Claims

The following FAQs address some common issues concerning doctor visits.
I just received an Explanation of Benefits from a recent hospital stay and it looks like the State Health Plan overpaid the hospital bill. Why?
The State Health Plan pays hospital inpatient charges based upon Diagnosis Related Groups (DRG). The State Health Plan takes into account many factors under the DRG payment method, including the patient's age, sex, hospital length of stay, seriousness of the diagnosis, and all procedures performed. Some patients are at higher risk and require more services than others. The amount paid to the hospital is based upon the average claims experience for all procedures, rather than upon billed charges. This sometimes does result in higher payment than the amount charged by the hospital.

The member is responsible for the $450 Plan year deductible (if not already satisfied), 20 percent coinsurance not to exceed $2,000 per fiscal year (if not already satisfied), $150 inpatient copayment per admission and charges for services not covered by the Plan. The 20% coinsurance amount for which the member is responsible is based upon the lesser of the hospital charge or the DRG allowance. Note also that the amount applied to the $5 million lifetime maximum will always be the lower amount based on the hospital charge or the DRG allowance.

What if I don't agree with the State Health Plan's payment amount?
Most problems or concerns can be resolved through Customer Services. However, if you do not agree with a decision made by the State Health Plan, you may submit a formal appeal to the Claims Processing Contractor (CPC). Appeals must be submitted within 60 days of receiving a denial or a benefits decision.

For more information about the appeals process, call Customer Services toll free at 1-800-422-4658.

What is the time limit for filing claims?
Claims for covered services must be filed within 18 months from the date of service. The Plan will not pay claims for services that are not received within the 18 month time limit.

Does the State Health Plan subrogate?
The State Health Plan intends to exercise its right of recovery as set out in NCGS 135-40.13 (g) and pursue all subrogation rights allowed by North Carolina law.

NCGS 135-40.13 Coordination of Benefits provides:

(g) Right of Recovery -- Whenever payments have been made by the Claims Processor with respect to covered services in a total amount which is, at any time, in excess of the maximum amount of payment necessary at that time to satisfy the intent of this provision, irrespective of to whom paid, the Claims Processor shall have the right to recover such payments, to the extent of such excess, from among one or more of the following, as the Claims Processor shall determine: any persons to or for or with respect to whom such payments were made, any insurance companies, or any other organizations.

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