2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 10. Definitions of Terms We Use in This Brochure
Page 137
Section 10. Definitions of Terms We Use in This Brochure
Page 137
- For non-emergency medical services performed in Preferred hospitals provided by physicians and other covered healthcare professionals identified under the NSA (see Section 4) that do not contract with your local Blue Cross and Blue Shield Plan and cannot balance bill you under this regulation, our allowance is equal to the lesser of the billed amount or the qualifying payment amount (QPA) determined in accordance with federal laws and regulations;
- For emergency medical and mental health and substance use disorders services performed in the emergency department of a hospital provided by physicians and other covered healthcare professionals, and air ambulance providers that do not contract with your local Blue Cross and Blue Shield Plan, our allowance is equal to the lesser of the billed amount or the qualifying payment amount (QPA) determined in accordance with federal laws and regulations;
- For services you receive outside of the United States, Puerto Rico, and the U.S. Virgin Islands from providers that do not contract with us or with the Overseas Assistance Center (provided by Geo-Blue), we use our Overseas Fee Schedule to determine our allowance. Our fee schedule is based on a percentage of the amounts we allow for Non-participating providers in the Washington, D.C., area, or a customary percent of billed charge, whichever is higher.
Important notice about using Non-participating providers!
(These providers are only covered on an exception basis)
Note: Using Non-participating or Non-member providers (Non-preferred) when an exception is granted (see Section 3) could result in your having to pay significantly greater amounts for the services you receive. Non-participating and Non-member providers are under no obligation to accept our allowance as payment in full. If you use Non-participating and/or Non-member providers, you will be responsible for any difference between our payment and the billed amount (except in certain circumstances involving covered Non-participating professional care – see below). In addition, you will be responsible for any applicable deductible, coinsurance, or copayment. You can reduce your out-of-pocket expenses by using Preferred providers whenever possible. To locate a Preferred provider, visit www.fepblue.org/provider to use our National Doctor & Hospital Finder, or call us at the customer service phone number on the back of your ID card. We encourage you to always use Preferred providers for your care.
Note: For certain covered services from Non-participating professional providers, your responsibility for the difference between the Non-participating Provider Allowance (NPA) and the billed amount may be limited. See Section 4, Important Notice About Surprise Billing.
Post-service claims
Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.
Precertification
The requirement to contact the local Blue Cross and Blue Shield Plan serving the area where the services will be performed before being admitted for inpatient care. Please refer to the precertification information listed in Section 3.
Preferred provider organization (PPO) arrangement
An arrangement between Local Plans and physicians, hospitals, healthcare institutions, and other covered healthcare professionals (or for retail pharmacies, between pharmacies and CVS Caremark) to provide services to you at a reduced cost. The PPO provides you with an opportunity to reduce your out-of-pocket expenses for care by selecting your facilities and providers from among a specific group. PPO providers are available in most locations; using them whenever possible helps contain healthcare costs and reduces your out-of-pocket costs. The selection of PPO providers is solely the Local Plan’s (or for pharmacies, CVS Caremark’s) responsibility. We cannot guarantee that any specific provider will continue to participate in these PPO arrangements.
Pre-service claims
Those claims (1) that require precertification or prior approval, and (2) where failure to obtain precertification or prior approval results in a reduction of benefits.