|
 |
| July 18, 2013 |
|
|
Important change to claims processing for PPO plans |
|
Effective November 1, 2013, members who have claims submitted by providers who participate in the Highmark Blue Shield (Highmark) professional provider network inside IBC's five-county service area will be subject to higher out-of-pocket costs and may also be subject to balance billing. Currently, claims submitted by a participating Highmark professional provider are processed as out of network and applied to a member's out-of-network deductible. These participating Highmark professional providers do not balance bill IBC members for covered services.
While members may continue to receive care from a Highmark participating professional provider, the following changes will apply for claims with dates of service on or after November 1, 2013:
- Claims for covered services from Highmark professional providers inside IBC's five-county service area (Philadelphia, Bucks, Chester, Montgomery, and Delaware counties) will continue to be processed as out-of-network claims. However, participating Highmark professional providers may balance bill members for the difference between what they charge for covered services and the allowed amount the IBC plan pays. Balance billing by out-of-network providers can significantly increase a member's out-of-pocket costs.
- Claims for covered services from Highmark professional providers outside IBC's five-county service area will be processed the same way they are today. There will be no impact to claims for covered services outside the Philadelphia five-county area.
While the current claims processing arrangement was originally developed to ensure members had expansive access to doctors and hospitals in IBC's five-county service area, IBC has since expanded its Personal Choice network to include a significant percent of Highmark's participating professional providers.
Since utilization of Highmark professional providers is relatively low among our Personal Choice membership, the majority of PPO members will not be impacted. In the past 12 months, only a small fraction of IBC's 424,000 PPO members have submitted claims from a participating Highmark professional provider. Further analysis shows that 45 percent of members who have used a Highmark professional provider in the past 12 months have submitted only one claim.
We understand that members who visit a Highmark professional provider may have concerns about any additional out-of-pocket costs they will incur due to balance billing. The three participating Highmark professional provider types most visited were chiropractors, behavioral health professionals, and physical therapists. Members can choose from more than 55,000 Personal Choice in-network doctors and specialists to help them lower their out-of-pocket costs, including 743 chiropractors, 3,215 behavioral health professionals, and 1,429 physical therapists.
Members can find a complete list of participating providers by visiting ibxpress.com or calling Customer Service at 1-800-ASK-BLUE (1-800-275-2583).
Communications
We are notifying customers and members about this change to their contract later this week.
Self-funded customers will receive an addendum to their Administrative Services Agreement, and we are reaching out to them to discuss the business impact on an individual basis. Fully insured group customers and group members will receive a letter notifying them about the change.
If you have any questions, please contact your IBC account executive.
|
