Blue Cross Blue Shield PPO

The Blue Cross Blue Shield (BCBS) PPO is a preferred provider organization (PPO) that combines the advantages of a national network with the option to use physicians and facilities outside the network, but at a higher cost.

When you join the BCBS PPO, you are not required to choose a primary care physician. There are two levels of coverage: in-network and out-of-network. The amount of coverage depends on where you receive treatment. You receive the highest level of benefits under your health care plan when you choose preferred providers. These are called your in-network benefits. You can also choose non-preferred providers, but your out-of-pocket costs are higher. These are called your out-of-network benefits.

In-Network Coverage. When you receive care from a BCBS PPO participating provider, you are covered in full, in and out of the hospital. You pay a $20 copayment for office visits and $100 for emergency room care (this fee is waived if you are immediately hospitalized). No claim forms are required.

Out-of-Network Coverage. When you choose Non-Preferred Providers you must pay a calendar-year deductible for most out-of-network services. The calendar year deductible begins on January 1 and ends on December 31 each year. The deductible is $500 for each member (or $1,000 for all family members covered under the same membership.) After you have met your deductible, you pay 20% co-insurance for most out-of-network covered services. When the money you paid for the 20% co-insurance combined with the deductible equals $2,500 (this is the out-of-pocket limit for a member in a calendar year (or $5,000 for all family members covered under the same membership), benefits for that member (or that family) will be provided in full, based on the allowed charge, for the rest of that calendar year. Bills for covered outpatient services are paid by you and then submitted on claim forms for reimbursement. Certain expenses do not apply toward your out-of-pocket limit. They include the following:

  • Charges in excess of reasonable and customary
  • Expenses for services not covered by the plan
  • Charges you incur for not following pre-certification procedures

When you participate in the BCBS PPO, you must follow a benefit management process. You need to follow some procedures when dealing with emergency care, whether within or outside the enrollment area. There are procedures to follow when making out-of-network claims and when appealing a denied claim.