Provider Overview

What are "providers"?

"Providers" is the term we use for doctors, other healthcare professionals, hospitals and other healthcare facilities that are licensed by the state and eligible to receive payment from Medicare.

What are "in-network providers"?

A provider is an "in-network provider" when they participate in our plan. When we say that in-network providers "participate in our plan," this means that we have arranged with them (for example, by contracting with them) to coordinate or provide covered services to members in our plan. In-network providers may also be referred to as "plan providers".

What are "out of network" providers?

A provider is an "out-of-network provider" when they do not participate in our plan.

Blue Advantage (PPO) plan members 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 medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher.

Blue Advantage (HMO) plan members must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Blue Advantage authorizes use of out-of-network providers.

What are "covered services"?

"Covered services" is the term we use for all the medical care, healthcare services, supplies and equipment that are covered by our plan. Covered services are listed in the Benefits Chart in the Evidence of Coverage.

Providers you can use to receive services covered by our Plan

While you are a member of our plan, you are required to use in-network providers to get your covered services except in limited cases such as emergency care, urgently needed care when our network is not available, or out of service area dialysis. All the providers that participate with our plan are listed in our provider directory.

If you get non-emergency care from out-of-network providers without prior authorization you must pay the entire cost yourself, unless the services are urgent and our network is not available, or the services are out-of-area dialysis services. If an out-of-network provider sends you a bill that you think we should pay for emergency services, please contact Customer Service.

Y0132_19-529_ITLU - Last updated 01/30/2020