The Primary Coverage Criteria apply to all benefits you may claim under your
Plan, no matter what types of health intervention may be involved or when or where
you obtain the intervention. Health Intervention or Intervention means
an item or service delivered or undertaken primarily to:
The Primary Coverage Criteria are designed to allow Plan benefits for only those
health interventions that are proven as safe and effective treatment. Members will
receive an Explanation of Benefit (EOB), and Providers will receive an Explanation
of Payment (EOP) with claims processing remarks that indicate that a claim was not
eligible for benefits since the Primary Coverage Criteria was not met.
Another goal of the Primary Coverage Criteria is to provide benefits only for the
less invasive or less risky intervention when such intervention would safely and
effectively treat the medical condition or to provide benefits for treatment in
an outpatient, doctor's office or home-care setting when such treatment would be
a safe and effective alternative to hospitalization. Examples of the types of health
interventions that the Primary Coverage Criteria exclude from coverage include such
things as the cost of a hospitalization for a minor cold or some other condition
that could be treated outside the hospital or the cost of some investigational drug
or treatment, such as herbal therapy or some forms of high-dose chemotherapy not
shown to have any beneficial or curative effect on a particular cancerous condition.
Finally, the Primary Coverage Criteria require that if there are two or more effective
alternative health interventions, the member's health plan or policy should limit
its payment to the Allowable Charge for the most cost-effective intervention.
Regardless of anything else in a member's health plan or policy, and regardless
of any other communications or materials received in connection with a member's
health plan or policy, the member will not have coverage for any service, prescription
drug, treatment, procedure, equipment, supplies or associated costs unless the Primary
Coverage Criteria set forth are met. At the same time, just because the Primary
Coverage Criteria are met does not necessarily mean the treatment or services will
be covered under a member's health plan or policy. For example, a health intervention
that meets the Primary Coverage Criteria will be excluded if the condition being
treated is a Pre-Existing Condition excluded by the member's health plan or policy.
To be covered, medical services, drugs, treatments, procedures, tests, equipment
or supplies (interventions) must be recommended by the member's treating physician
and meet all of the following requirements:
Language Assistance Available
Arkansas Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association and is licensed to offer health plans in all 75 counties of Arkansas.
Copyright © 2001-2016 Arkansas Blue Cross and Blue Shield