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Reimbursement Change for Non-Participating Ambulance Providers

Important Changes in Ambulance Service Reimbursements
In an effort to deliver more affordable products to our accounts and members, Blue Cross Blue Shield of Massachusetts is changing the way we reimburse members for services received from non-participating1 ambulance companies.

  • Starting March 14, 2011, members will be reimbursed directly for covered services provided by non-participating, privately owned and for-profit ambulance companies, including ambulance services provided by Children's Hospital.
  • Claims will be paid to the subscriber for services rendered on or after November 15, 2010.

This includes payment for both emergency and non-emergency ambulance services. It will then be the member's responsibility to reimburse the provider.

How Payments Will Be Calculated
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:

  • Access BlueSM
  • Blue Choice®
  • Blue Choice New EnglandSM
  • BlueCard® program claims originating from states other than Massachusetts
  • HMO Blue New EnglandSM
  • Indemnity
  • Medicare products (including Medicaid)
  • New England members who have a PCP outside of Massachusetts, dental products,
  • Veteran's administration services
  • Services provided by privately owned, not-for-profit ambulance providers, with the exception of Children's Hospital
  • Services provided by municipally owned and operated ambulance companies

Why We're Making This Change
In most cases, non-participating providers are reimbursed as much as three to five times more than in-network providers for the same ambulance services2. We are implementing this change to better manage the cost and quality of the health care our members receive by helping to ensure that they are treated by contracted, in-network providers.

Communicating This Change
We will be communicating this change to members, and providers using the timeline below:

  • Members who have used non-participating providers for non-emergency services three 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 Focus Newsletter in May.

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

 

1. For the purposes of this, a non-participating provider is defined as a provider who does not have a contract with Blue Cross Blue Shield of Massachusetts for the member's product.
2. This average does not include payment for Medicare Advantage members.

Blue Cross Blue Shield of Massachusetts

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