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Reimbursement Change for Non-Participating Providers

In an effort to deliver more affordable products, Blue Cross Blue Shield of Massachusetts is implementing a change in the way we reimburse Massachusetts based providers who do not participate in our network.

Effective October 1, 2010, we will reimburse members directly for covered services provided by most non-participating providers* and it will be the member's responsibility to reimburse the provider. The payment to the member will reflect the provider's billed charge, or in some cases the usual and customary charge based on the Massachusetts indemnity fee schedule, less any applicable copayments, co-insurance, or deductibles.

This reimbursement change applies to all products and services, with the following exceptions:

  • Indemnity
  • Blue Choice® 1
  • HMO Blue New EnglandSM, Blue Choice New EnglandSM, and Access BlueSM New England members who have a PCP outside of Massachusetts
  • Dental products
  • Medicare products (including Medicaid)
  • Some BlueCard® program claims originating from states other than Massachusetts
  • Veteran's Administration services

In most cases, non-participating providers are reimbursed as much as three to five times more than in-network providers for the same services.** By implementing this change, we seek to better manage the cost and quality of the health care our members receive through greater transparency, and by helping to ensure that they are treated by contracted, in-network providers.

We will be communicating this change to members and providers:

  • Members who have used non-participating providers 2 or more times over the past 13 months will receive a notification letter informing them of the change and encouraging them to use in-network providers in the future.
  • Providers will receive notification through a Provider FYI in late August.

If you have any questions, please contact your account executive.

 

* For the purposes of this, a non-participating provider is defined as a provider who does not have a contract with BCBSMA for the member's product.

** This average does not include payment for Medicare Advantage members.

Blue Cross Blue Shield of Massachusetts

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