What is Fraud?
Fraud is a crime. Any person and/or member who engages in an activity intended to defraud the plan may be guilty of fraud.
An act, practice or omission considered fraud or intentional misrepresentations of material fact made by any applicant for health insurance coverage may be used to void their application, or the Certificate of Insurance, and cause the denial of claims.
As a member:
- Review Explanation of Benefits (EOB). Make sure benefits are correct.
- Don’t let someone else get treatment with your identity. If your ID card is lost or stolen, report the loss to BCBSND.
- Provide complete and accurate information on claims and any other forms. Answer all questions as best you can.
Report any suspected fraud or abuse
- Call the BCBSND Fraud Hotline at 1-877-537-2830 with:
- Concerns about charges on an Explanation of Benefits (EOB).
- Suspicions of any illegal insurance activity.
All calls are confidential. BCBSND’s goal is to make sure that members get the care they need while being responsible with resources. If there is a pattern of unnecessary services, benefit abuse/misuse or fraud is validated, BCBSND may lock you in to one provider and/or pharmacy. This program is called the Coordinated Services Program (CSP). BCBSND will send you a letter if this happens. The letter will tell you what provider and/or pharmacy you must use and how long you’ll be in the CSP program before reevaluation.
