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BlueChoice Healthcare Plan HMO

PW_A086798
 
As part of being an HMO member, your employees and their covered dependents must choose a PCP which can be an internist, general practitioner or pediatrician. Adult members may not select a pediatrician as their PCP nor may an internist be selected as a PCP for a child. The Provider Directory/ Member Guide your employees should’ve received upon enrollment provides information on the providers able to service the age group desired. Additionally, our statewide provider directory is available on every page of this Web site under the “Find a Doctor” link.  
Your employees that wish to change their PCP may do so by using our online service, Member Access, by completing a PCP selection form or by contacting customer service. Changes received through the Web or customer service by the 25th of the month will be effective the first of the next month. Changes received after the 25th will be effective the following month.  
For example:  
Your employee submits a PCP selection change on July 25.The new PCP will be effective August 1.
Your employee submits a PCP selection change on July 26.The new PCP will be effective September 1.
 
If a PCP withdraws from our HMO Plan, we will notify your employees to select a new PCP. If no response is received, we will select one for them. The PCP selected has the right not to accept a BCBSGa member as a patient or cease being a member’s PCP upon notice to our office. If this is the case, we will notify your employee(s) and select a PCP for them until they have an opportunity to choose a PCP. It is important to note that once an employee has selected a PCP in a particular area, the PCP will make all hospital and specialist referrals within that area. 
Accessing a Specialist: No Referral Required
Your employees with HMO coverage do not need a referral to the below list of specialists:  
Network OB/GYN: Women may self-refer to an in-network OB/GYN for obstetric or gynecological related care without a referral from a PCP. They may also be seen for non-obstetrical or non-gynecological related care but requires a referral to receive benefits. Without a referral, benefits will not apply. Surgery and inpatient admissions require prior authorization from BCBSHP.
Network Dermatologist: Employees may go to in-network dermatologists without a referral from a PCP for general office visits. Certain procedures may require a referral or pre-certification to receive benefits.
Network Ophthalmologist: For covered services
Network Optometrist: For contact lenses, glasses or exams
 
Accessing a Specialist: Referral Required
To access a specialist, the PCP will contact us to authorize referrals to in-network specialists. We will then state on the referral notification form, the number of visits authorized and the expiration dates. Copies of these forms are available for the patients’ records. Referrals are valid for 30 days only, unless otherwise noted. All services must be coordinated through a PCP to receive benefits with the following exceptions: 
 
Pre-Admission Certification (PAC)
In-network pre-admission certification is the responsibility of the admitting physician. If a member is hospitalized and pre-authorization was not obtained, all charges will be denied. You and your employees will be held harmless if all network guidelines are followed. This means that your employees will not be responsible for any bill in excess of related copays. Non-covered services are always the member’s responsibility. Pre-admission certification is not a guarantee of payment.  
 
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Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.