaaaast Billst Billst Billst Billst BillThis is the total due on your last bill.

AAAAAdjdjdjdjdjustmenustmenustmenustmenustmentttttThis is the amount that was manually adjusted to the bill. An adjustment only appears if aretroactive change that cannot be processed by the billing system is made to a group ormember’s rate.

PaPaPaPaPayyyyymenmenmenmenment Ret Ret Ret Ret ReccccceiveeiveeiveeiveeivedddddThe amount of your last payment and the date we credited it to your account.

Remaining AmounRemaining AmounRemaining AmounRemaining AmounRemaining Amount Dt Dt Dt Dt DueueueueueThe difference between the balance due on your last bill and your payment.

BBBBBeeeeeggggginning Prinning Prinning Prinning Prinning Premium femium femium femium femium for tor tor tor tor the Dhe Dhe Dhe Dhe Due Daue Daue Daue Daue DattttteeeeeThe amount owed for this due date before any changes were made. It is the same as theBEGINNING PREMIUM FOR NEXT DUE DATE on your last bill.

NeNeNeNeNet Prt Prt Prt Prt Premium Aemium Aemium Aemium Aemium ActivctivctivctivctivityityityityityThis is the combined total of all changes/activity your group was billed.

CCCCCurururururrrrrrenenenenent Prt Prt Prt Prt Premium Comemium Comemium Comemium Comemium Comprprprprprisisisisiseeeeed Ofd Ofd Ofd Ofd OfThe breakdown of total premiums billed for all the types of coverage your group has. The totalof these amounts equal the current premium.

CCCCCurururururrrrrrenenenenent Prt Prt Prt Prt PremiumemiumemiumemiumemiumThe total current premium billed for this due date. We calculate it by adding or subtractingNET PREMIUM ACTIVITY to or from the BEGINNING PREMIUM FOR THIS DUE DATEamount.

PPPPPleleleleleaaaaassssse Pae Pae Pae Pae Pay Ty Ty Ty Ty This Amounhis Amounhis Amounhis Amounhis AmountttttThe total due for your group as of this due date. For this amount, add the REMAININGAMOUNT DUE to the CURRENT PREMIUM.




LLLLLeeeeess Anss Anss Anss Anss Any Amouny Amouny Amouny Amouny Amount Paid Bt Paid Bt Paid Bt Paid Bt Paid But Not Sut Not Sut Not Sut Not Sut Not Showhowhowhowhown An An An An AbbbbboveoveoveoveoveIf you have sent a payment and we have not credited it on this month’s bill, subtract thatpayment from the PLEASE PAY THIS AMOUNT figure and pay the difference.

PPPPPleleleleleaaaaassssse Pae Pae Pae Pae Pay Pagy Pagy Pagy Pagy PageeeeeThe following information explains how BlueCross calculated your current premium.

SSSSSubububububssssscccccrrrrribibibibiber Couner Couner Couner Couner Count Aft Aft Aft Aft Afttttter Changer Changer Changer Changer ChangeeeeesssssThis is the total contract count of all active members by type membership and coverage fornext month’s billing. The Roster of Membership page shows the employees and their coveragewith projected premiums to be billed.

ReReReReRettttturururururn Sn Sn Sn Sn Stttttub Pagub Pagub Pagub Pagub PageeeeeAt the top of the page, the PLEASE PAY THIS AMOUNT line shows the premium amountdue to BlueCross. Return the bottom portion of this page, RETURN STUB, with yourpayment. To ensure prompt, accurate posting of premiums to your account, it is important towrite the amount of payment on each stub and to return the stub(s) with your payment.

RoRoRoRoRoststststster of Mer of Mer of Mer of Mer of MembembembembembershipershipershipershipershipThe Roster of Membership is the last page or pages of a bill. It is a complete list of all activeemployees on your group and shows each employee’s projected premiums for his or herpresent coverage. When added together, the amount given for each employee equals the figureon the BEGINNING PREMIUM FOR NEXT DUE DATE line. A roster is not a bill; it is simplya list of active employees.People sometime confuse a roster with the Changes/Activity page because the same employeemay appear on both. This occurs when you add a new employee or change an employee’scoverage. However, the name of an employee who terminated employment will show as an“LE” on the Changes/Activity page, but will no longer appear on the Roster page, since he orshe is no longer active.Compare the roster with your personnel records to make sure we have accounted for allemployees. Report any discrepancies to BlueCross immediately.If you do not report discrepancies promptly, your group will be liable for paying premiums foran employee who has terminated. In the case of a late Membership Application, we will assignthe delayed effective date.

BBBBBeeeeeggggginning Prinning Prinning Prinning Prinning Premium femium femium femium femium for Neor Neor Neor Neor Nexxxxxt Dt Dt Dt Dt Due Daue Daue Daue Daue DattttteeeeeThe total premium of your next bill for your current employees if there are no changes.

WherWherWherWherWhere te te te te to So So So So Send Prend Prend Prend Prend Premiumsemiumsemiumsemiumsemiums:::::Mail Address (Payments only): BlueCross BlueShield of SC

Attn: Cashier’s AX-A31PO Box 6000Columbia, SC 29260




Overnight Address (Payments only): BlueCross BlueShield of SCAttn: Cashier’s AX-A314101 Percival RoadColumbia, SC 29229

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Continuation of Coverage

COBRAUnder the Consolidated Omnibus Budget Reconciliation Act (COBRA) employees and/ortheir dependents who would otherwise lose coverage may choose to keep their group coveragefor up to 18, 29 or 36 additional months. Employees who are not eligible for COBRA may beentitled to continue their coverage for six months under State Continuation, depending on thecircumstances. Employees or dependents eligible for coverage under continuation may nottake conversion coverage instead.It is important to note that continuation of group coverage under COBRA or StateContinuation applies only to health and dental coverage. Group life insurance must becancelled and may be converted to an individual policy with Companion Life.If, at the time of the qualifying event, an employee (or his or her dependents) has not decidedto continue coverage, it is best to terminate his or her coverage pending the decision. Theemployee has 60 days to make a decision. Then, if the employee or dependent(s) decide toaccept the extension, we will restore coverage as of the termination date with no lapse incoverage and bill your company retroactively to the termination date.Here are the instructions for proper notification:

� Complete the required block indicated in Block 1. The effective date in Block 2 must bethe date of the qualifying event (i.e., the date the employee or his or her dependentswould otherwise lose coverage).

� In the event that the extension of coverage applies only to the former employee’sdependents (i.e., the employee will not be retaining coverage for him or herself ), writethe dependent’s name in Block 4 and his or her Social Security number in Block 5. Also,write the former employee’s Social Security number in the space provided in Block 15.

� In Block 13, enter the date of the event causing the extension of coverage.� In Block 14, check the type membership box for each type coverage being retained.

Under Continuation, the former employee or his/her dependent(s) will continue to appear onyour bill’s roster of membership. However, you must collect premiums and send payment to usfor the person’s coverage, along with the payment due for your active employees. Continuationpayments must be payable to the employer and the employer must send a company check to usfor all premiums due.

NotNotNotNotNote:e:e:e:e:If an employee elects COBRA coverage and then becomes entitled to Medicare, theCOBRA coverage will be terminated. However, if an employee becomes entitled toMedicare and then becomes eligible for COBRA, the employee may continue bothMedicare and COBRA coverage.




HHHHHow Cow Cow Cow Cow COBROBROBROBROBRA and SA and SA and SA and SA and Stttttaaaaattttte Cone Cone Cone Cone Contintintintintinuauauauauation Aftion Aftion Aftion Aftion Affffffeeeeect Yct Yct Yct Yct Your Grour Grour Grour Grour Group Houp Houp Houp Houp Heeeeealtaltaltaltalth Ph Ph Ph Ph PlanlanlanlanlanThe Consolidated Omnibus Budget Reconciliation Act (COBRA) allows members who wouldotherwise lose coverage to maintain their group health coverage for additional periods of time.The law applies to employees, spouses, ex-spouses and dependents, and affects health, drugand dental coverage. It includes all group health plans maintained by an employer.The major points of COBRA are outlined below. Please remember that this is just an outline;you should consult your lawyer or tax advisor for specific guidance about COBRA.

MaMaMaMaMajjjjjor Pror Pror Pror Pror Provovovovovisions of Cisions of Cisions of Cisions of Cisions of COBROBROBROBROBRAAAAA• Extends your group health coverage for certain time periods to most terminated

employees, employees’ widows and separated or divorced spouses and certaindependent children.

• Makes the same group health coverage available to workers and spouses age 65 andolder as is available to younger workers and their spouses, thereby removing the age 69cap. With this provision, Medicare pays benefits (for workers and their spouses age 65and older) after the group health plan if the employer has 20 or more employees. Forsmaller employers, Medicare typically pays first.

• Makes health plans the primary payer for VA healthcare furnished to a veteran whodoes not have a service-connected disability.

• Makes health plans the primary payer for inpatient medical care provided to non-activeduty beneficiaries in military medical facilities.

AfAfAfAfAffffffeeeeectctctctcteeeeed Grd Grd Grd Grd GroupoupoupoupoupsssssCOBRA applies to employers with 20 or more employees, excluding churches and the federalgovernment. COBRA also applies to the following employers:

(1) Employers with less than 20 employees if they normally had 20 or more employees inthe previous calendar year.

(2) Employers with less than 20 employees if the employers participate in a group healthplan sponsored by several employers, at least one of which has 20 or more employees.

AfAfAfAfAffffffeeeeectctctctcteeeeed Indivd Indivd Indivd Indivd Individuals/Diduals/Diduals/Diduals/Diduals/Duraurauraurauration of Coveragtion of Coveragtion of Coveragtion of Coveragtion of CoverageeeeeCOBRA requires employers to allow the following people to continue their health coverage,after they ordinarily would not be eligible, for a period of up to 18, 29 or 36 months, dependingon the circumstances:

••••• 18 months for employees, and their dependents, who lose coverage through (1) areduction in work hours —for instance, full-time to part-time, (2) voluntary

NNNNNOOOOOTE:TE:TE:TE:TE: The provision making health plans the primary payer for care received at certainVA and military facilities applies to all third party payers.




resignation, (3) economic layoff, and (4) involuntary termination, other than grossmisconduct.

••••• 29 months where the Social Security Administration finds an employee to be disabledand the disability began within 60 days of the COBRA qualifying event. The employeemust promptly notify the employer of this situation.

••••• 36 months for (1) surviving spouses and children of deceased employees, (2) separated,divorced or Medicare-eligible spouses and their dependent children, or (3) dependentsof employees who would lose coverage because they no longer meet the health plan’sdefinition of a dependent child.

NOTE: During an 18-month continuation of coverage period, some spouses and dependentchildren may have another situation occur from the three listed immediately above. If so, theyare entitled to continuation of coverage for an overall total of up to 36 months.

TTTTTerererererms of Coveragms of Coveragms of Coveragms of Coveragms of CoverageeeeeUnder COBRA, the following rights are provided to covered individuals.

• To remain in their health plans at their own expense for the new time periods;• To participate in this continued coverage without proof of insurability;• To receive the same conversion options and other terms that the plan provides for

similarly situated individuals;• To take up to 60 days to elect continued coverage. The 60-day period begins on the

date coverage would otherwise end, or on the date the employee or dependent receivesa required notice of the right to continue coverage, whichever is later; and

• To pay monthly premiums.

CoCoCoCoCost of Coveragst of Coveragst of Coveragst of Coveragst of CoverageeeeeCOBRA allows employers to charge a premium equal to 102 percent of the cost of the plan forother similarly situated individuals with similar coverage. The employer may retain the extratwo percent for the administrative costs.The employer may require the individual to pay both the employer and the employee’s share ofthe premium costs, even if active employees only pay the employee’s share.You must calculate the premium in advance for 12-month periods. You must allow coveredindividuals to pay premiums monthly, if they prefer. Employees should pay all premiums to theemployers.The premium (covering the period from the date coverage normally ends to the datecontinued coverage is elected) must be paid to the employer by the 45th day after the employerreceives the election of continued coverage.For other premiums, there is a grace period of 31 days after the due date or a longer graceperiod if such applies to the plan.




EEEEEarararararly Tly Tly Tly Tly Terererererminaminaminaminamination of Coveragtion of Coveragtion of Coveragtion of Coveragtion of CoverageeeeeCOBRA allows employers to stop coverage before the end of the 18, 29 or 36 month period if(1) the employer abolishes all health plans for all employees, (2) the individual does not pay thepremium on time, or (3) the individual becomes covered by another group health plan or byMedicare.

ReReReReRespspspspsponsibilitieonsibilitieonsibilitieonsibilitieonsibilities of Ems of Ems of Ems of Ems of Employersployersployersployersployers• To notify employees and their spouses, in writing, of their COBRA rights, both at the

time of hire and on termination.• To notify individuals of their continued coverage rights within 14 days after the

employer, as plan administrator, learns that individuals are eligible for continuation ofcoverage.

• To collect premiums.• To monitor 18, 29 and 36-month periods.• To terminate coverage early if the individual becomes covered by another group plan or

does not pay the premium.• To notify the ERISA plan administrator, if this is someone other than the employer,

within 30 days after an employee’s death, job separation, reduction in hours oreligibility for Medicare.

ReReReReRespspspspsponsibilitieonsibilitieonsibilitieonsibilitieonsibilities of Ems of Ems of Ems of Ems of Employeployeployeployeployeeeeees/Ds/Ds/Ds/Ds/Deeeeepppppendenendenendenendenendentttttsssss• To notify the employer within 60 days of separation, divorce or change in a dependent’s

status.• To make a timely election of continued coverage.• To pay premiums to the employer on a timely basis.

State Continuation CoverageState law also gives employees the right to continue their group health coverage, but for aperiod of only six months. State continuation coverage applies only to groups of less than 20employees and does not apply to any groups covered by COBRA. As long as an employee iscovered by the group health plan for at least six months prior to termination from the grouphealth coverage, he or she is entitled to continuation coverage under South Carolina law (S.C.Code §38-71-770). Continuation coverage is not available if the employee still has access to agroup healthcare plan or if he or she is eligible for Medicare. Although there are no specificstate regulations to provide guidance for employers on how to administer state continuationcoverage (such as those for COBRA), employers are urged to follow the COBRA guidelinesdiscussed above.

Coordination of BenefitsCoordination of benefits, sometimes called COB, is a method of paying benefits for peoplewho are covered under more than one group health coverage plan or program so that no more




than the actual cost of medical care is paid. BlueCross sends a questionnaire to employees toupdate other carrier information every two years. If they do not complete and return thisquestionnaire, it may delay claims.

PrPrPrPrPrimarimarimarimarimary and Sy and Sy and Sy and Sy and Seeeeecccccondarondarondarondarondary Coveragy Coveragy Coveragy Coveragy CoverageeeeePrimary coverage is the group health plan that pays first when an employee or dependent has aclaim for benefits. If the primary plan does not pay the entire claim, the employee should file aclaim to the secondary plan.There are various reasons why primary coverage does not pay the entire claim. For instance,the primary group health plan may pay 80 percent of covered charges, rather than 100 percent.There may be a deductible to be met before the primary plan will pay. Some of the services orsupplies on the claim may not be covered under the primary plan; however, they may becovered under the secondary plan.

PrPrPrPrPrimarimarimarimarimary/Sy/Sy/Sy/Sy/Seeeeecccccondarondarondarondarondary Ry Ry Ry Ry Ruleuleuleuleulesssss(1) The group health coverage plan provided where an employee works is primary for that

employee. If the same employee is also covered as a dependent under a spouse’s groupplan, the spouse’s plan is secondary for the employee; for the spouse, the spouse’scoverage is primary.

(2) If a person works at several places and each place has a group health plan, the plan heor she has been covered under longest is primary.

(3) When a husband and wife work at different places, both of which have group healthcoverage, we determine who is primary by the birthday rule (under this plan the parentborn earlier in the year by month is primary).

(4) When a group health plan does not have a COB provision, that plan is primary.

CoCoCoCoCoororororordinadinadinadinadinating Bting Bting Bting Bting Benefenefenefenefenefititititits fs fs fs fs for an Emor an Emor an Emor an Emor an Employeployeployeployeployeeeeee’’’’’s Ds Ds Ds Ds DeeeeepppppendenendenendenendenendentttttsssssWhen BlueCross receives a claim for an employee’s dependent and does not have anyinformation about other group health and prescription drugs coverage, it will delay the claim.BlueCross will send a questionnaire to the employee, requesting information about othergroup coverage.If BlueCross has information that other group health coverage is primary and receives adependent claim that does not include the amount paid by the other coverage, it will deny theclaim. The employee will receive an Explanation of Benefits (EOB) from BlueCross explainingthat it had denied the claim but will reopen it when BlueCross gets a copy of the primary plan’sEOB, even if the other plan paid nothing toward the incurred expenses.

CoCoCoCoCoororororordinadinadinadinadination of Btion of Btion of Btion of Btion of Benefenefenefenefenefititititits Bs Bs Bs Bs Beeeeetwetwetwetwetween Men Men Men Men Meeeeedicdicdicdicdicararararare and Eme and Eme and Eme and Eme and Employer Grployer Grployer Grployer Grployer Group Houp Houp Houp Houp Heeeeealtaltaltaltalth Coveragh Coveragh Coveragh Coveragh Coverage Pe Pe Pe Pe PlanslanslanslanslansThe following information is a guideline on the Medicare coordination of benefits (COB) rulesunder current federal law. For additional details and a full explanation, BlueCross suggests youconsult your attorney or tax advisor.




Here are the general rules for Medicare COB:• If the employee or spouse is collecting Social Security retirement benefits, he or she

receives some Medicare benefits and the Medicare system covers them.• On groups of less than 20 employees, Medicare is the primary payer. With an employee

over 65, the question of who is primary becomes an issue of whether the employee isreceiving retirement benefits. If he or she receives retirement benefits, then MedicarePart A will cover him or her and Medicare will be primary. If he or she does NOTreceive retirement benefits, Medicare Part A will not cover him or her and the grouphealth coverage will continue to be primary.

• For groups of more than 20 employees, the group health plan is primary. When anemployee is over 65, whether or not receiving retirement benefits, the group healthcoverage is primary and Medicare is secondary. (If the employee does not receiveretirement benefits, then Medicare will not cover him or her anyway.) Medicarebecomes primary only after the employee retires and no longer works.

• If an employee or spouse is under 65 and has end-stage renal disease (ESRD), Medicareis primary unless the group size is 100 or more. However, Medicare is prprprprprimarimarimarimarimaryyyyy forpersons age 65 and older who have ESRD.

There are a few, limited exceptions to these general rules:(1) Medicare is primary if the patient is not entitled to Medicare Part A on the basis of his

earnings record or the earnings record of another person.(2) Medicare is primary for a spouse who’s disabled and under 65 years of age if the group

size is under 100 employees.(3) Medicare is primary for employed persons receiving disability payments from their

employer if (a) they were entitled to Social Security disability benefits in the monthbefore reaching age 65 or (b) if they are not receiving pay subject to FICA tax. Sick payis subject to FICA tax for the first six calendar months after the last calendar month inwhich the employee worked for the employer. (This refers to persons who are stillconsidered employees by their employer and who are still enrolled under the grouphealth plan for employees. For the purposes of these COB rules, they are notconsidered workers).

(4) Medicare is primary for spouses age 65 and older of employed persons falling underitem (3) above, since they are not considered spouses of workers.

Note:If an employee elects COBRA coverage and then becomes entitled to Medicare, theCOBRA coverage will be terminated. However, if an employee becomes entitled toMedicare and then becomes eligible for COBRA, the employee may continue bothMedicare and COBRA coverage.




When Is Medicare Primary?If an employer has 20-99 active employees apply these rules:

If Member Age Active Retired Medicare Entitlement Is Medicare Why? is . . . Employee Employee Reason is . . . Primary?

Employee Over X Age No The Tax Equity and Fiscal65 Responsibility Act of 1982

(TEFRA) shifted the primaryresponsibility for coverage ofmedical claims for olderemployees and their spousesto group health plans ofemployers with 20 or moreemployees.

Employee Over X Age Yes Medicare is always primary 65 for rrrrreeeeetirtirtirtirtireeeeeeeeeesssss over age 65.

Spouse Over X Age No The Deficit Reduction Act of or Child 65 1984 (DEFRA) mandated

that all employees andspouses between ages 65 and70 with employer-sponsoredhealth coverage have primarycoverage under the employer-sponsored plan and second-ary coverage under Medicareas long as the employee wasactive and under 70.

Spouse Over X Age Yes Medicare is always primary or Child 65 for rrrrreeeeetirtirtirtirtireeeeeeeeeesssss over age 65.

Employee Over X Disabled No The Tax Equity and Fiscal or 65 Responsibility Act of 1982 Dependent (TEFRA) shifted the primary

responsibility for coverage ofmedical claims for olderemployees and their spousesto group health plans ofemployers with 20 or moreemployees.

Employee Over X Disabled Yes Medicare is always primary or Spouse/ 65 for rrrrreeeeetirtirtirtirtireeeeeeeeeesssss over age 65. Child




SubrogationSubrogation means the assumption of a third party, such as an insurance company, of anotherperson’s legal right to collect a debt or damages. Most health coverage contracts employershave with BlueCross contain a subrogation provision.If someone causes an employee or dependent to be injured, subrogation allows BlueCross torecover benefits it has paid for the injured person’s medical care from the person, firm, corporationor organization responsible for the bills. If the injured person sues the responsible party or accepts asettlement, BlueCross has the right to recover benefits from the injured person.BlueCross also has the right to recover benefits paid for the injured person from benefitsavailable to that person under uninsured or under-insured motorist’s provisions of automobileinsurance policies.When a potential subrogation case is detected, BlueCross sends the employee a questionnaireto be completed and returned. The employee will not lose benefits or incur additional expenseif BlueCross recovers benefits from the third party.

Workers’ CompensationBy law, most employers are required to have workers’ compensation insurance (workers’ comp)for their employees. Workers comp pays benefits in connection with illnesses or injuriesresulting from employees’ jobs.To avoid duplicate payment made by a workers’ comp insurance company, BlueCross excludesbenefits for work-related medical expenses from its health coverage contracts.

If Member Age Active Retired Medicare Entitlement Is Medicare Why? is . . . Employee Employee Reason is . . . Primary?

Employee Under X X Disabled Yes The Omnibus Budget or Spouse/ 65 Reconciliation Act of 1986 Child made Medicare the second-

ary payer for any disabledemployee or dependentunder age 65 who hascoverage under a employer-sponsored large group healthplan. However, this DDDDDOEOEOEOEOESSSSSNNNNNOOOOOT APPLT APPLT APPLT APPLT APPLYYYYY to groups withLESS THAN 100 employees.

Employee Any X X ESRD (with No Group coverage is primary or Spouse/ Age or without Not until for the first 30 months. Child disability or age) the 31st

MonthYes If …If …If …If …If … Medicare had already

been paying primary due todisability before the memberwas eligible due to ESRD.




When BlueCross receives a claim indicating treatment was necessary due to a work-relatedsituation, it denies the claim. The EOB says BlueCross may reopen the claim if workers’compensation does not cover it.When BlueCross detects a pppppotototototenenenenentialtialtialtialtial workers comp, it sends the employee a questionnaireasking if medical expenses are the result of a work-related illness or injury. If so, and if theemployee has filed a claim with the S. C. Workers’ Compensation Commission, BlueCrossreviews the claim filed with the commission, as well as the commission’s hearing ruling.If the commission rules that the workers’ comp insurance company should pay the employee’smedical bills, BlueCross contacts hospitals, doctors, etc., to recover the benefits it already paid.If a case is resolved before a ruling by the S. C. Workers’ Compensation Commission,BlueCross recovers benefits paid from the person or party that was paid by the workers’ compinsurance company.

HHHHHow Wow Wow Wow Wow Worororororkkkkkersersersersers; Com; Com; Com; Com; Compppppensaensaensaensaensation Wtion Wtion Wtion Wtion Worororororkkkkksssss: A Sam: A Sam: A Sam: A Sam: A Sample Cple Cple Cple Cple CaaaaassssseeeeeJohn Doe works for ABC Company, whose group health coverage is with BlueCross. ABC hasits workers’ comp insurance with WC Insurance.John is injured at work when a forklift he is driving turns over. BlueCross pays his medical billsbut, through the questionnaire John completes, BlueCross learns that the accident happened atwork and that John has filed a claim with the SC Workers’ Compensation Commission. At thecommission’s hearing, John’s claim is declared compensable by workers’ compensationinsurance.BlueCross notifies John’s doctor and the hospital that WC Insurance is responsible for his billsand asks for a refund on claims BlueCross previously paid.

ERISA InformationSSSSStttttaaaaatttttemenemenemenemenement of Et of Et of Et of Et of ERRRRRIIIIISA RSA RSA RSA RSA RighighighighightttttsssssParticipants in this health coverage plan have certain rights and protection under theEmployee Retirement Income Security Act of 1974 (ERISA).Under ERISA, all plan participants are entitled to the following:(1) To examine without charge, at the plan administrator’s office and at other specifiedlocations, all plan documents, including health coverage or insurance contracts and copies ofall documents filed by the plan with the U.S. Department of Labor, such as detailed annualreports and plan descriptions.(2) To receive a summary of the plan’s annual financial report. The plan administrator isrequired by law to furnish each participant with a copy of this summary annual report.In addition to creating rights for plan participants, ERISA imposes duties upon the people whoare responsible for the operation of the plan. The people who operate health coverage handletheir duties prudently and in the interest of all plan participants and beneficiaries.No one, including employers or any other person, may fire employees or discriminate againstthem in any way to prevent them from obtaining a benefit or exercising their rights under




ERISA. If all or part of a claim for a benefit is denied, employees must receive a writtenexplanation of the reason for the denial. Employees have the right to have the plan reviewedand their claims reconsidered.Under ERISA, there are steps employees can take to enforce the rights explained above. Forinstance, if they request material from the plan and do not receive it within 30 days, they mayfile suit in a federal court.In such a case, the court may require the plan administrator to provide the material and pay upto $100 a day until the employee receives it, unless it was not sent because of reasons beyondthe administrator’s control.If an employee has a claim for benefits, which is denied or ignored, the employee may file suitin a state or federal court.If the plan fiduciaries misuse the plan’s money, or if employees are discriminated against forrequesting their rights, they may seek help from the U. S. Department of Labor. Or they mayfile suit in a federal court. The court will decide who should pay the court costs and legal fees.If an employee is successful in such a suit, the court may order the person the employee suedto pay these costs and fees. If the employee loses the suit, the court may order the employee topay the costs and fees.If employees have any question about the health coverage plan, they should contact the planadministrator. If they have any questions about the administrator’s statements or about theirrights under ERISA, they should contact the nearest area office of the U.S. Labor-ManagementServices Administrator, Department of Labor.

Denial of a ClaimIf BlueCross denies all or part of an employee’s (or dependent’s) claim for benefits, theemployee will receive an Explanation of Benefits (EOB) explaining the reason. If theinformation BlueCross received with the claim was incomplete, the EOB will tell the employeewhat additional facts or materials are needed and why.For example, when a person becomes 65 years of age, a questionnaire is sent out requestingMedicare information. This is to verify that the employee is still actively at work. UntilBlueCross receives the information, it will deny claims.It is important for employees to understand the reason for the denial so that they can decidewhether they want to appeal the denial and request that the claim be reviewed again.Employees should read their health coverage booklet. The booklet outlines the terms andconditions of their group’s health coverage.Employees may review their employer’s health coverage contract with BlueCross. The contractis the legal document that provides a complete description of their health coverage. To reviewthe contract, employees should contact the group’s Benefits Coordinator. The personnel officecan tell them how to do that.There are certain time periods in which a claim must either be paid or denied. Your contractoutlines those time frames, as does the Employee Booklet in the sections on Claims Filing and




Appeal Procedures. In general, if an employee is not satisfied with the outcome of a claim orwants additional information about it, he or she should contact BlueCross. The employeeshould carefully read these sections in pursuing an appeal of a denial of a claim.




The Health Insurance Portability and Accountability Act(HIPAA)The Health Insurance Portability and Accountability Act (HIPAA) is a set of laws passed inseveral phases. Two of those phases had an important effect on employee healthcare and arediscussed here. Each employer should understand generally how these laws affect theircoverage and the coverage offered to their employees.

Portability and Creditable CoverageThe first phase of HIPAA mandated that employees’ health insurance coverage be protectedwhen an employee changed jobs. An employee builds up “cccccrrrrreeeeeditditditditditaaaaable cble cble cble cble coveragoveragoveragoveragoverageeeee” so that if he orshe changes jobs, he or she is entitled to coverage under a new plan without the exclusion ofsome conditions that existed prior to his or her new employment. The new plans must coverpre-existing conditions when the employee has creditable coverage. If the employee does nothave the full amount of creditable coverage, HIPAA directs how to calculate the maximumamount of time a condition can be treated as pre-existing.If an employee has creditable coverage when he or she joins a BlueCross group plan, his or herformer insurance company must provide a certificate of creditable coverage or a recent bill anda bill from one year prior to the effective date of coverage. BlueCross will also accept a signedstatement or telephone call from the group with the following information: name of coveredmembers, Social Security number, effective date of coverage, cancellation date and name ofprior carrier. Similarly, if an employee leaves a BlueCross group plan to go to another group,we are required to provide them with the certificate of creditable coverage.Other provisions of HIPAA direct that certain benefits be provided under any group healthplan, how and when dependents can be added to a group health plan, and the enrollmentrights generally of your employees. All of this information is covered in other parts of thisguide. Please be assured that BlueCross follows all the requirements of HIPAA.

PrivacyIn 2003, a new portion of the HIPAA law created standards to safeguard the medical recordsand personal health information (PHI) of individuals. This privacy rule requires insurers andother persons to maintain strict rules on using and releasing PHI to other persons or groups.As a result of this rule, BlueCross cannot communicate with a group in ways that would use amember’s PHI. We can release information only with a proper authorization from the memberstating that some other person can receive information from us about his or her medicalcondition or other PHI. HIPAA also requires that if an employee or individual member sendsus a request, we must provide him or her with a list of all situations in which we shared his orher PHI with any other entity.You will be receiving enrollment and cancellation information, which may include PHI, but wewill always try to include only the minimum necessary information, as this is also required byHIPAA. If your members want an accounting of other situations in which we have shared PHI,they must make a request directly to BlueCross.




What Type of Information Will You Receive from BlueCross?Because of the requirements of the HIPAA Privacy Rule, BlueCross will provide you withenrollment information — which may include some PHI — but only the minimum amountnecessary. The information we share with you should be no more than is required to completeour standard enrollment form, or a cancellation form. Whenever possible, you should allowyour agent (instead of you) to handle all forms which contain PHI to maintain the greatestdegree of privacy for your employees.

Your Rights and Those of Your Employees under the Privacy RuleBlueCross makes every attempt to comply fully and completely with the regulations relating tothe HIPAA Privacy Rule. As part of our efforts, we have implemented privacy procedures,designated a Privacy Officer on both the corporate level and within the Group and IndividualDivision of BlueCross, trained our employees to enable them to fully comply with theserequirements, issued a privacy notice to all members describing our procedures and theirrights under HIPAA, set up a process for complaints about our handling of a member’s PHI,and entered into agreements with business associates (such as our agents) who are required tofollow the same high standards. In the future, we will maintain our records for a minimum ofsix years, in either a paper or electronic form.

MMMMMembembembembembers’ rers’ rers’ rers’ rers’ righighighighighttttts under ts under ts under ts under ts under the Hhe Hhe Hhe Hhe HIIIIIPPPPPAAAAAA PrA PrA PrA PrA Privivivivivacacacacacy Ry Ry Ry Ry Rule incule incule incule incule include:lude:lude:lude:lude:• The right to access, inspect and copy their PHI;• The right to request amendments to their PHI, an accounting of disclosures of PHI, and

place restrictions on the use or sharing of their PHI; and• The right to privacy under HIPAA. You cannot require an employee to waive his or her

privacy rights; neither can an employee be subject to retaliation for refusing to waivehis or her rights under HIPAA.

An emAn emAn emAn emAn employerployerployerployerployer’’’’’s rs rs rs rs reeeeespspspspsponsibilitieonsibilitieonsibilitieonsibilitieonsibilities under Hs under Hs under Hs under Hs under HIIIIIPPPPPAAAAAAAAAAAs the plan sponsor, an employer is required to follow HIPAA regulations. You should reviewinformation at the Department of Health and Human Services Web site to determine whichrequirements may apply to your business.

• You may need to identify any business associates with whom you share Personal HealthInformation, and enter into agreement with them to ensure proper use of PHI.

• In all situations, you need to limit the use of PHI to the minimum necessary for thepurpose you wish to accomplish

• You must permit your members (employees) access to their PHI, allow them to requestthat this information be updated or corrected, allow them to restrict the use and

PPPPPleleleleleaaaaassssse re re re re remembemembemembemembemembererererer::::: The employer is the plan sponsor. If the plan receives PHI, you arerequired to follow HIPAA regulations to safeguard your employees’ privacy.




disclosure of their PHI, and permit them to request an accounting of any disclosures oftheir PHI.

• You should retain a copy of the Notice of Privacy Practices forwarded to you byBlueCross.




Customer Service

Hours of OperationOur CCCCCustustustustustomer Somer Somer Somer Somer Sererererervvvvvicicicicice hours of ope hours of ope hours of ope hours of ope hours of operaeraeraeraeration artion artion artion artion are 8:30 ae 8:30 ae 8:30 ae 8:30 ae 8:30 a.m. t.m. t.m. t.m. t.m. to 5:30 p.m. Mo 5:30 p.m. Mo 5:30 p.m. Mo 5:30 p.m. Mo 5:30 p.m. Mondaondaondaondaonday ty ty ty ty thrhrhrhrhroughoughoughoughoughFFFFFrrrrridaidaidaidaidayyyyy.

Automated Voice Response UnitWe also have an aaaaautututututomaomaomaomaomattttteeeeed Vd Vd Vd Vd Voicoicoicoicoice Ree Ree Ree Ree Respspspspsponsonsonsonsonse Ue Ue Ue Ue Unit (nit (nit (nit (nit (VVVVVRRRRRUUUUU))))) that you may use 24 hours a day,seven days a week. If you want to use the automated Voice Response Unit, please call 1-800-1-800-1-800-1-800-1-800-868-2500 868-2500 868-2500 868-2500 868-2500 or (803) 788-0500(803) 788-0500(803) 788-0500(803) 788-0500(803) 788-0500. Listed below are instructions for Benefits Coordinators andMembers on using our automated Voice Response Unit. If you decide that you would prefer tospeak to someone, press “0” at any time to reach a Customer Service Representative.(Link to Customer Service Unit)

Benefits Coordinators Instructions for VRUPlease call 1-800-868-2500 or (803) 788-0500:

ReReReReReqqqqqueueueueuest Prst Prst Prst Prst Premium Infemium Infemium Infemium Infemium Infororororormamamamamationtiontiontiontion1) Dial Extension 44153.2) Press 2.3) Enter the nine-digit group number.4) Press 1 if the group number entered is correct.5) Press 1.6) Premium information will play.

ReReReReReqqqqqueueueueuest Hst Hst Hst Hst Heeeeealtaltaltaltalth Claim Fh Claim Fh Claim Fh Claim Fh Claim Fororororormsmsmsmsms1) Dial Extension 44153.2) Press 2.3) Enter the nine-digit group number.4) Press 1 if the group number entered is correct.5) Press 2.6) Press 1.7) Press 1.8) Forms will be mailed to address on our files.




ReReReReReqqqqqueueueueuest Drst Drst Drst Drst Drug Claim Fug Claim Fug Claim Fug Claim Fug Claim Fororororormsmsmsmsms1) Dial Extension 44153.2) Press 2.3) Enter the nine-digit group number.4) Press 1 if the group number entered is correct.5) Press 2.6) Press 1.7) Press 2.8) Forms will be mailed to address on our files.

ReReReReReqqqqqueueueueuest Dst Dst Dst Dst Denenenenentttttal Claim Fal Claim Fal Claim Fal Claim Fal Claim Fororororormsmsmsmsms1) Dial Extension 44153.2) Press 2.3) Enter the nine-digit group number.4) Press 1 if the group number entered is correct.5) Press 2.6) Press 1.7) Press 3.8) Forms will be mailed to address on our files.

ReReReReReqqqqqueueueueuest Emst Emst Emst Emst Employeployeployeployeployee Ae Ae Ae Ae Applicpplicpplicpplicpplicaaaaationstionstionstionstions1) Dial Extension 44153.2) Press 2.3) Enter the nine-digit group number.4) Press 1 if the group number entered is correct.5) Press 2.6) Press 2.7) Applications will be mailed to address on our files.

ReReReReReqqqqqueueueueuest a Copy of tst a Copy of tst a Copy of tst a Copy of tst a Copy of the Lhe Lhe Lhe Lhe Laaaaast Grst Grst Grst Grst Group Billoup Billoup Billoup Billoup Bill1) Dial Extension 44153.2) Press 2.3) Enter the nine-digit group number.4) Press 1 if the group number entered is correct.




5) Press 2.6) Press 3.7) Last group bill will be mailed to address on our files.

ReReReReReqqqqqueueueueuest a Bst a Bst a Bst a Bst a Benefenefenefenefenefit Bit Bit Bit Bit Booooookleokleokleokleoklettttt1) Dial Extension 44153.2) Press 2.3) Enter the nine-digit group number.4) Press 1 if the group number entered is correct.5) Press 2.6) Press 4.7) Benefit booklet will be mailed to address on our files.

ReReReReReqqqqqueueueueuest a Const a Const a Const a Const a Contract Stract Stract Stract Stract Scccccheheheheheduleduleduleduledule1) Dial Extension 44153.2) Press 2.3) Enter the nine-digit group number.4) Press 1 if the group number entered is correct.5) Press 2.6) Press 5.7) Contract schedule will be mailed to address on our files.

ReReReReRetrtrtrtrtrieieieieieve tve tve tve tve the Mhe Mhe Mhe Mhe Membembembembembership Mailing Aership Mailing Aership Mailing Aership Mailing Aership Mailing Addrddrddrddrddreeeeessssssssss1) Dial Extension 44153.2) Press 2.3) Enter the nine-digit group number.4) Press 1 if the group number entered is correct.5) Press 2.6) Press 6.7) Mailing address will play.

Group Membership AX-G10P.O. Box 100177Columbia SC 29202




ReReReReRetrtrtrtrtrieieieieieve tve tve tve tve the Prhe Prhe Prhe Prhe Premium Mailing Aemium Mailing Aemium Mailing Aemium Mailing Aemium Mailing Addrddrddrddrddreeeeessssssssss1) Dial Extension 44153.2) Press 2.3) Enter the nine-digit group number.4) Press 1 if the group number entered is correct.5) Press 1.6) Listen to Premium Information.7) Press 3.

BlueCross BlueShield of SCAttn: Cashier’s AX-A31P.O. Box 6000Columbia SC 29260

Member Instructions for VRUPlease call 1-800-868-2500 or (803) 788-0500:

ReReReReReqqqqqueueueueuest Bst Bst Bst Bst Benefenefenefenefenefititititits and Eligs and Eligs and Eligs and Eligs and Eligibilityibilityibilityibilityibility1) Dial Extension 44153.2) Press 1.3) Enter the numeric portion of your ID number followed by the pound sign (#).4) Press 2.5) If the ID Number you entered is correct press 1.6) Benefits and Eligibility Press 1.7) Enter the birth date (10041963).8) If date is correct Press 1. You will need specific information to proceed.

ReReReReReqqqqqueueueueuest Ist Ist Ist Ist ID CD CD CD CD CARARARARARDDDDD1) Dial Extension 44153.2) Press 1.3) Enter the numeric portion of your ID number followed by the pound sign (#).4) Press 2.5) If the ID Number you entered is correct press 1.6) For ID CARD Press 4.7) Press 1.8) Verify Zip Code.




Re Re Re Re Reqqqqqueueueueuest Hst Hst Hst Hst Heeeeealtaltaltaltalth Claims Fh Claims Fh Claims Fh Claims Fh Claims Fororororormsmsmsmsms1) Dial Extension 44153.2) Press 1.3) Enter the numeric portion of your ID number followed by the pound sign (#).4) Press 2.5) If the ID Number you entered is correct press 1.6) For Forms 4.7) Press 2.8) Verify Zip Code.

ReReReReReqqqqqueueueueuest Bst Bst Bst Bst Benefenefenefenefenefit Bit Bit Bit Bit Booooookleokleokleokleokletttttsssss1) Dial Extension 44153.2) Press 1.3) Enter the numeric portion of your ID number followed by the pound sign (#).4) Press 2.5) If the ID Number you entered is correct press 1.6) For Benefit Booklets 4.7) Press 3.8) Verify Zip Code.

ReReReReReqqqqqueueueueuest Hst Hst Hst Hst HIIIIIPPPPPAAAAAA BA BA BA BA Benefenefenefenefenefit Bit Bit Bit Bit Booooookleokleokleokleokletttttsssss1) Dial Extension 44153.2) Press 1.3) Enter the numeric portion of your ID number followed by the pound sign.4) Press 2.5) If the ID Number you entered is correct press 1.6) For HIPAA Information 4.7) Press 4.8) Verify Zip Code.




Customer Service UnitIf you prefer to speak to someone instead of using the automated Voice Response Unit, pleasecontact our Customer Service Unit between 8:30 a8:30 a8:30 a8:30 a8:30 a.m. and 5:30 p.m.m. and 5:30 p.m.m. and 5:30 p.m.m. and 5:30 p.m.m. and 5:30 p.m. at 1-800-868-2500 or1-800-868-2500 or1-800-868-2500 or1-800-868-2500 or1-800-868-2500 or(803) 788-0500, e(803) 788-0500, e(803) 788-0500, e(803) 788-0500, e(803) 788-0500, exxxxxtttttension 41010. ension 41010. ension 41010. ension 41010. ension 41010. To give our customers the S.T.A.R. treatment (ServiceThat’s Above the Rest), our customer service representatives are designated to three regions —Greenville, Columbia and Charleston. Each county is assigned to a specific region. The regionsand counties are listed below.

GrGrGrGrGreeeeeenenenenenvvvvville Reille Reille Reille Reille Regggggion:ion:ion:ion:ion:Includes the following counties: Abbeville, Anderson, Cherokee, Greenville,Greenwood, Laurens, Oconee, Pickens, Spartanburg and Union.

Columbia ReColumbia ReColumbia ReColumbia ReColumbia Regggggion:ion:ion:ion:ion:Includes the following counties: Aiken, Calhoun, Chester, Chesterfield, Clarendon,Darlington, Dillon, Edgefield, Fairfield, Florence, Kershaw, Lancaster, Lexington, Lee,Marlboro, McCormick, Newberry, Richland, Saluda, Sumter and York.

CharCharCharCharCharleleleleleststststston Reon Reon Reon Reon Regggggion:ion:ion:ion:ion:Includes the following counties: Allendale, Bamberg, Barnwell, Beaufort, Berkeley,Charleston, Colleton, Dorchester, Georgetown, Hampton, Horry, Jasper, Marion,Orangeburg and Williamsburg.

When you call Customer Service, you will select the region your county is assigned to:If you are calling from the Greenville Region, you should press 1.If you are calling from the Columbia Region, you should press 2.If you are calling from the Charleston Region, you should press 3.

Your call will then be routed to a customer service team dedicated to servicing your specificregion. You will talk to the same representatives each time you call us!Please note that when you call Customer Service with questions about your group’s account,we will ask you specific questions about your group. This is a preventive measure we take tomake sure we protect your privacy. You may be asked for your group’s name, group BlueCrossnumber, group address and your name. For example, if you are inquiring about your bill, pleasebe prepared to give the bill print date that you are inquiring about.In addition, please make your employees aware that if they call Customer Service, we will askthem similar questions about their policy. We will ask for their name, BlueCross ID number,address and date of birth. They should also be aware that if someone other than the membercalls on their behalf, we will give information only if there is a HIPAA Service Authorizationon file giving a specific individual permission to receive information about the member’s fileon the member’s behalf.While these measures may seem inconvenient, they are necessary preventive measure to helpprotect your privacy rights.




Contact Lists

Contact List for Group Membership, Columbia, SCMail Address: BlueCross BlueShield of SC

Group Membership AX-G10P.O. Box 100177Columbia, SC 29202

Overnight Address (Except payments): BlueCross BlueShield of SCGroup Membership AX-G10I-20 @ Alpine RoadColumbia, SC 29219

Mail Address (Payments only): BlueCross BlueShield of SCAttn: Cashier’s AX-A31P.O. Box 6000Columbia, SC 29260


Customer Service Unit: 1-800-868-2500 Extension 41010(803) 788-0500 Extension 41010

Automated Voice Response Unit: 1-800-868-2500 Extension 44153(803) 788-0500 Extension 44153

Fax: (803) 264-0143(803) 264-8460 (Billing only)

E-mail Addresses: [email protected]@BCBSSC.com(Billing only)

Corporate Web site: www.SouthCarolinaBlues.comManagement: Thomas Stallworth, Customer Service Supervisor, Extension 49470

Jason Perla, Billing Supervisor, Extension 45998Lonetta Thompson, Renewal Processing/Par Audit Supervisor, Extension 44837Christina Shannon, Maintenance Apps Processing Supervisor, Extension 49157Susan Surratt, Billing, Maintenance and Customer Service Manager,

Extension 41581Carol Thomas, New Business Unit and Renewal Manager, Extension 41336Sandy Cartledge, Senior Director, Extension 42505Terry Peace, Vice-President, extension 43746





Contact List for Group ClaimsAAAAAdministdministdministdministdministererererereeeeed by Bd by Bd by Bd by Bd by BlueCrlueCrlueCrlueCrlueCroooooss Bss Bss Bss Bss BlueSlueSlueSlueSlueShiehiehiehiehield of Sld of Sld of Sld of Sld of Soutoutoutoutouth Ch Ch Ch Ch Carararararolinaolinaolinaolinaolina, Columbia, Columbia, Columbia, Columbia, Columbia, SC, SC, SC, SC, SCClaims Mail Address: BlueCross BlueShield of SC

Group Claims AX-F25P.O. Box 100300Columbia, SC 29202-3300

Overnight Address: BlueCross BlueShield of SCGroup Claims AX-F25I-20 @ Alpine RoadColumbia, SC 29219

Medical Records Address: BlueCross BlueShield of SCAttn: Records AX-F25P.O. Box 100246Columbia, SC 29202-3246

Customer Service Unit: 1-800-868-2500 Extension 43475(803) 788-0500 Extension 43475

Automated Voice Response Unit: 1-800-868-2500 Extension 41000(803) 788-0500 Extension 41000

Fax: (803) 264-9703 In-state Medical Records(803) 264-7568 Out-of-State Medical Records(803) 264-0172 Non-medical Records Correspondence

Email: [email protected] Non-medical Records [email protected] In-state Medical [email protected] Out-of-State Medical Records

Management: Tammy Ross, Customer Service Supervisor, Extension 45307Shauna Golston, Correspondence & Appeals Supervisor, Extension 42896Philicia Robinson, Claims Supervisor, Extension 44410Karen Jones-Eskew, Claims Supervisor, Extension 42922Sandra Walker, Claims Manager, Extension 43136Vera Smith, Service, Correspondence & Appeals Manager, Extension 42076Jane Miller, Director, Extension 42656Terry Peace, Vice-President, Extension 43746




Contact List for Group Membership and ClaimsAAAAAdministdministdministdministdministererererereeeeed by Td by Td by Td by Td by Thomahomahomahomahomas H. Cos H. Cos H. Cos H. Cos H. Coopopopopoper & Co., Incer & Co., Incer & Co., Incer & Co., Incer & Co., Inc.....Mail Address: Thomas H. Cooper & Co., Inc.

PO Box 22557Charleston, SC 29413

Overnight Address: Thomas H. Cooper & Co., Inc.Fountain Walk, Suite 210360 Concord StreetCharleston, SC 29401

Membership & Health ClaimsCustomer Service: 1-800-815-3314

(843) 722-2115Fax: (843) 722-2866Corporate Web site: www.tccofsc.com

Management: Stephen Stewart, Supervisor, Extension 250Bridgette Cunningham, Supervisor, Extension 224Peggy Austin, Vice-President, Extension 222

http://www.tccofsc.com/content.asp?catID=8564




Frequently Asked Questions1. How do I contact BlueCross?2. Where do I send premiums?3. Where do I send applications?4. How do I report problems with my bill?5. What is Extension of Liability?6. How do I request Extension of Liability?7. How do I request State Continuation?8. What is creditable coverage?9. How do I request a Certificate of Creditable Coverage?10. What is a new enrollee?11. What is a special enrollee?12. What is a late enrollee?13. Who do I contact if I want to make changes to my benefits?14. Do I have to offer employees COBRA or State Continuation coverage?15. Who do I contact to get additional Membership Applications?16. When should I submit changes in employee statuses?17. When can members add newborn, adopted or court ordered dependents?18. What do I do if I do not receive my bill?19. How do I get information during non-business hours about my bill?20. What is a pre-existing condition?21. How do I access the Web site?22. What is available on the Web site?




HHHHHow do I cow do I cow do I cow do I cow do I cononononontttttact Bact Bact Bact Bact BlueCrlueCrlueCrlueCrlueCroooooss?ss?ss?ss?ss?You can contact us by calling our Customer Service Unit at 1-800-868-2500 or (803) 788-0500,extension 41010, between the hours of 8:30 a.m. and 5:30 p.m., Monday through Friday. Youcan also use our automated Voice Response Unit (VRU), available 24 hours a day, seven days aweek. There are additional customer service numbers listed under “Contact Lists” for claimsand Thomas Cooper & Co. (Link to Contact Lists)

WherWherWherWherWhere do I se do I se do I se do I se do I send prend prend prend prend premiums?emiums?emiums?emiums?emiums?Mail Address (Payments only): BlueCross BlueShield of SC

Attn: Cashier’s AX-A31P.O. Box 6000Columbia, SC 29260


If you wish to hand deliver your payments, you must take them to the Security Desk located atPercival Road before 4:30 p.m., Monday through Friday. Security will contact the Cashier’sOffice and someone will come to meet you and pick up your payment.

WherWherWherWherWhere do I se do I se do I se do I se do I send aend aend aend aend applicpplicpplicpplicpplicaaaaations?tions?tions?tions?tions?When applications are complete, please mail them to the following address:BlueCross BlueShield of South CarolinaGroup Membership, AX-G10P.O. Box 100177Columbia, SC 29202You may fax the membership applications to BlueCross at (803) 264-0143. If you fax theapplication you do notdo notdo notdo notdo not need to mail the hard copy.(Link to Customer Service Unit)If Thomas Cooper & Company Inc. administers your group; please send your applications to:Thomas Cooper & Co. Inc.P.O. Box 22557Charleston, SC 29414Fax (803) 264-9284

HHHHHow do I row do I row do I row do I row do I reeeeepppppororororort prt prt prt prt problems woblems woblems woblems woblems wititititith mh mh mh mh my bill?y bill?y bill?y bill?y bill?Call our Customer Service Unit at 1-800-868-2500 or (803) 788-0500, extension 41010.

WhaWhaWhaWhaWhat is Et is Et is Et is Et is Exxxxxtttttension of Lension of Lension of Lension of Lension of Liaiaiaiaiability?bility?bility?bility?bility?




WhaWhaWhaWhaWhat is Et is Et is Et is Et is Exxxxxtttttension of Lension of Lension of Lension of Lension of Liaiaiaiaiability?bility?bility?bility?bility?If a member’s coverage under this contract ends and, at the time coverage ends, the member iseither confined in a hospital or totally disabled, that member may request to retain coveragefor the disabling condition only.

HHHHHow do I row do I row do I row do I row do I reeeeeqqqqqueueueueuest Est Est Est Est Exxxxxtttttension of Lension of Lension of Lension of Lension of Liaiaiaiaiability?bility?bility?bility?bility?On a Membership Application, check the box beside “Other” in Block 1 and write “Extensionof Liability” on the line provided. Then complete Blocks 3, 4, 8, 9 and 23.

HHHHHow do I row do I row do I row do I row do I reeeeeqqqqqueueueueuest Sst Sst Sst Sst Stttttaaaaattttte Cone Cone Cone Cone Contintintintintinuauauauauation?tion?tion?tion?tion?Check “Other” in Block 1, write “State Continuation” on the line provided and complete blocks2, 4, 5, 7, 8, 13 and 14. Block 15 is required if you are requesting continuation coverage for adependent.

WhaWhaWhaWhaWhat is ct is ct is ct is ct is crrrrreeeeeditditditditditaaaaable cble cble cble cble coveragoveragoveragoveragoverage?e?e?e?e?An employee builds up cccccrrrrreeeeeditditditditditaaaaable ble ble ble ble coverage so that if he or she changes jobs, he or she isentitled to coverage under the new plan without the exclusion of some conditions that existedprior to his or her new employment. The new plans must cover pre-existing conditions whenthe employee has creditable coverage. If the employee does not have the full amount ofcreditable coverage, HIPAA directs how to calculate the maximum amount of time a conditioncan be treated as pre-existing. If an employee has creditable coverage when he or she joins aBlueCross group plan, his or her former insurance company must provide a Certificate ofCreditable Coverage. Similarly, if an employee leaves a BlueCross group plan to go to anothergroup, we are required to provide him or her with the Certificate of Creditable Coverage.(Link to Pre-existing Condition)

HHHHHow do I row do I row do I row do I row do I reeeeeqqqqqueueueueuest a Cerst a Cerst a Cerst a Cerst a Certiftiftiftiftificicicicicaaaaattttte of Cre of Cre of Cre of Cre of Creeeeeditditditditditaaaaable Coveragble Coveragble Coveragble Coveragble Coverage?e?e?e?e?Call our Customer Service Unit at 1-800-868-2500 or (803) 788-0500, extension 41010.

WhaWhaWhaWhaWhat is a net is a net is a net is a net is a new enrw enrw enrw enrw enrolleolleolleolleollee?e?e?e?e?An employee hired after the initial enrollment and who meets eligibility requirements.

WhaWhaWhaWhaWhat is a spt is a spt is a spt is a spt is a speeeeecccccial enrial enrial enrial enrial enrolleolleolleolleollee?e?e?e?e?An employee who did not enroll when first eligible because he or she had other coverage, butwho now has lost that other coverage and wants coverage under your group policy. A newspouse, newborn or court ordered dependent is considered a special enrollee.

WhaWhaWhaWhaWhat is a lat is a lat is a lat is a lat is a lattttte enre enre enre enre enrolleolleolleolleollee?e?e?e?e?An employee or dependent who did not enroll when he or she was first eligible, but whodesires to enroll at a later date and is not the result of a birth, adoption, court order, marriage,death or divorce.....




Who do I cWho do I cWho do I cWho do I cWho do I cononononontttttact if I wact if I wact if I wact if I wact if I wananananant tt tt tt tt to mako mako mako mako make ce ce ce ce changhanghanghanghangeeeees ts ts ts ts to mo mo mo mo my by by by by benefenefenefenefenefititititits?s?s?s?s?Your agent can assist you in making any changes to your group’s benefits. However, if anemployee wants to make status or coverage changes to his or her own policy, a MembershipApplication must be completed with the appropriate information and submitted by the groupto BlueCross for processing.

DDDDDo I hao I hao I hao I hao I have tve tve tve tve to ofo ofo ofo ofo offffffer emer emer emer emer employeployeployeployeployeeeeees Cs Cs Cs Cs COBROBROBROBROBRA or SA or SA or SA or SA or Stttttaaaaattttte Cone Cone Cone Cone Contintintintintinuauauauauation ction ction ction ction coveragoveragoveragoveragoverage?e?e?e?e?The law requires that employers offer employees continuation of coverage (COBRA or StateContinuation) if they have experienced a qualifying event. (Link to Continuation of Coverage)

Who do I cWho do I cWho do I cWho do I cWho do I cononononontttttact tact tact tact tact to go go go go geeeeet additional Mt additional Mt additional Mt additional Mt additional Membembembembembership Aership Aership Aership Aership Applicpplicpplicpplicpplicaaaaations?tions?tions?tions?tions?You can request Membership Applications and other forms by going to our Web site,SouthCarolinaBlues.com. You can also call us at 1-800-868-2500 or (803) 788-0500, extension41010.

When should I submit cWhen should I submit cWhen should I submit cWhen should I submit cWhen should I submit changhanghanghanghangeeeees in ems in ems in ems in ems in employeployeployeployeployee ste ste ste ste staaaaatttttusususususeeeees?s?s?s?s?We must receive Membership Applications within 31 days of any change (birth, adoption,marriage, death or divorce). Otherwise we will process the application as a late enrollee. Wemust receive a Membership Application no later than 31 days from the date of termination toavoid extending coverage for an additional 31 days. The cancellation will be effective on thefirst billing date following the termination date.

When cWhen cWhen cWhen cWhen can memban memban memban memban members add neers add neers add neers add neers add newbwbwbwbwborororororn, adoptn, adoptn, adoptn, adoptn, adopteeeeed or cd or cd or cd or cd or courourourourourt ort ort ort ort orderderderderdereeeeed ded ded ded ded depppppendenendenendenendenendenttttts?s?s?s?s?We must receive Membership Applications within 31 days of the birth, adoption or courtorder. Otherwise we will process the application as a late enrollee. We will exclude coverage forthe first 12 months, then subject the member to a six-month pre-existing waiting period. If thedependents have cccccrrrrreeeeeditditditditditaaaaable ble ble ble ble coverage through previous insurance, they should attach theCertificate of Creditable Coverage to the application and mail or fax it to BlueCross.

WhaWhaWhaWhaWhat do I do if I do not rt do I do if I do not rt do I do if I do not rt do I do if I do not rt do I do if I do not reeeeeccccceive meive meive meive meive my bill?y bill?y bill?y bill?y bill?Call our Customer Service Unit at 1-800-868-2500 or (803) 788-0500, extension 41010.

HHHHHow do I gow do I gow do I gow do I gow do I geeeeet inft inft inft inft infororororormamamamamation durtion durtion durtion durtion during non-busineing non-busineing non-busineing non-busineing non-business hours ass hours ass hours ass hours ass hours abbbbbout mout mout mout mout my bill?y bill?y bill?y bill?y bill?We have an automated Voice Response Unit (VRU) that you may use 24 hours a day, sevendays a week. If you want to use the automated Voice Response Unit, please call 1-800-868-1-800-868-1-800-868-1-800-868-1-800-868-2500 2500 2500 2500 2500 or (803) 788-0500(803) 788-0500(803) 788-0500(803) 788-0500(803) 788-0500. We have included detailed instructions on how to use the VRU forBenefits Coordinators and Members in this guide under “Customer Service.”(Link to Customer Service)

WhaWhaWhaWhaWhat is a prt is a prt is a prt is a prt is a pre-ee-ee-ee-ee-existing cxisting cxisting cxisting cxisting condition?ondition?ondition?ondition?ondition?Physical or mental conditions (regardless of the cause) for which medical advice, diagnosis,care or treatment was received or recommended within the six-month period prior to theenrollment date.





HHHHHow do I acow do I acow do I acow do I acow do I acccccceeeeess tss tss tss tss the Whe Whe Whe Whe Weeeeeb sitb sitb sitb sitb site?e?e?e?e?You can access our Web site at www.SouthCarolinaBlues.com

WhaWhaWhaWhaWhat is at is at is at is at is avvvvvailaailaailaailaailable on tble on tble on tble on tble on the Whe Whe Whe Whe Weeeeeb sitb sitb sitb sitb site?e?e?e?e?You can access information about our available health and dental plans, discounts and addedvalues and prescription drugs. You can also order forms or supplies, locate a doctor or accessyour own claims information by creating a profile on My Insurance Manager SM.





Glossary of TermsAAAAActivectivectivectivectivelylylylyly-a-a-a-a-attttt-----worworworworworkkkkk— an employee must: (1) have begun and not be absent from work

because of leave of absence or temporary lay-off, unless the absence is due to a HealthStatus Related Factor other than substance abuse or chemical dependency; and (2) beperforming the normal duties of his or her occupation at one of the employer’s placesof business or at a location to which the employee must travel to do his or her job.

AAAAAttttttttttaineaineaineaineained Red Red Red Red Reduction Agduction Agduction Agduction Agduction Ageeeee — life insurance coverage decreases by 35% at age 65 and by 50%at age 70. Your Companion Life group contract shows the reduction age for yourcompany.

CCCCCOBROBROBROBROBRA — A — A — A — A — under the Consolidated Omnibus Budget Reconciliation Act, (COBRA),employees and/or their dependents who would otherwise lose coverage may choose tokeep their group coverage for up to 18, 29 or 36 additional months provided they meetthe definition of having a qualifying event.

CoCoCoCoCoororororordinadinadinadinadination of Btion of Btion of Btion of Btion of Benefenefenefenefenefitititititsssss (COB) — a method of paying benefits for people who arecovered under more than one group health coverage plan or program so that no morethan the actual cost of medical care is paid.

CrCrCrCrCreeeeeditditditditditaaaaable Coveragble Coveragble Coveragble Coveragble Coverage —e —e —e —e — an employee builds up creditable coverage so that if he or shechanges jobs, he or she is entitled to coverage under the new plan without the exclusionof some conditions that existed prior to his or her new employment. The new plansmust cover pre-existing conditions when the employee has creditable coverage. If theemployee does not have the full amount of creditable coverage, HIPAA directs how tocalculate the maximum amount of time a condition can be treated as pre-existing. If anemployee has creditable coverage when he or she joins a BlueCross group plan, his orher former insurance company must provide a Certificate of Creditable Coverage.Similarly, if an employee leaves a BlueCross group plan to go to another group, we arerequired to provide them with the Certificate of Creditable Coverage.

EfEfEfEfEffffffeeeeective Dactive Dactive Dactive Dactive Dattttteeeee — the date the employee’s coverage is to begin.

EligEligEligEligEligibility Daibility Daibility Daibility Daibility Dattttteeeee — the date the employee becomes eligible for coverage. The date isdetermined by the number of days in your group’s probationary period.

EligEligEligEligEligible Dible Dible Dible Dible DeeeeepppppendenendenendenendenendentttttsssssA “Dependent” is (1) an employee’s spouse, or (2) an employee’s unmarried child under19 years of age, or under age 23 if a full-time student enrolled in an accredited,educational institution. This includes a natural child, adopted child or any other childdependent upon the employee for support. Full-time student determination will bebased upon the standards of the accredited institution.An “Incapacitated Dependent” is an unmarried child who is (1) incapable of self-sustaining employment by reason of mental retardation or physical handicap, and (2)dependent upon the employee for support. The employee must provide written proofof such a dependency and incapacity within 31 days of the dependent’s 19th or 23rd




birthday if a full-time student enrolled in an accredited, educational institution. Werequire proof of incapacity every two years.Written proof of incapacity is an attending physician’s statement with the dependent’sname and date of birth, along with the named condition causing incapacity andprognosis. The group is responsible for attaching this information to the MembershipApplication.

EligEligEligEligEligible Emible Emible Emible Emible Employeployeployeployeployeeeeeesssss — All employees must satisfy the following conditions to be eligiblefor coverage under a small group contract: be an active, full-time employee of thegroup; work at least 30 hours a week and at least 48 weeks a year; and be actively atwork on the effective date of coverage

EEEEERRRRRIIIIISASASASASA — Participants in this health coverage plan have certain rights and protectionsunder the Employee Retirement Income Security Act of 1974 (ERISA). Under ERISA,all plan participants are entitled to the following:To examine without charge, at the plan administrator’s office and at other specifiedlocations, all plan documents, including health coverage or insurance contracts andcopies of all documents filed by the plan with the U.S. Department of Labor, such asdetailed annual reports and plan descriptions; andTo receive a summary of the plan’s annual financial report. The plan administrator isrequired by law to furnish each participant with a copy of this summary annual report.In addition to creating rights for plan participants, ERISA imposes duties upon thepeople who are responsible for the operation of the plan. The people who operatehealth coverage handle their duties prudently and in the interest of all plan participantsand beneficiaries.

EEEEExxxxxplanaplanaplanaplanaplanation of Btion of Btion of Btion of Btion of Benefenefenefenefenefititititits (EOB)s (EOB)s (EOB)s (EOB)s (EOB) — A statement a health plan sends to a covered personwho files a claim. It lists the services provided, the amount billed and the paymentmade. The EOB also explains why a claim was or was not paid, and providesinformation about the individual’s rights of appeal.

EEEEExxxxxtttttension of Lension of Lension of Lension of Lension of Liaiaiaiaiability bility bility bility bility — If a member’s coverage under this contract ends and, at the timecoverage ends, the member is either confined in a hospital or totally disabled, thatmember retains coverage for the disabling condition only.

GrGrGrGrGroup Noup Noup Noup Noup Numbumbumbumbumbererererer — a 10-digit number assigned to each group used for identification. Agroup with 00 as the eighth and ninth digit (i.e., 05-12345-00-1) indicates that this is themain group number. If an employer has more than one group number, the eighth andninth digits are sequentially numbered (01, 02, etc.). These are called sub-groupnumbers. Multiple group numbers can signify several things. Sub-group numbers canindicate subsidiaries of a company, different locations or departments, etc.

HHHHHIIIIIPPPPPAAAAAAAAAA — The Health Insurance Portability and Accountability Act (HIPAA) is a set oflaws that mandate that employees’ health insurance coverage be protected when anemployee changes jobs. In 2003, a new portion of the HIPAA law created standards tosafeguard the medical records and personal health information (PHI) of individuals.This privacy rule requires insurers and other persons to maintain strict rules on usingand releasing PHI to other persons or groups.




IneIneIneIneIneligligligligligible Emible Emible Emible Emible Employeployeployeployeployeeeeeesssss — new hires who have not completed their probationary period,employees covered as a dependent of a spouse on the same group, or part-time orseasonal employees.

LLLLLaaaaattttte Enre Enre Enre Enre Enrolleolleolleolleollee — e — e — e — e — an employee who did not enroll when he or she was first eligible, butdesires to enroll at a later date.....

NeNeNeNeNew Enrw Enrw Enrw Enrw Enrolleolleolleolleollee — e — e — e — e — an employee hired after the initial enrollment and who meets eligibilityrequirements.

ParParParParParticticticticticipaipaipaipaipation Ation Ation Ation Ation Audit — udit — udit — udit — udit — a periodic review of groups to make sure they meet the minimumparticipation requirements.

PrPrPrPrProbaobaobaobaobationartionartionartionartionary Py Py Py Py Perererererioioioioioddddd — the length of time an employee must work for a company beforethe employee is eligible for health coverage.

RefRefRefRefRefusalusalusalusalusal — an employee who chooses not to enroll in the group plan your company offersbecause he or she does not want it.

SSSSSpppppeeeeecccccial Enrial Enrial Enrial Enrial Enrolleolleolleolleolleeeeee — an employee who did not enroll when first eligible because he or shehad other coverage, but now has lost that other coverage and wants coverage underyour group policy.

SSSSSppppponsonsonsonsonsorororororeeeeed Md Md Md Md Membembembembembershipershipershipershipership — occurs when an employee is a sponsor of a covered spouse inthe same group or for a COBRA dependent.

SSSSStttttaaaaattttte Cone Cone Cone Cone Contintintintintinuauauauauation Coveragtion Coveragtion Coveragtion Coveragtion Coverageeeee — State law gives employees the right to continue theirgroup health coverage, but for a period of only six months. State continuation coverageapplies only to groups of less than 20 employees and does not apply to any groupscovered by COBRA.

SSSSSubrubrubrubrubrooooogagagagagationtiontiontiontion — the assumption of a third party, such as an insurance company, of anotherperson’s legal right to collect a debt or damages.

WWWWWaiver — aiver — aiver — aiver — aiver — an employee who chooses not to enroll in the group plan your company offersbecause he or she is already covered on another policy.

WWWWWorororororkkkkkers’ Comers’ Comers’ Comers’ Comers’ Compppppensaensaensaensaensationtiontiontiontion — most employers are required to have workers’ compensationinsurance (workers’ comp) for their employees. Workers’ comp pays benefits inconnection with illnesses or injuries resulting from employees’ jobs.

Updated July BBBenefenefenefititits Cos Cos ......Updated July 18, 2008 BBBenefenefenefititits Cos...

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