How to Use the Student Health Insurance Plan

With SHIP, all care must begin at University Health Services (UHS) - Tang Center. When you need medical care, simply call to make an appointment.SHIP members pay $15 for a Primary Care office visit and $30 for an Urgent Care clinic visit. For most other services, SHIP members pay 20% of UHS fees. There are no claims to file for UHS visits.

If you need services at another health care facility or physician's office, your UHS clinician will make the referral. You must have outside appointments pre-authorized by the Insurance Office. Off-campus care (care outside of the Tang Center) is coordinated by UHS clinicians, and the SHIP staff will provide authorizations for covered services and ensure that your claims are handled accurately.

For off-campus care, SHIP contracts with Anthem Blue Cross to provide medical and mental health services through their extensive network of hospitals and providers. If providers or facilities are used that are not part of the Anthem Blue Cross Prudent Buyer Provider Network, your claims will be paid at a percentage of the "limited fee schedule," which is often significantly lower than the network rate. See SHIP and Anthem Blue Cross - What's the Connection? for explanation.

To find an Anthem Blue Cross Prudent Buyer provider you can call the customer service number on the back of your health insurance card, or go to the Anthem Blue Cross web site.

If you are out of the area and require care that is of medical necessity please contact the Student Health Insurance Office at (510) 642-5700 for authorization. SHIP covers authorized medically indicated care worldwide.

SHIP covers emergency health care worldwide. If you go to the emergency room, retroactive authorization is required for ER or Urgent Care visits prior to November 1, 2007.

No authorization from the Student Health Insurance Office is required for visits to an emergency room or urgent care center on or after November 1, 2007. Please provide facility with your Anthem Blue Cross card. Claims submitted to Anthem Blue Cross will be processed according to the SHIP benefits.

All follow-up care must be authorized in advance by the Student Health Insurance Office.

Most non-emergency services provided outside of UHS must receive prior authorization or your claim may not be paid.

Services outside UHS that do not require pre-authorization include:

• Services provided in a hospital emergency room (after 11/1/2007)
• Prescriptions filled outside of UHS
• Chiropractic services
• Mammograms
• Acupuncture

For all other non-emergency medical care outside UHS, bring medical referrals to Student Health Insurance Office, Room 3200, Tang Center or call (510)642-5700 for UHS pre-authorization.

When students receive care outside of the Tang Center, the health care provider may require payment of the student's portion of fees at the time of service, or they may send a bill after SHIP has paid the covered amount. Most providers will submit bills directly to Anthem Blue Cross. If a student receives a bill for the full cost of services, the student should send that bill to the Student Health Insurance Office. Claims must be submitted within 12 months of the date of service.

Anthem Blue Cross is a member of the BlueCross BlueShield Association, which coordinates member claims through its BlueCard® Program. For out of state claims: when you are outside of California and receive health care services, you should request that your provider bill the local Blue Cross - Blue Shield company in that state to ensure your services are covered according to your SHIP benefits. For out of country claims: be sure to obtain a bill that contains all of the information listed below. For convenience, you can print and use an "international claim form" from the BlueCard® Worldwide website.

To ensure proper payment or reimbursement of your claim, make sure you get an itemized bill from the provider. An itemized bill includes:

1. Provider's name, address, and tax identification number. Individual providers must also include their professional license number.
2. Patient's name, address, date of birth, and Social Security number.
3. Dates of service.
4. Procedure codes for services rendered
5. Charges for each service.
6. Date of injury and description of how the injury occurred, if the claim is for treatment of an injury. This is especially important on claims for dental injury.
   

If any of this information is not included on a claim, the insurance payment may be delayed or denied. Most providers are aware of what is required for processing an insurance claim and will be happy to exchange an incomplete bill with one containing all of the required information.

For prescriptions filled outside of UHS, you should receive what most pharmacies refer to as an "insurance company receipt." If not, ask the pharmacist or clerk for one before you leave the store.

To file a claim:

1. Obtain a claim reimbursement label from the Tang Information Center, located in the lobby.
2. Complete the label as directed in the instructions provided and attach it to the itemized bill or prescription receipt.
3. Place the bill/receipt with the completed label in the drop box at the Tang Information Center.

Expect to receive an Explanation of Benefits from Anthem Blue Cross within six weeks. If you have not received an Explanation of Benefits after six weeks, feel free to call the Student Health Insurance Office at 510-642-5700 for assistance. You may also call Anthem Blue Cross directly at 800-888-2108.

Remember: It is very important that you keep your address updated with Tele-Bears or Bear Facts. This is how Anthem Blue Cross knows your address for reimbursement. When you move or go away for the summer, please remember to update your address.

There is a $200 plan year deductible for most services provided outside UHS. SHIP members are responsible for the first $200 of charges each plan year. Once the deductible has been satisfied, SHIP benefits begin. Services provided at UHS, pharmacy claims and outpatient psychotherapy are not subject to the $200.00 deductible.

Amounts over the "limited fee schedule" as determined by Anthem Blue Cross do not accumulate toward the deductible (see Glossary).

Services provided at UHS will be billed exclusively to SHIP regardless of whether you have dual coverage through another plan in addition to SHIP. For services provided outside of UHS, SHIP is secondary to all other insurance plans, (except Medi-Cal) meaning the other plan must pay for services first. In this case, SHIP will cover any charges, within the plan's benefit limits, not covered by your other plan. In order to coordinate coverage and payment, Anthem Blue Cross may ask you for information about your other plan.

Students are responsible for no more than $3,200 of out-of-pocket expenses each plan year (which includes the $200.00 plan year deductible). If you have paid $3,200 in co-insurance and deductibles (not including Pharmacy co-payments), you will no longer be required to pay co-insurance for the remainder of the plan year. The out-of-pocket maximum does not apply to amounts exceeding stated benefit limits (for example, Pharmacy or Physical Therapy limits) or to services not covered by the plan.

SHIP has a $400,000 lifetime maximum.