A preferred provider organization, BlueChoice PPO offers your employees flexibility and lots of choice in deciding which type of provider to visit for care.
Finding a Preferred Physician
Because the provider directory your employees receive is subject to change, we encourage them to click on the “Find a Provider”
link located on every page of this Web site. We suggest that your employees ask a provider if they belong to the BlueChoice PPO network at the time they call for an appointment.
Copays are a fixed dollar amount that your employees pay for selected services. Services covered under a copay are not usually subject to your employees’ calendar year deductible or coinsurance when they use network BlueChoice PPO providers.
Your employees must pay an office copay each time they visit a physician. The Certificate Booklet and Provider Directory/Member Guide provide a listing of services that are, and are not covered under the physician office copays. With BlueChoice PPO, your employees may visit any health care provider they choose to receive medical care. However, benefits will be paid at a reduced level if the providers are not participants of the BlueChoice PPO network.
Periodic Health Assessment
Early detection and treatment of illnesses and routine immunizations are important to maintaining the health of your employees’. Periodic health assessments are covered under your employees physician office copay only when the services are provided by a BlueChoice PPO physician. The type and frequency of examinations, diagnostic tests and immunizations for children and adults are based on recognized medical standards. Your employees’ examinations may vary based on each employee’s medical history and the professional judgement of his/her physician.
to access our online preventive care guidelines.
Pre-Admission Certification (PAC)
In-network pre-admission certification is the responsibility of the admitting physician. If an employee is hospitalized and pre-authorization was not obtained, all charges will be denied. The employer and employee will be held harmless if all network guidelines are followed. This means that the member will not be responsible for any bill in excess of related copays. Non-covered services are always the member’s responsibility.
The employee, the physician or the hospital must obtain approval for all hospital admissions to a non-preferred hospital. If an employee is hospitalized and preauthorization was not obtained, all charges will be denied. The employee will be responsible for all hospital charges. Pre-admission certification is not a guarantee of payment.
Admissions are approved only when the appropriateness of the inpatient setting can be substantiated. Actual payment is based upon eligibility for coverage and the effective enrollment date for an employee and also will be dependent on, but not limited to, specific group coverage and the status of the coverage on the date services are rendered. Please review your Certificate Booklet to learn more about covered services and plan exclusions and limitations.
Medical Treatment in Georgia – BlueChoice PPO coverage for routine medical care offers the same level of coverage delivered anywhere in Georgia, if the member uses a network provider.
Otherwise, benefits will fall into the out-of-network category. Emergencies will be handled according to your group’s in-network benefits.
Medical Treatment in Another State –
Medical treatment received in another state for medical emergencies or accidental injury will be covered according to your group’s in-network benefits. Medical service received for any condition that is not a medical emergency or accidental injury will be covered according to your group’s out-of-network benefits. However, your employees may also utilize the BlueCard Program
to receive in-network benefits.