What is a Preferred Provider Organization (PPO) plan and how does it work? A preferred provider organization (PPO) plan works for you in two ways: 1) through a panel or network of physicians and other service providers (such as hospitals and labs) or 2) through providers you select that are not in the network. Each time you or a covered family member needs care, you choose whether to see an in network or an out of network provider.
Network providers are listed in your plan's provider directory. When you use an in network provider, you generally receive a higher level of benefits. Also, fees from in network providers tend to be lower because the providers and the network have negotiated to have the providers accept certain fees for certain services.
How do I find Blue Cross participating provider? There are two ways to find Blue Cross of California participating providers: Call Coresource Member Services. They can assist you in finding a participating provider in your area. Go to the website at www.bluecrossca.com to retrieve a list of Blue Cross of California's Prudent Buyer participating providers*.
*Blue Cross of California's networks offer coverage nationally; members have access to preferred-level benefits from any participating provider in any of the Blue Cross' networks across the country. The plan would be administered based on the plan design of your home network. Members who are traveling (or reside outside of Califfornia) can call Coresource Member Services or visit Blue Cross' website at www.bluecares.com to access a list of local participating providers (this website is only to be utilized if traveling / residing outside of California). Members also may access non-participating providers at the non-preferred benefit level.
With a PPO plan, do I name a primary care physician? The PPO plan does NOT require you to name a primary care physician (PCP) or coordinate your care through a particular doctor. However, you are free to choose a primary doctor (and encouraged to do so), whether or not that doctor participates in the network.
What are the advantages of obtaining my care from in network providers? There are several advantages when you go in network. Generally, 1) You don't need to submit claim forms and wait to be reimbursed by your plan; 2) Your in network provider obtains any needed pre authorization for you; 3) You receive a higher level of benefits because participating providers have agreed in advance to provide their services at a lower fee; 4) Some plans provide preventive care services in network -- services for out of network preventive care are NOT covered (refer to your plan documents for specific benefit information)
How does the PPO plan work when I go out of network? You may use any covered health care provider you choose. However, your cost will generally be higher and you have certain added responsibilities.
For example: You must obtain pre authorization for certain covered expenses such as a hospital stay. If you don't obtain the required pre authorization, the amount of benefits available will be reduced or the expenses will not be covered at all. This means your financial responsibility will be higher.
You must complete claim forms and file claims to receive payment (note, you MUST file your claims in a timely fashion, failure to file a claim in a timely fashion WILL result in the claim being denied and the entire claim will be your financial responsibility).
The plan will not cover any benefit reductions due to failure to pre authorize certain treatments.
The plan will not cover any charges above the allowable amount (this means your financial responsibility will be higher).
How can I find out what my coverage will be for certain procedures? Please refer to your Summary Plan Description. Some of your co-pay amounts may also be listed on your Member ID card. If you can't find the data you need in either location, please contact Member Services at 866-280-4120.
What services require prior approval or a referral? Referrals are not required for office visits. All inpatient admissions and certain other services require prior pre authorization excluding normal maternity admissions, which require notification only. Participating physicians are responsible for obtaining pre authorization approval.
What is pre authorization? Pre authorization is the process by which a health care company reviews the proposed treatment and determines if the treatment is medically necessary (it is not a guarantee of benefits -- this process is merely to determine if the proposed procedure is medically necessary). If you receive care out of the network, you MUST obtain pre authorization for certain covered expenses such as a hospital stay. If you don't obtain the required pre authorization, your financial responsibility will be higher because the benefits payable by the plan will be reduced or the expenses will not be covered at all.
What is an out of pocket maximum? An out of pocket maximum is the most you would have to pay out of your own pocket for eligible expenses in any one given calendar year. Check your SPD for details. Once you reach the out of pocket maximum for a given year, the plan would pay all eligible expenses for covered services at 100% until any lifetime maximum benefit is reached.
What is the difference between deductibles, coinsurance and copayments? Deductible and Coinsurance usually go hand in hand. The deductible is the amount you must pay toward a claim before your insurance begins to pay. A deductible is generally set on a calendar year basis, meaning it will be required that your deductible be met as of January 1 of each year before any claims will be paid by the insurance carrier. You will usually see that a benefit will be paid at a percentage after the deductible has been met. For example an item might be payable at 70% after the calendar year deductible is met. Your responsibility will be what is left of the calendar year deductible plus 30%. The 30% is considered your coinsurance.
A copayment or copay is a set fee that you must pay for the use of specific medical services covered by the insurance plan. Copayments are generally set for medical office visits, emergency room visits, hospital admissions and prescriptions. The difference between copay and coinsurance is that copay is a set fee and coinsurance is a percentage of the cost.
What is coordination of benefits (COB)? Coordination of Benefits is a process developed to prevent duplication of payment when more than one insurance carrier covers a person. It limits the total benefits received to no more than the actual amount incurred for care. The most common rule for determining primary and secondary payment is as follows: Your primary insurance is the coverage you select through your own employer while coverage under your spouse’s employer is generally your secondary carrier (for your spouse it would be the opposite). If children are covered under two plans, the heath insurance of the parent whose birthday falls first in the calendar year is usually considered the primary plan. There are multiple rules in determining primary and secondary payers depending on the situation. If you need help in determining which one applies to your situation, please refer to your Coresource SPD, see your Benefits Department, contact Coresource or contact PSW Benefit Resources.
This is a very important part of your health insurance benefits. Your insurance carrier will generally request COB information from you once a year. The request will be for information regarding you and/or your spouse and/or dependents. When your insurance carrier requests this information from you, it is critical that you respond to their request correctly and promptly. One major reason for delays in claims processing is due to the need for information regarding coordination of benefits. Some insurance carriers will pend and deny claims if the COB information is not received. It is also critical that when there is another insurance carrier, your provider must submit the other insurance payment information (Explanation of Benefits) with the claim. Again, failure to provide this information may cause claims to pend or deny.
A provider has billed me; how do I know how much of the bill to pay? Part of contractual agreements with network physicians include the requirement that physicians accept the network's payment, plus the member's plan copayment, or copayment percentage, as payment in full. Contracting physicians are instructed to collect the copayment / coinsurance amount listed on your ID card. Any provider reimbursement for services will be less the copayment amount. Balance billing for costs over the contracted rate is not permitted by participating providers. For out-of-network claims, members may be subject to deductibles and coinsurance. You may call Member Services to confirm what you need to pay. You are also responsible for any costs billed by the provider over reasonable and customary charges.
What happens in an emergency? In a true emergency, get the care you need as quickly as you can. If you are able, contact Member Services at the number on your identification card, even in an emergency. However, even if you are unable to contact Member Services, get the care you need. Even if you need to go out of network, your plan will cover emergency care at in network benefit levels as long as you follow the plan rules.
Check to see how your plan defines a true emergency. Examples typically include severe bleeding, chest pain, and unconsciousness (life or limb threatening).
What happens if I need care while I'm traveling? If it's not an emergency and you need care while traveling, call member services at the number on your identification card. Member Services can refer you to an in network provider (if available).
In a true emergency, get the care you need as quickly as you can. If you are able, contact Member Services at the number on your identification card, even in an emergency. However, even if you are unable to contact Member Services, get the care you need. Even if you need to go out of network, your plan will cover emergency care at in network benefit levels as long as you follow the plan rules.
Check to see how your plan defines a true emergency. Examples typically include severe bleeding, chest pain, and unconsciousness (life or limb threatening).
Are there expenses that don't count toward my deductible? Yes. Some of your expenses will NOT count towards your deductible. For example, any penalty you may pay because you failed to pre authorize treatment. Other examples are -- amounts above the allowable amount or amounts for services that are deemed not medically necessary (or not a covered benefit under the health plan).
More Questions? Contact the Benefits Department or call our insurance broker, PSW Benefit Resources at (877) 866-2623.