Reimbursement for Out-of-Network PPO Providers
Effective January 1, 2012 (upon renewal), claim payments will change under our commercial PPO plans for covered services provided by most non-participating covered providers (professional, ancillary, and institutional providers). This change applies to our Blue Care ElectSM and Preferred Blue PPOSM plans.
Reimbursement for out-of-network providers will be based on a usual and customary fee schedule. The usual and customary fee schedule will be based on the standard allowance that Blue Cross Blue Shield of Massachusetts has established for its indemnity products. For instances in which the provider's actual charges are greater than the usual and customary charge, the member will be responsible for the applicable cost sharing amount, plus the difference, if any. This change does not apply to non-participating emergency rooms, hospital-based emergency medicine physicians, or hospital-based anesthetists, pathologists, or radiologists. For these non-participating providers, the provider's actual charge is used to calculate a member's benefits. If you have questions about any of these changes, please contact your account executive.