As a Blue member, your employees enjoy the convenience of carrying their member ID card and knowing that health care benefits are accepted wherever they go.
BlueCard PPO is a nationwide program provided in cooperation with all Blue Cross Blue Shield plans.
This program ensures health care coverage for Blue members with covered dependents living in another Blue Plan area or while traveling within the United States. It also offers your employees access to international inpatient hospital coverage in specified locations. Employees will receive participating provider discounts and efficient processing of medical claims incurred when traveling away from home.
Through this program, your employees have access to Blue PPO or participating provider networks and medical services outside of Georgia. Out-of-state and out-of-country participating providers will provide the same level of service that your employees receive in Georgia. The providers will accept your employee’s member ID card, file the claim and accept the local BCBS plan’s fee allowances.
The member ID card should always be presented before receiving services. This card identifies your employee as a Blue member to any hospital and physician. It also tells the provider and the local BCBS plan (by the XKC or other group-specific prefix to the member number) that the claim should be processed through the BlueCard Program. BlueCard allows members to access PPO and participating providers nationwide who are obligated to accept negotiated fees as payment in full for covered services.
Claims for out-of-state medical care should be filed with the provider’s local BCBS plan. After processing, payment will be made by the local BCBS plan to the provider. Your employee will receive an Explanation of Benefits (EOB) from us, which will give him/her the amount paid and explain any expenses that are his/her and/or the provider’s responsibility. The employee should only pay the amounts in the “You Owe” columns. If an employee becomes ill and requires medical treatment while away from home on vacation or business, he/she may arrange medical care from a participating provider in the local Blue plan area and the claim will be processed through the BlueCard Program. Employees can determine if a provider is participating by contacting the provider’s office, by visiting our online Provider Directory at www.bcbs.com
. Claims will be filed automatically for members who receive care away from home through the BlueCard Program. In an emergency, members should seek immediate care from the nearest health care provider.
| Savings to members - Members are responsible for non-covered services, their standard low copay or deductible and coinsurance up to the negotiated amount, all of which reduces out-of- pocket costs. |
| Savings for providers - Providers save significant time and money through efficient, timely payment for services rendered. Savings are passed on to providers in the form of reduced administrative costs for claims processing. |
| Easy to use - Members simply show their membership card to a Blue Cross and Blue Shield network physician or hospital to receive the same benefits offered by their local plan. |
Members admitted to a hospital when out-of-state are responsible for obtaining all coverage authorizations required by their Contract. If the required authorizations are not obtained and penalties are applied to the claim, the member is liable to pay the penalty. If a member is admitted to a preferred or non-preferred hospital and pre-certification was not received, the member is liable for all denied charges. In a medical emergency, all eligible charges will be paid at the in-network benefit level. The following is a general guide for pre-certification:
Pre-certification is required for, but not limited to:
| All in-patient hospitalizations (excluding maternity related in-patient care) |
| Home health care services |
Services not requiring pre-certification include but are not limited to:
| Physician office visits |
| Adult preventive health assessments (a periodic examination based on established medical guidelines) |
| Routine well-baby examinations (as recommended by the American Pediatric Association) |
| Immunizations (vaccinations administered to children and adults) |
| Annual gynecological examinations |
| Mammograms, Pap tests and prostate screenings |
| Diagnostic X-rays and laboratory tests when provided and billed by the treating physician |
| Annual flu vaccinations |
BlueCard members now have access to inpatient hospital services while traveling abroad. BlueCard Worldwide, an extension of the domestic Blue Cross Blue Shield provider network, allows members traveling or living abroad to receive covered inpatient health care from participating hospitals in select countries around the world.
Preferred and Participating Providers
There are two types of health care professionals in the BlueCard program: preferred and participating.
Preferred: These health care professionals, typically physicians and hospitals, have negotiated special contracts and are a part of a PPO network.
Participating: These health care professionals, also referred to as Traditional providers, are ones who might not participate in a PPO network but have agreed to perform services at a discounted rate for BlueCard members. Typically, members would go to a participating provider if there are no PPO health care professionals in their area who can provide the medical care they need. Your employees receive the greatest benefit when they elect to use preferred or participating providers. These providers will file claims as well as accept your employees’ member ID cards as proof of payment, less any copays and/or deductibles. When your employees use non-preferred providers, covered services will be paid at the lower out-of-network rate and they will pay more out-of-pocket.
Your employees may also be asked:
| To pay for services up front,|
| To file their own claims with the local Blue Cross Blue Shield plan, and |
| They may be “balance billed” if charges exceed the amount allowed by the local Blue Cross Blue Shield plan. Balance-billed means the provider will bill your employees for charges above the amount allowed by your Plan or the difference between billed charges and the amount paid. |