Blue Shield to Allow 2014 Out-Of-Network Claims to be Reviewed

On Tuesday, November 3, 2015, the DMHC announced a settlement with Blue Shield regarding its Non-Routine Survey of Blue Shield's provider directories for 2014 non-grandfathered Individual and Family Plans.

As part of the settlement, Blue Shield will notify certain ON and OFF Exchange Individual & Family Plan members that they are eligible to resubmit out-of-network claims for covered services received in 2014 for review if they feel that they were led to believe that their provider was in their plan's network by Blue Shield or the provider. Should their claims qualify under the settlement, Blue Shield will reprocess and pay the claims as if they were from an in-network provider.

The letter and claims review form will be mailed to eligible members only on or before December 31, 2015. Members who wish to submit one or more claims for review under the settlement must return the claims review form to Blue Shield by February 12, 2016.

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