How to ask Blue Cross of Idaho for a coverage decision

Medical Coverage Decision

You have the right to ask Blue Cross of Idaho Care Plus to pay for items or services you think should be covered. This is called an "organization determination" (also called a coverage decision).

An organization determination (referred to here as a coverage decision) is a decision Blue Cross of Idaho Care Plus makes about your benefits and coverage and whether we will pay for the medical services you or your doctor have requested. You can also contact us to ask for a coverage decision before you receive certain medical services. You might want to ask us to make a coverage decision beforehand if your doctor is unsure whether we will cover a particular medical service or if your doctor refuses to provide medical care you think you need.

You, your representative, or your doctor can ask us for a coverage decision by calling, writing, or faxing your request to us.

To make your request

Call 1-888-494-2583 (TTY 1-800-377-1363). We are available from 8 a.m. to 8 p.m., seven days a week.

For fast (expedited) coverage decisions, call the same number at 1-888-494-2583 (TTY 1-800-377-1363).

Fax 1-208-387-6811 You may contact us by fax for expedited coverage decisions.

Write Blue Cross of Idaho Care Plus, P.O. Box 8406, Boise, ID 83707

How long will it take to get a coverage decision?

When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "expedited" (fast) deadlines. A "fast coverage decision" is called an "expedited determination."

Standard coverage decision A standard coverage decision means we will give you an answer within 14 days of receiving your request.

Expedited (fast) coverage decision If you think your health could be seriously harmed or that you could lose your ability to function by waiting the standard 14 days for a decision, you can ask for an "expedited" (fast) decision. We will give you an answer within 72 hours of receiving your request for a fast coverage decision.

To get a fast coverage decision, you must meet two requirements:

  • You must be asking for coverage of medical care you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care you have already received.)
  • You must need a fast decision because using the standard deadlines could cause serious harm to your health or hurt your ability to function.

How to request an expedited (fast) coverage decision

If your doctor tells Blue Cross of Idaho Care Plus that your health requires a "fast coverage decision," we will automatically agree to give you a fast coverage decision

If you ask for a fast coverage decision on your own, without your doctor's support, we will decide whether your health requires that we give you a fast coverage decision.

  • If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead).
  • This letter will explain that we will automatically give a fast coverage decision if your doctor asks for it.
  • The letter will also explain how you can file a "fast complaint" about our decision to give you a coverage decision using the standard deadline. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.

Extended time for a decision

We can take up to 14 more calendar days to make either a standard or fast decision if you ask for more time or if we need information (such as medical records from out-of-network providers) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.

If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.

If we do not give you our answer within the standard or fast time (or if there is an extension at the end of that period), you have the right to appeal. You also have the right to file an appeal if you disagree with our coverage decision.

When we tell you we will not cover a service

In some cases we might decide a service is not covered or is no longer covered by your plan. If we say no to part or all of what you requested, we will send you a detailed written explanation as to why we said no and instructions on how to appeal our decision.

When approval is required before receiving an item or service

For some types of items or services, your doctor may need to get approval in advance from our plan (this is called getting "prior authorization"). Those services that require advance approval are included in your Evidence of Coverage.

Y0010_MK19182_M Accepted 10/1/2018
Last updated 10/01/2018

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