Out-of-Network Benefits

You may have to file your claim when you receive a covered service from a non-preferred provider in Massachusetts or a non-preferred provider outside of Massachusetts who does not have a payment agreement with the local Blue Cross Blue Shield Plan. Claims for out-of-network services should be filed, along with a Blue Cross Blue Shield claim form, available online from Human Resources, within two years of the date charges for the service were incurred, to:

P.O. Box 986030
Boston, MA  02298

Note: When you receive covered services outside the United States, you must file your claim to the Blue Card Worldwide Service Center. (The Blue Card Worldwide International Claim Form you receive from Blue Cross Blue Shield will include the address to mail your claim.) The service center will prepare your claim, including the conversion to U.S. currency and forward it to Blue Cross Blue Shield for repayment to you.

Utilization Review Requirements

Utilization Review is an important feature of the out-of-network portion of the BCBS PPO. It helps to ensure that you receive the appropriate medical care in the most cost-efficient setting—whether it be the hospital, a specialty facility, or your own home. Utilization Review includes:

  • Pre-admission review – For all non-emergency and non-maternity hospital admissions in the United States, you must call (1-800-327-6716) in advance to get your stay approved. Within two working days of receiving all necessary information, Blue Cross Blue Shield will determine if the health care setting is suitable to treat your condition. Failure to follow the pre-admission review procedure may result in your having to pay for expenses that otherwise would be covered.
  • Concurrent review/discharge planning – This program automatically monitors your stay in the hospital to help ensure that you are discharged on time and receive necessary services once you are discharged.

Be sure to follow utilization review provisions. If you do not follow these provisions, plan benefits will be reduced. The BCBS PPO benefits are automatically subject to utilization review without any steps on your part.

Cost of Out-of-Network Care

When you receive services from an out-of-network provider, Blue Cross bases its payment on the equivalent of 150 percent of what Medicare pays for the service (or “allowed amount”).

This means that you will be responsible for paying the difference between the allowed amount that Blue Cross pays and the amount the provider charges, which can be significant. This is known as balance billing.