HMO/POS HMO/POS. Member Guide & Provider Directory. Directorio de Proveedores y Guía para los Miembros COMIENZA EN LA PÁGINA 44

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1 / Member Guide & Provider Directory / Directorio de Proveedores y Guía para los Miembros / Member Guide & Provider Directory / Directorio de Proveedores y Guía para los Miembros COMIENZA EN LA PÁGINA 44

2 Welcome to to Your / Even though this is a thick book, we designed it in a way that hopefully helps you understand your health Even though this is a thick book, we ve designed it in a way that hopefully helps you understand plan. But, before we get into all of the details of our plans, we thought you might want a little background your health plan. But, before we get into all of the details of our plans, we thought you might want information about who we are and how we ended up where we are in the health insurance industry. a little background information about who we are and how we ended up where we are today in the health insurance industry. History Of Blue Cross Blue Shield We know you ve probably heard our name before, but did you know, the Blue Cross and Blue Shield brands are the nation s oldest and largest family of health benefits companies and the most recognized brands in the health insurance industry? Our Symbols The blue Greek cross symbol was first used in an advertisement (ad) in 1934 for an early hospital prepayment plan in Minnesota, which is now known as Blue Cross and Blue Shield of Minnesota. After the first ad, the Association s executive secretary, E.A. van Steenwyk, wanted to continue using the cross symbol to identify the Association s health plans. Soon, the blue cross symbol was used in other parts of the country. And, in 1939, the Chicago-based American Hospital Association (AHA) started using the blue cross symbol to signify the health plans that met certain standards. The AHA continued to manage the use of this symbol until the Blue Cross Association was formed in These organizations remained affiliated until The shield symbol was created in Buffalo, New York in Carl Metzger, an early pioneer in the Blue movement, wanted to use a design that would set apart the new medical plan; however, he also wanted to make sure there was an obvious link to the Blue Shield plan. Soon, the shield symbol was used among the growing number of Blue Shield Plans. In 1948, the shield symbol was informally adopted by nine plans and called the Associated Medical Care Plans, which was later renamed the National Association of Blue Shield Plans. Soon, the Blue Cross and Blue Shield organizations merged and their brand symbols came together to become one of the most recognized brands in the nation. Currently The business of Blue Cross Blue Shield occurs through a series of independent licensees that offer insurance plans within defined regions. In fact, Blue Cross Blue Shield offers some type of health insurance coverage in all 50 states! Some of the state plans merged to increase efficiency, some plans are managed by not-forprofit organizations, while others have become for-profit companies. Our parent company operates Blue Cross and/or Blue Shield plans in 14 states, including Georgia. After the merger with Anthem in late 2004, our parent company became the nation s largest health benefits company. Our mission is to improve the lives of the people we serve (people like you!) and the health of our communities. And, we take this mission very seriously. Espanol comienza en la página 44. Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

3 3 Enrollment Kit! Indicates information applicable to the plan Indicates information applicable to the plan Table of Contents Bringing Everything to the Local Level Now you know a little bit about how the Blues came to be, here s a little information about Blue Cross Blue Shield Healthcare Plan of Georgia (BCBSHP). Georgians like you have relied on BCBSHP since 1937 to provide quality health care coverage. And we deliver! Just ask the 2.9 million people who count on us everyday to answer their calls, pay their claims and help ensure they have continued access to quality, affordable health care coverage. Take some time to read through this / Member Guide and keep it in a convenient place so you can access it when you need it. It s an important resource as you become more familiar with your benefits and how your plan works. Member Guide History of Blue...2 Contacting Us...4 Frequently Asked Questions...5 Definitions of Commonly Used Terms...8 Member Access...10 Service Area Map...11 Explanation of Benefits...12 Plan Information...14 Plan Information Coverage Away From Home...27 Prescription Drug Coverage Health Program Member Rights and Responsibilities Evaluation of New Technologies Appeals Confidentiality Disclosure of Financial Agreements...41 Provider Qualifications...41 Provider Directory Primary Care Physicians...3 Specialists: No Referral Required Specialists: Referral Required Hospitals Ancillaries/Other Providers Pharmacies Vision Discount Program Providers Complementary Medicine Discount Program Providers Physician Index Disclaimer: This Member Guide offers a summary of your health plan. Your Certificate Booklet is your legal contract with BCBSHP. The language in your Certificate Booklet controls. Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

4 4 Essential Navigational Items Here are a few telephone numbers and Web sites you may want to keep in a handy place. Customer Care (800) 441-CARE (2273) Fax: (877) Hours: 7:30 a.m. to 7:00 p.m. Monday - Friday (excluding holidays) If you re out-of-town and you need to find a physician (for emergency services), just call (800) 810-BLUE (2583) or go to bcbsga.com. However, if you re out-of-town and you need to find a physician (for non-emergency services), remember to call your primary care physician (PCP) so he or she may make the arrangements. Future Moms Maternity Management Program (866) If you re pregnant, you ll want to join our FREE program! Behavioral Health or Substance Abuse (800) Ask Your Doctor... Can you take a generic drug? Approximately 75 percent of the brand name FDA-approved prescription drugs have generic drug versions! Your prescription savings could be 30 to 60 percent or more. 24/7 NurseLine (888) 724-BLUE (2583) This is a nurse information line that s available 24/7 to help you make an informed decision about your health. AudioHealth Library (888) 724-BLUE (2583) If you have questions about general health topics, just call the number listed above. This library contains more than 300 taped messages about various illnesses, treatments, drugs, medical tests and procedures. And, each message is approximately three to five minutes in length. By the way, in case you re wondering, the information is updated regularly and it s recorded in English and Spanish. ConditionCare Programs (800) If you have a chronic condition like diabetes or asthma, you ll want to learn more about our FREE programs that help you better manage your health. Health Improvement Resource Line (800) You can call this number 24/7 to request educational materials on a variety of health topics. Our Web site bcbsga.com Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

5 5 Frequently Asked Questions We aren t surprised if you have a few questions about some of the information that s included in this guide. Therefore, we ve included a list of some of the most frequently asked questions for your convenience. If you have additional questions for us, just call our customer care department at (800) 441-CARE (2273). 1. How can I find out the copay amount I have to pay for a visit to my PCP or specialist and for prescriptions? You ll see the amount you need to pay for copays listed on the front of your member ID card. 2. How can I maintain coverage on a college-aged dependent? You may continue receiving coverage of college-aged dependents if they remain your dependents (aren t married) and in each calendar year they are enrolled as full-time students in a post-secondary institution of higher learning (such as a fully accredited technical school, college or university). You can maintain coverage by calling the customer care number on the front of your member ID card; our associates are ready to assist you! 3. What types of specialists may I visit without a referral from my PCP? If you re a woman, you may go to a network OB/GYN doctor for pregnancy, gynecological problems or annual exams without a PCP referral. In addition, as a member, you don t need a PCP referral to see a network ophthalmologist or dermatologist for covered services. If you d like to see the complete list of specialists that don t require a referral, please see the No Referral Needed section on page 17 for members and page 23 for members. Just remember, you must visit a network specialist to ensure coverage. 4. How can I find out if a particular doctor or medical facility is part of the network? If you d like to see the most up-to-date list of providers, just go to our online directory at bcbsga.com. This section is updated each week. You can also turn to the Provider Directory section of this book. (This list was current at the time it was printed.) 5. Can I change my PCP whenever I want to? If so, how do I do it? Absolutely! If you request a change by the 25 th of the month, the change will become effective on the first day of the following month. We ll send you a new member ID card that lists the name and telephone number of your new PCP. If you don t request a change by the 25 th of the month, the change becomes effective on the first day of the month that immediately follows the upcoming month. For example, if you make the change on June 29, the change becomes effective on August 1. TIP: Your online Member Access account details your coverage including copay amounts, deductibles, types of coverage and much more. Check it out today - bcbsga.com Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

6 6 Frequently Asked Questions You may call us at (800) 441-CARE (2273) to make your change or you may visit bcbsga.com and make your change online in the Member Access section. Remember, you need to have a username and password in order to make your change online. If you don t have one, just go to bcbsga.com today to request one. 6. How will I know if I have access to behavioral health, mental health and substance abuse benefits? All you need to do is review your Benefits Summary or your Certificate Booklet to see if your employer has this coverage in their contract. all of the care you receive, except when you receive emergency care or for one of the exceptions listed in the third question in this section. And, if your PCP refers you to a specialty care physician, they ll provide the information needed. 11. What if I don t get prior approval or a referral? Your PCP must approve all of the care you receive except when you have an emergency, or for one of the reasons listed in the third question in this section. If you visit a specialist without a referral, you ll need to pay for the cost of your visit (unless it was an emergency). 7. How can I find out if I have vision, dental or prescription drug benefits? All you need to do is check your Benefits Summary to see if you have this coverage. If you do, your copay amount is listed on the front of your member ID card. 8. How can I find out what types of prescription drugs are covered on my plan? The first thing you should do is check your Benefits Summary to make sure you have coverage. All prescriptions that are written by a network physician and filled at a network pharmacy are covered according to our drug formulary. You can check out our Drug Formulary online at bcbsga.com. Just go to Pharmacy in the Learn More section of our home page. 9. How do I change my name or address? You should contact the staff in your company s human resources or benefits department so they can make the changes for you. 10. How can I get prior approval or a referral? Your PCP will refer you to another doctor or a specialist if you need specialty care. In addition, your PCP must approve 12. What do I do if I need care while I m traveling? If you have an emergency while you re traveling, then you should call 911 (or the local emergency number), or go to the nearest hospital emergency room. Now, if you become ill or need urgent care, then remember the following: Always carry your current member ID card for easy reference and easy access to service Call your PCP for prior authorization and pre-certification 13. Can I get reimbursed for the prescription drugs I received from a pharmacy not in the network? Members: No, your plan does not cover prescriptions filled by an out-of-network pharmacy. If you go to a pharmacy not in the network, you will need to pay for the full amount of the prescription. Members: Yes, as long as your policy covers your prescription. We ll reimburse you according to the guidelines in your contract. However, keep in mind, it will cost you more if you go to an out-of-network pharmacy. Just remember to take a claim form with you to the out-ofnetwork pharmacy (you can also download one from the Member section of our Web site at bcbsga.com). Once it s filled out, fax it to (877) Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

7 7 14. How do I file a claim? It s easy. If you need to file a claim, then you must use the Member Health Expense Report. You can access this form by going to the Member section of our Web site. You may also call our customer care department or talk with someone in your company s human resources or benefits department. Once you have the form, follow the instructions and attach your detailed information (such as the date of service, provider, charges, etc.). Then, you can fax the claim, and your detailed information, to (877) Or, you may mail it to: BCBSGa, P.O. Box 7368, Columbus, GA How much time do I have to file a claim? If your provider submits the claim form, then we must receive it within the timeframe agreed upon within the provider s contract. If you submit the form, then we must receive it within the timeframe agreed upon in your policy. Please keep in mind we aren t liable for the benefits of the plan if your claim isn t filed within the pre-determined timeframe. If you d like more information then you should contact our customer care department at (800) 441-CARE from 7:30 a.m. to 7:00 p.m., Monday through Friday (except on holidays). 16. What happens to my coverage if I move out of the area? We want to make sure our records are up-to-date, so please ask your employer to update your records by giving us your new contact information. And, you may need to contact our customer care department to change your PCP if his or her location is no longer convenient to your home or office. Helpful Healthy Tip Get cancer screenings regularly. Ask your doctor how often you should be screened. He or she may advise you to get screenings at an early age if you have certain risk factors or a family history of cancer. 17. Is there a way to give you feedback? Yes! All you need to do is complete our online survey. Just go to bcbsga.com and click on Member Survey We Want to Hear from You! You can also complete the survey found in this book. 18. How do I know what benefits aren t covered? The following items are a generic list of non-covered items. You ll find the complete list in your Certificate Booklet. Acupuncture Blood pressure monitoring Smoking cessation and weight loss programs Eye refraction Air filters Central or unit air conditioners, heap-filters, humidifiers, dehumidifiers or purifiers Hydro-air vacuum Radial keratotomy Heating pads, hot water bottles, Band Aids, tape, thermometers, sterile water, bed boards, non-sterile gloves Pools, spas, whirlpools or saunas Special toilet seats Routine physical exams, screenings, procedures and immunization programs necessitated by employment, foreign travel, participation in school athletic programs, recreational camps or retreats Services rendered by the public health department, a nurse midwife, social worker or professional counselor Physical fitness, exercise, massage, ultraviolet or tanning equipment Hypo-allergenic pillows, mattresses or waterbeds Escalators, elevators, ramps, stair glides, emergency alert equipment, motor-driven chairs or beds and handrails Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

8 8 Definitions of Commonly Used Terms We know you ll come across the following terms in various sections of this guide, so we thought you d probably want to know the meaning of these words right now. As with anything, please refer to your Certificate Booklet for complete details. Benefits Summary Your Benefits Summary is a condensed listing of your medical benefits. It highlights your copay amounts, coinsurance levels, deductibles and any applicable benefit maximum amounts. You will receive your Benefits Summary prior to enrollment. Certificate Booklet This booklet summarizes your employer s health care benefits program. It s written in an easy-to-read language to help you (and those enrolled in your benefits plan) understand your health care benefits. Coinsurance Coinsurance is an arrangement where the insured person pays a fixed percentage of the cost of medical care after the deductible is paid. Copay A copay is a specified amount of money you pay at the time you receive health care services (the health care plan pays the remainder). Copay is similar to coinsurance, except coinsurance is usually a percentage of certain charges while the copay is a fixed dollar amount. For example, a copay might be $20 per visit. Some of the services that may require a copay include office visits, prescription drugs, diagnostic services, hospital stays and some therapies. Refer to your Certificate Booklet for specific requirements. Deductible This is the amount the insured person (you) must pay before your health plan pays for covered services. The deductible is usually a set amount. For example, a health plan might require a member to pay the first $300 during a calendar year before the health plan begins paying for covered services. HEDIS (Healthplan Employer Data and Information Set) This is a set of standard performance measures designed to make sure purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. A group of major employer groups and health plans developed this industry-wide set of standards. HEDIS is also the set of performance measures used by the National Committee for Quality Assurance (NCQA). In addition, NCQA coordinates the development process and acts as the focal point for HEDIS information. HEDIS data are not reported to NCQA; they are only reported to employers who request the data as part of the bid process. There are 62 HEDIS performance measures that focus on quality of care, member access and satisfaction, utilization, enrollment and disenrollment, health plan management and finance. (Health Maintenance Organization) An is a plan where a health benefits company manages all aspects of the health services of the insured which is you, the member. An is designed so each member has a primary care physician (PCP) who is responsible for the overall care of members assigned to him or her. Specialty services require a specific referral from the PCP to the specialist. Non-emergency hospital admissions also require specific preauthorization by the PCP. Typically, services aren t covered if they re performed by a provider who isn t an network provider, unless it s for an emergency situation. Our product is called BlueChoice Healthcare Plan, and it offers lower out-of-pocket costs. Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

9 A Little Background Information On NCQA 9 Out-Of-Pocket Costs These are costs, such as copays, coinsurance levels and deductibles, which you (or whomever is insured) must pay. Out-of-Pocket Maximum This is the maximum amount you pay for expenses covered under your plan. Please refer to your Benefits Summary for your specific out-of-pocket maximum. (Point of Service) A is an option offered by some health benefits companies that lets members go outside the plan s provider network for covered care, but it requires them to pay higher out-of-pocket costs than they would for in-network providers. Our product is called BlueChoice Option, and it offers in-network and out-of-network levels of coverage. Helpful Healthy Tip Eat healthy foods and plan healthy meals. Eat plenty of high-fiber, nutrient-rich fruits and vegetables. Avoid high-fat foods, watch out for too much sugar, salt and weight gain. You may recall, we briefly mentioned the National Committee for Quality Assurance (NCQA) in the HEDIS definition; but, we didn t go into too much detail about who they are and their importance. We thought you might want more information about them, so we ve included it here. Who is NCQA and What is its Significance? The NCQA is an independent, non-profit organization that reviews and reports on the quality of the nation s managed care plans. They do this by measuring the quality of care and service provided by managed health care plans like ours via an accreditation survey. Their standards help ensure you receive high quality health care and excellent service. NCQA also encourages health plans to create an environment for continuous improvement. The NCQA accreditation process evaluates how well a health plan manages quality throughout every part of its delivery system (for example, with the physicians, hospitals and providers affiliated with the plan, as well as administrative services) to continuously improve health care for you. What Does the Accreditation Mean? The NCQA accreditation survey process includes on-site and off-site evaluations of 62 HEDIS performance measures conducted by a team of physicians and managed care experts. A committee of physicians analyzes the team s findings and assigns an accreditation level based on the performance level of the health plan they are evaluating. The accreditation lets you know the care you receive and the physicians who provide that care meet or exceed the health care industry s highest standards of quality. We re happy to let you know, we recently received an accreditation status of Excellent from NCQA! Excellent is the highest possible level an organization can receive. What Else? More than 75 percent of Americans enrolled in s are in plans that have been reviewed by NCQA. And now, many employers are mandating accreditation of the plans they offer their employees. Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

10 10 Member Access Nowadays, we do so many things online pay bills, research information, even read the news. So, we thought you might also be interested in a safe, secure and confidential way to manage some of your health benefits online. Member Access is safe and confidential and lets you perform a variety of functions 24/7 including: Change your PCP View and manage your benefits Request a new member ID card Review and print an explanation of benefits (EOB) Look-up the latest medical content on the Web It s simple and takes less than five minutes to sign up! All you need to do is: 1. Go to bcbsga.com 2. Select Member 3. Click on Register Now 4. Complete the required fields and your user name and password will be generated immediately (Make sure you have your member ID card handy because you ll need your HCID/member ID and group ID numbers.) Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

11 11 Map of Service Area for our and Plans Catoosa Dade Whitfield Murray Walker Gordon Chattooga Floyd Bartow Fannin Union Gilmer Lumpkin Pickens Dawson Cherokee Forsyth Towns Rabun White Habersham Stephens Banks Franklin Hall Hart Service Area Jackson Madison Elbert Polk Haralson Carroll Heard Barrow Cobb Gwinnett Clarke Paulding Oconee DeKalb Walton Douglas Fulton Rockdale Clayton Newton Morgan Fayette Henry Coweta Jasper Putnam Spalding Butts Oglethorpe Wilkes Lincoln Greene Taliaferro Columbia McDuffie Warren Richmond Hancock Glascock Pike Lamar Baldwin Burke Troup Jefferson Meriwether Monroe Jones Washington Upson Bibb Wilkinson Jenkins Harris Crawford Screven Talbot Johnson Twiggs Emanuel Taylor Peach Muscogee Houston Laurens Bleckley Treutlen Candler Bulloch Effingham Chattahoochee Marion Macon Schley Pulaski Dooly Dodge Montgomery Evans Wheeler Toombs Stewart Bryan Webster Sumter Tattnall Chatham Wilcox Telfair Crisp Quitman Liberty Randolph Terrell Jeff Davis Lee Ben Hill Appling Long Turner Clay Calhoun Dougherty Worth Tift Irwin Coffee Bacon Wayne McIntosh Early Miller Baker Mitchell Colquitt Cook Berrien Atkinson Ware Pierce Brantley Glynn Lanier Seminole Decatur Grady Thomas Brooks Lowndes Clinch Charlton Camden Echols Information is accurate as of the publication date and is subject to change. Current information may be seen at Information is accurate Customer as of the publication Care Number date 1 and (800) is 441-CARE subject to (2273) change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

12 12 Explanation Of Benefits Post Office Box Columbus, Georgia Blue Cross and Blue Shield of Georgia, an Independent Licensee of Blue Cross Blue Shield Association John Doe 123 Main Street Columbus, Georgia EXPLANATION OF BENEFITS THIS IS NOT A BILL CHECK NO. Page: 1 Statement Date: 09/03/ Claim Number: IF YOU HAVE QUESTIONS, CALL XXX-XXXX 7:30a.m.-7:00p.m. Eastern time, Weekdays Log on to and get the power of BLUE working for you TODAY. PROVIDER OF SERVICE SERVICE DATES MARY BLUE TYPE OF SERVICE AMOUNT CHARGED AMOUMT ALLOWED PROVIDER RESPONSIBILITY NOT COVERED Employee Name: 2 Employee ID Number: Patient Name: Member ID Number (Patient): Group Name: Group Number: YOU OWE DEDUCTIBLE COINSURANCE COPAY OTHER INSURANCE PAYMENT 08/25/05 08/25/05 MEDICAL AMOUNT WE PAID SEE REMARKS THIS PRODUCT IS ADMINISTEDED BY BLUE CROSS BLUE SHIELD OF GEORGIA (BCBSGa), AN INDEPENDENT LICENSEE OF THE BLUE CROSS BLUE SHIELD ASSOCIATION. BCBSGa PROVIDES ADMINISTRATIVE CLAIMS PAYMENT SERVICES ONLY AND DOES NOT ASSUME ANY FINANCIAL RISK OR OBLIGATIONS WITH RESPECT TO CLAIMS. CALENDAR YEAR DEDUCTIBLE SUMMARY FOR CLAIMS PAID THROUGH 09/03/05 BENEFITS PAID THIS PAGE: $ INDIVIDUAL MEDICAL DEDUCTIBLE $ PAYMENT MADE TO: JOHN DOE 2005 IN-NETWORK INDIVIDUAL COINSURANCE MAXIMUM MET $ OUT-OF-NETWORK INDIVIDUAL COINSURANCE MAXIMUM MET $55.98 TOTAL LIFETIME MAXIMUM BENEFIT MET TO DATE $ REMARKS Mailing Address: Please use this address for any correspondence you send to BCBSGA. Mailing Address: Please use this address for any correspondence you send to us. Employee Information: This information includes the covered employee's name and I.D. number, patient's name and member I.D. number, employer or group name, and the employer's group number. Employee Information: This information includes the covered member s name and ID number, patient s name and member ID number, employer or group name, and the employer s group number. Provider of Service: An institution, individual, or organization that provides a medical service for you. Service Dates: Date(s) the patient received care. Provider of Service: An institution, individual, or organization that provides a medical service for you. Type of Service: This section indicates the type of care received, such as medical, surgical or laboratory. Amount Charged: The amount your provider charged for the service or care you received. Service Dates: Date(s) the patient received care. Type of Service: This section indicates the type of care received, such as medical, surgical or laboratory. Amount Charged: The amount your provider charged for the service or care you received. Amount Allowed: The portion of the amount charged that is allowed for under your contract. Information is accurate as of the publication date and is subject to change. Current information Amount Allowed: The portion may be seen of theat amount bcbsga.com. charged Customer that iscare allowed Number for under (800) your 441-CARE contract. (2273)

13 13 8 Provider Responsibility: The patient is not responsible for the payment of these charges. 9 Not Covered: Charges which are not covered under your contract and which you are responsible for paying. 8 10Provider Responsibility: You are not responsible for deductibles stated in your contract. the payment of these charges. 9 11Not Covered: Charges which are not covered under your contract and which you are responsible for paying. 12 your contract. 10 Deductible: The amount of covered expenses that you must pay before you are eligible for 13benefits. This includes all deductibles stated in your contract Coinsurance: The portion of covered services which is your responsibility to pay Copay: The fee collected at the time service is rendered by the provider. This fee is a flat dollar amount which is indicated in your contract. 16 Other Insurance: The amount of benefit dollars paid toward this claim by another insurance company due to coordination of benefits. Deductible: The amount of covered expenses that you must pay before you are eligible for benefits. This includes all Coinsurance: The portion of covered services which is your responsibility to pay. Amount We Paid: The amount we paid for the service listed on your explanation of benefits. Copay: The fee collected at the time services are rendered by the provider. This fee is a flat dollar amount which is indicated in See Remarks: A number is placed here if an explanation is needed to clarify actions taken on your claim. Other Insurance: The amount of benefit dollars paid toward this claim by another insurance company due to coordination of Benefits Paid This Page: The amount paid for all the claims listed. Amount We Paid: The amount BCBSGA paid for the service listed on your explanation of benefits. Remarks: Numbered remarks referring to the claims. General remarks without a number also may appear here. See Remarks: A number is placed here if an explanation is needed to clarify actions taken on your claim. The corresponding comments are found in the Remarks section at the bottom of this chart. Benefits Paid This Page: The amount paid for all the claims listed Remarks: Numbered remarks referring to the claims. General remarks without a number also may appear here. EXPLANATION OF HEADINGS: -FOR PROVIDER USE ONLY- UCR The difference between the amount charged and the usual, customary and reasonable allowance as defined in the provider contract. Pay Adjustment The amount of contracted discount or other fee adjustment as defined in the provider agreement. Withholds The amount to payment withheld as defined in the provider agreement. Not Covered Noncovered services for which the provider is liable. TYPE OF SERVICE (TS) F SURGICAL CENTER/AMBULATORY W PHYSICAL THERAPY 4 DIAGNOSTIC X-RAY N DONOR SERVICES Y SECOND OPINION 5 DIAGNOSTIC LAB P DME PURCHASE Z THIRD OPINION 6 RADIATION THERAPY R DME RENTAL 1 MEDICAL CARE 7 ANESTHESIA T THERAPY PSYCH 2 SURGERY 8 SURGERY ASSISTANT U OCCUPATIONAL THERAPY 3 CONSULTATION 9 OTHER MEDICAL SERVICE OTHER COVERAGE Y YES, OTHER INSURANCE IS INDICATED N NO OTHER COVERAGE INDICATED PATIENT RESPONSIBILITY Includes services not covered under the subscriber s contract deductibles and coinsurance. Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

14 14 BlueChoice Healthcare Plan () Understanding Your New Member ID Card Member Name SAMPLE SUBSCRIBER Member ID XKH123H Group Number Group Name TESTGROUP OF GEORGIA, INC. PCP Name MARCUS WELBY PCP Telephone Benefits Effective as of 01/01/2004 Co-Pays 15 OV 20 SP OV 50 ER 250 IN HOSP 20 CHIRO 10 G-RX 25 B-RX 40 NON PREF 20 MAIL G-RX 50 MAIL B-RX Dental Co-Ins 80% BASIC DEDUCT 50 Coinsurance 100% IN M&S 100% IN Dental Co-Ins 80% BASIC DEDUCT 50 Customer Service BlueChoice On-Call BLUE Healthcare Plan Your member-specific information including name, member ID number, and group name and number Your member ID is a unique set of letters and numbers and is not your Social Security number Your Plan s benefits effective date Your emergency room copay amount Your office visit copay amounts If you have questions about your benefits, please call this number Your 24/7 NurseLine Important claims filing information Important phone number for your pharmacy benefits Important Pre-admission Certification information you need to know Please note: This is a sample member ID card and may not be representative of your actual benefits. Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

15 15 How Does BlueChoice Healthcare Plan () Work? If you re like most people, you might understand the general idea of an ; however, you probably have a few questions about some of the minor details. As a member of BlueChoice Healthcare Plan (), the first thing you need to do is choose your primary care physician (PCP). Your PCP is a doctor you select from our network of providers. He or she is either a doctor in family practice, internal medicine, pediatrics or general practice. Your PCP provides and coordinates most of your health care, including routine checkups and treatment for medical problems. He or she also makes referrals to specialists and hospitals. Types of PCP Doctors You probably already know there are different doctors for different groups of patients, but do you know the difference between the most commonly visited doctors? When selecting your PCP, you choose from the specialties listed below: Family and general practice doctors treat patients of all ages. They re trained in several disciplines including internal medicine, pediatrics, gynecology, general surgery and psychiatry. Internal medicine doctors treat adults who are age 14 and older. Pediatricians treat children up to age 21. Keep in mind, each person on your plan may choose a different PCP if they want to. However, children who are younger than 14 years old must choose either a pediatrician or a family practice doctor. Choosing Your PCP Just about everyone would agree that selecting a PCP is a big decision. You re going to see this person on a semi-regular basis, and hopefully for a number of years, so choose carefully! To make things easy on you, you should consider choosing someone who has an office that s close to where you live or work. You ll also want to consider someone who has office hours that fit your schedule. One of the best ways to find a doctor is to get a referral from your friends or coworkers. Remember, this person is a key partner in helping you manage your health, so be choosy! If you had a doctor from a previous health plan, and you see that he or she is in our network, you may want to choose him or her as your PCP. But, if they aren t in our network, you ll need to choose a new PCP when you enroll. TIP: Once you ve made your decision, you may want to call the doctor s office to make sure he or she is accepting new patients. This is also a good time to talk with the doctor, or his or her staff, about their procedures for new patients, referrals and emergencies. Changing Your PCP If you want to change your PCP, it s easy. It s just a call or click away. Either way, the changes are at your fingertips! You can do one of two things. Either call (800) 441-CARE (2273), or visit bcbsga.com and make your changes in the Member Access section. If you make your change by the 25th of the month, it ll be effective the first day of the next month. You ll receive your new member ID card in the mail, and your new card will have the name and telephone number of your new PCP listed on it. Please Note: If you want to make your changes online, then you must have a username and password. If you don t have one, don t worry; just go to bcbsga.com to request one. Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

16 16 BlueChoice Healthcare Plan () Scheduling Your Visit Scheduling an appointment is really easy. Once you select your PCP and receive your member ID card, you ll see your PCP s telephone number listed on your ID card. Just call this number to schedule an appointment. That s all it takes! Preparing for Your Initial Visit The Boy Scouts of America was right on target when they picked Be Prepared as their motto. In fact, if you keep this motto in mind while you plan for your first visit with your PCP, everything should go smoothly. When you re on the telephone talking with the staff at your PCP s office, remember to ask about the documents you should bring with you. It s better to be safe than sorry. Some items you should consider bringing include: Your member ID card A list of the medicines you currently take Immunization/shot records Medical records, X-rays A completed health history form (this is usually sent by your PCP s office right after you schedule your appointment) Paying for Your Visit With Your PCP Each time you visit your PCP you need to pay your copay. You ll see the exact amount of your copay listed on your member ID card, your Certificate Booklet and on your Benefits Summary. You can also find this amount listed in the Member Access section at bcbsga.com. Receiving a Bill When you re an member, you shouldn t be billed for any authorized services you receive from your PCP beyond any required copay. SPECIALTY PHYSICIAN CARE We know there will be times in your life when you need to see a specialist. Some specialists don t require a referral from your PCP, and others do. Referrals You ll probably agree, one of the benefits of choosing an is the convenience of having your PCP make referrals and help coordinate your care. As you know, referrals from your PCP are required for your plan to cover the cost of your visits. O.K., since you now know you need a referral to see a specialty physician (in most cases), you re probably wondering how you get the referral and when you ll see the specialist? Once your PCP gives you the name of a specialist to call, you should call him or her to schedule an appointment. As for when you ll see the specialist, it depends on a couple of things: the severity of your problem and the specialist s schedule. If your PCP thinks you need immediate care, you ll get it! And, you ll see this specialist as many times as your PCP feels is appropriate. However, if you don t like the network specialist your PCP refers you to, just ask your PCP to refer you to another specialist. If you ve seen a specialist before you become a member of our plan, one of two things could happen. Your PCP may decide you should continue seeing that doctor, or your PCP may be able to treat your problem. If your PCP thinks you need to see a specialist who isn t in the network, then a referral to a non-network physician may be approved. If approved, your treatment will be covered as if you re seeing a network specialist. How to Find a Network Doctor 1. Turn to the Provider Directory portion of this book: Primary Care Physicians page Specialists: No referrals required page Specialists: Referrals required page Visit our online provider directory at bcbsga.com, it s updated weekly for your convenience Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

17 GETTING ANOTHER OPINION It s completely understandable to want a second opinion before you make a decision about your health. If you feel you need a second opinion, just remember to contact your PCP so he or she can refer you to another network specialist (and to make sure this visit is covered). You ll pay your usual copay for the second opinion visit. No Referral Required Specialists There are instances when you won t need a referral. For instance, as long as the following types of specialists are a part of the network, you won t need a referral. These include obstetricians and gynecologists (OB/GYNs), dermatologists, ophthalmologists, as well as behavioral, mental health and substance abuse specialists. 17 OB/GYN Your Benefit Covered services include pregnancy, obstetrical or gynecologicalrelated conditions and annual exams How To Receive Them As long as your obstetrician or gynecologist (OB/GYN) is in the network, your services are covered. But, if you re at least 12 weeks pregnant on the effective date of your plan and your OB/GYN is not in the network, you may continue seeing your doctor and receive in-network benefits. However, in order to receive coverage, you need to complete a Continuation of Care form. You can get a copy of this form by calling our customer care department at (800) 441-CARE (2273). You can also print a copy of this form by going to bcbsga.com. However, if you re less than 12 weeks pregnant on the effective date of your plan and your OB/GYN isn t in our network, you ll need to choose an OB/GYN who is in the network. If you see an OB/GYN who isn t in the network, then you re responsible for paying for the services you receive. Dermatologist Your Benefit Covered services include medical conditions only How To Receive Them As long as you see an in-network dermatologist for a covered medical condition (not routine care), your services are covered. However, if you see a dermatologist who is outside the network, you re responsible for paying for the services you receive. Ophthalmologist Your Benefit Covered services include medical conditions only How To Receive Them As long as you see an in-network ophthalmologist for a covered medical condition (not routine care), your services are covered. But, if you see an ophthalmologist who isn t in the network, you re responsible for paying for the services you receive. Behavioral, mental health and substance abuse specialists Your Benefit Covered services include: Mental health care Treatments for substance abuse How To Receive Them Just call (800) from 8 a.m. to 6 p.m., Monday through Friday. You should review your Benefits Summary or your Certificate Booklet to make sure this is one of the covered benefits in your plan. Although you don t have to notify your PCP when you see one of these no-referral required specialists, you may want to let him or her know you re seeing a specialist the next time you visit them. Even though you don t need a referral, you must still pay your copay. This amount is listed on your member ID card, your Certificate Booklet and in the Member Access section of bcbsga.com. Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

18 18 BlueChoice Healthcare Plan () HOSPITAL SERVICES Non-Emergency Inpatient Hospital Services As an member, you have access to a quality statewide network of health care facilities. Your Benefit If you want details about the services covered by your Group s plan, simply review your Certificate Booklet or your Benefits Summary. How To Receive Them If you need to be hospitalized, your PCP will arrange your admission to a hospital that is a part of the network. In addition, we ll talk with your network doctor about your procedure and your length of stay in the hospital. Remember, the amount you pay for hospitalization depends on your Group s coverage. Please refer to your Certificate Booklet or your Benefits Summary. EMERGENCY CARE If you experience a sudden, serious and unexpected illness, injury or health problem (such as sudden and unexpected severe pain), you may need emergency care! Your Benefit The emergency care you receive is covered if you experience an illness, injury or health problem you believe could endanger your health if you don t receive medical care immediately. This includes medically necessary mental health emergencies and emergencies associated with substance abuse. The good news is you re covered 24/7 for emergency services anywhere in the world! We define a medical emergency as a condition of recent onset and sufficient severity, including severe pain, that would lead a prudent layperson possessing average knowledge of medicine and health to believe that the condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in his or her health being in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ. How To Receive Them Call 911 or go immediately to the emergency room of the nearest hospital or emergency facility. If you aren t admitted to the hospital, but you re treated and discharged, you ll need to pay your emergency room copay. However, if you are admitted, the copay is waived. Your PCP should be notified within 48 hours of receiving emergency care. We suggest you don t go to the emergency room for conditions that aren t medical emergencies because non-emergency use of the emergency room is not a covered benefit. If you re unsure if it s an emergency, call your PCP or our 24/7 NurseLine, at (888) 724-BLUE (2583). Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

19 19 NON-EMERGENCY OUTPATIENT SERVICES Your Benefit If you need to have one of the following services, don t worry because you re covered. These services include: Pre-admission tests Surgery Diagnostic X-rays Laboratory services How To Receive Them Your network physician will coordinate your admission for outpatient services. OTHER SERVICES members also have access to a group of ancillary providers, such as labs, medical equipment companies, home health agencies and others. If there isn t a network provider in your area, your network doctor will request approval for use of a non-network provider. If his or her request is approved, then you ll only be responsible for your copay. And remember, your PCP or specialist is the one who coordinates the care you receive from ancillary providers. Helpful Healthy Tip Be proactive about your health. Remember to keep up with the health screenings your doctor recommends. Visit your doctor as soon as you notice a troubling symptom. Try to learn all you can about your health and medical needs. If you develop an illness, discuss all treatment options with your doctor. Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)

20 20 BlueChoice Option Point-of-Service () Understanding Your New Member ID Card Member Name SAMPLE SUBSCRIBER Member ID XKH123H Group Number Group Name TESTGROUP OF GEORGIA, INC. PCP Name MARCUS WELBY PCP Telephone Benefits Effective as of 01/01/2004 Co-Pays 15 OV 20 SP OV 50 ER 250 IN HOSP 20 CHIRO 10 G-RX 25 B-RX 40 NON PREF 20 MAIL G-RX 50 MAIL B-RX Dental Co-Ins 80% BASIC DEDUCT 50 Coinsurance 100% IN M&S 100% IN Dental Co-Ins 80% BASIC DEDUCT 50 Customer Service BlueChoice On-Call BLUE Option Your member-specific information including name, member ID number, and group name and number Your member ID is a unique set of letters and numbers and is not your Social Security number Your Plan s benefits effective date Your emergency room copay amount Your office visit copay amounts If you ha ve q ue st ions about your benefits, please call this n umbe r Yo ur 2 4/7 NurseLine Impo rt ant claims filing information Impo rt ant p hone n umber for your pharmacy benefits Impo rt ant Pre-admis sion C er tification i nformation y ou need to k now Please note: This is a sample member ID card and may not be representative of your actual benefits. Information is accurate as of the publication date and is subject to change. Current information may be seen at bcbsga.com. Customer Care Number (800) 441-CARE (2273)