June 12, 2019

What is Blue Cross and Blue Shield (Blue) MA PPO Network Sharing?

All Blue MA PPO Plans participate in reciprocal network sharing. This network sharing allows all Blue MA PPO members to obtain in-network benefits when traveling or living in the service area of any other Blue MA PPO Plan as long as the member sees a contracted MA PPO provider.

What does the Blue MA PPO Network Sharing mean to me?

If you are a contracted MA PPO provider with BlueCross BlueShield of South Carolina and you see MA PPO members from other Blue Plans, these members will be extended the same contractual access to care and will be reimbursed in accordance with your negotiated rate with your BlueCross BlueShield of South Carolina contract. These members will receive in-network benefits in accordance with their member contract.

If you are not a contracted MA PPO provider with BlueCross BlueShield of South Carolina and you provide services for any Blue MA members, you will receive the Medicare allowed amount for covered services. For urgent or emergency care, you will be reimbursed at the member’s in-network benefit level. Other services will be reimbursed at the out-of-network benefit level.

How do I recognize an out-of-area member from one of these Plans participating in the Blue MA PPO network sharing?

The MA in the suitcase indicates a member who is covered under the MA PPO network sharing program. Members have been asked not to show their standard Medicare ID card when receiving services. Instead, members should provide their Blue Cross and/or Blue Shield member ID.

Do I have to provide services to MA PPO members from these other Blue Plans?

If you are a contracted MA provider with BlueCross BlueShield of South Carolina, you should provide the same access to care as you do for BlueCross BlueShield of South Carolina MA PPO members. You can expect to receive the same contracted rates for such services.If you are not a BlueCross BlueShield of South Carolina MA contracted provider, you may see Blue MA members but you are not required to do so. Should you decide to provide services to Blue MA members, you will be reimbursed for covered services at the Medicare allowed amount based on where the services were rendered and under the member’s out-of-network benefits. For urgent or emergency care, you will be reimbursed at the in-network benefit level.

What if my practice is closed to new local Blue MA PPO members?

If your practice is closed to new local Blue MA PPO members, you do not have to provide care for Blue MA PPO out-of-area members. The same contractual arrangements apply to these out-of-area network sharing members as your local MA PPO members.

How do I verify benefits and eligibility?

• Call BlueCard Eligibility at 1-800-676-Blue (2583) and provide the member’s prefix located on the ID card.
• You can also use the online tool, My Insurance Manager^SM, to access the following for BlueCross BlueShield of South Carolina members: Benefits and Eligibility, Claims Entry, Prior Authorization Request and Status, Claims Status, Remittance Information, Your Mailbox, and EDI Reports.
  
  This valuable tool can be freely accessed after you have registered with a valid Tax ID number in our system as described below. Secure encryption technology ensures that any information you send or receive is completely confidential. My Insurance Manger can provide you with eligibility information and general benefits for BlueCross BlueShield of South Carolina MA members. It can also give eligibility information and general benefits at the service-type level for BlueCard^® members. This system is not available while weekly maintenance is performed on Sunday evenings from 5 p.m. until midnight.

If you experience difficulty obtaining eligibility information, please record the prefix and report it to Provider Services at 800-868-2510.

Where do I submit the claim?

You should submit the claim to BlueCross BlueShield of South Carolina under your current billing practices. Do not bill Medicare directly for any services rendered to a Blue MA member.

What will I be paid for providing services to these out-of-area MA PPO network sharing members?

If you are a MA PPO contracted provider with BlueCross BlueShield of South Carolina, benefits will be based on your contracted MA PPO rate for providing covered services to MA PPO members from any MA PPO Plan. Once you submit the MA claim, BlueCross BlueShield of South Carolina will work with the other Blue Plan to determine benefits and send you the payment.

What will I be paid for providing services to other MA out-of-area members not participating in the MA PPO Network Sharing?

When you provide covered services to other MA PPO out-of-area members not participating in network sharing, benefits will be based on the Medicare allowed amount. Once you submit the MA claim, BlueCross BlueShield of South Carolina will send you the payment. However, these services will be paid under the member’s out-of-network benefits unless for urgent or emergency care.

What is the member cost sharing level and co-payments?

Claims for MA PPO members who see MA PPO contracted providers in the BlueCross BlueShield of South Carolina network will pay at the same cost sharing level (in-network cost sharing) they would pay if they received covered benefits from any MA PPO in-network providers. You can collect the co-payment amounts from the member at the time of service.

May I balance bill the member the difference in my charge and the allowance?

No, you may not balance bill the member for this difference. Members may be billed for any deductibles, co-insurance, and/or co-pays.

What if I disagree with the reimbursement amount I received?

If there is a question concerning the reimbursement amount, contact your local Plan at 800-868-2510. We will coordinate with the respective Blue plan when necessary on your behalf.

Who do I contact if I have a question about MA PPO network sharing?

If you have any questions regarding the MA program or products, contact BlueCross BlueShield of South Carolina at 800-868-2510.