Out-of-Network Providers

For Capital Blue Cross HMO and Capital Blue Cross PPO Members

How to Get Care from Out-of-Network Providers

Capital Blue Cross PPO

As a member of our plan, you can choose to receive care from out-of-network providers. Our plan will cover services from either in-network or out-of-network providers, as long as the services are covered benefits and are medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher. Here are other important things to know about using out-of-network providers:

• You can get your care from an out-of-network provider, however in most cases that provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to participate in Medicare. If you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. Check with your provider before receiving services to confirm that they are eligible to participate in Medicare.
• You don’t need to get a referral or prior authorization when you get care from out-of-network providers. However, before getting services from out-of-network providers you may want to ask for a pre-visit coverage decision to confirm that the services you are getting are covered and are medically necessary. (See Chapter 9, Section 4 of your Evidence of Coverage for information about asking for coverage decisions.)

Without a pre-visit coverage decision, if we later determine that the services are not covered or were not medically necessary, we may deny coverage and you will be responsible for the entire cost. If we say we will not cover your services, you have the right to appeal our decision not to cover your care. See Chapter 9 of your Evidence of Coverage: (What to do if you have a problem or complaint) to learn how to make an appeal.

• It is best to ask an out-of-network provider to bill the plan first. But, if you have already paid for the covered services, we will reimburse you for our share of the cost for covered services. Or if an out-of-network provider sends you a bill that you think we should pay, you can send it to us for payment. See Chapter 7 of your Evidence of Coverage: (Asking us to pay our share of a bill you have received for covered medical services or drugs) for information about what to do if you receive a bill or if you need to ask for reimbursement.
• If you are using an out-of-network provider for emergency care, urgently needed care, or out-of-area dialysis, you may not have to pay a higher cost-sharing amount. See Section 3 of your Evidence of Coverage for more information about these situations.

Capital Blue Cross HMO

In most cases, care you receive from an out-of-network provider will not be covered. Listed below are three exceptions:

• The plan covers emergency care or urgently-needed care that you get from an out-of-network provider. For more information about this, and to see a description of emergency or urgently-needed care, see Chapter 3 of your Evidence of Coverage.
• If you need medical care that Medicare requires our plan to cover and the providers in your network cannot provide, you can get this care from an out-of-network provider. In this situation, you will pay the same as you would pay if you got the care from a network provider. Please contact Customer Service at the number below for assistance with prior authorization.
• Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside of the plan’s service area.

Questions?

Contact customer service with questions on these matters: Toll Free for HMO members: 800.779.6962 (TTY: 711); for PPO members: 866.987.4213 (TTY: 711),, Monday through Friday, 8:00 AM to 8:00 PM, with extended hours October 1-March 31.