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Reimbursement Changes: Facilities & Non-Participating Providers in Blue Choice & Blue Choice Plan 2

Reimbursement Changes for Facilities and Non-Participating Providers in Blue Choice & Blue Choice Plan 2

In an effort to deliver more affordable products to our accounts and members, we are changing the way we reimburse members in certain plans for services received from non-participating1 providers and facilities in Massachusetts, effective January 16, 2012.

How This Change Will Be Applied

Product How Non-Participating Providers Are Paid, Effective January 16, 2012
  • Blue Choice

  • Blue Choice Plan 2
Members will be reimbursed directly for covered services provided by most non-participating providers, including ambulance providers, and it will be the member's responsibility to reimburse the provider.
  • Indemnity

  • HMO Blue New EnglandSM members who have a PCP outside of Massachusetts

  • Blue Choice New EnglandSM members who have a PCP outside of Massachusetts

  • Access BlueSM New England members who have a PCP outside of Massachusetts

  • Claims originating from states other than Massachusetts

  • Medicare products (including Medicaid)

  • 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
No change.
All other health plans Members will be reimbursed directly when they receive services from non-participating or out-of-network facilities.

 

How Payments Will Be Calculated
Payments for covered services may be mailed directly to the member in accordance with their plan and our policies and procedures. 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.

It will be the member's responsibility to reimburse the out-of-network facility. If members do not receive a bill, they should contact the provider.

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 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 two 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 November and through a Provider FYI mailing.

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

1. For the purposes of this change, 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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