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BCBSGa PPO Plan FAQs
1. How do I get additional information about my plan or benefits?
You can verify your benefits using our on-line service, Member Access. You will need to register for a username and password if you haven't already done so. You can also call customer service at the number listed on your member ID card from 7 AM to 7 PM, Monday through Friday (excluding holidays).
2. How and when can I contact the health plan?
Our friendly, helpful and knowledgeable customer service associates are available to answer your questions from 7 AM to 7 PM, Monday through Friday (excluding holidays). Simply call the customer service number listed on your member ID card for assistance, or email us at websupport@bcbsga.com.
3. How do I change my name or address?
To change your address, simply call the customer service number listed on your member ID card. Our customer service associates stand ready to help you with your needs. If you need to change your name, you will need to complete a Member Change form and submit legal documentation as well. Customer service can provide you with the appropriate form.
4. What are your customer service hours?
Our associates are available from 7 AM to 7 PM, Monday through Friday (excluding holidays).
5. How do I get a provider directory?
You can search our provider directory 24-hours a day, seven-days a week, or you can call customer service and request a printed version be sent to your home or office.
6. How do I get a list of preferred drugs (formulary information)?
A list of the most commonly prescribed formulary drugs is available on our Web site. This list is updated throughout the year. You can also contact our customer service associates to find if a particular drug is included on our formulary. The phone number for customer service is listed on your member ID card.
Enrollment
1. How can I cover my newborn from birth?
First, congratulations on the birth of your baby! To add your child to your health care coverage policy, simply contact your group administrator or customer service within the first 31 days after your baby's birth. If you do not add your baby within the first 31 days, you will have to wait until your company's next open enrollment period. To complete your newborn's enrollment, you will need to complete a member change form.
2. How do I obtain coverage for my newly adopted child?
All you need to do is contact your group administrator or customer service within the first 31 days of the official adoption date. If you do not add your baby within the first 31 days, you will have to wait until your company's next open enrollment period. Legal documentation of the adoption will be required to complete your new child's enrollment.
3. How do I add or delete family members?
Please contact your group administrator or call customer service at the number listed on your member ID card. You will need to complete a member change form to add or delete dependents.
4. Can I cover a dependent who lives out-of-state or my child away at school?
As a member of our PPO plan, you and your child (until the age of 26) have the advantage of using our BlueCard PPO program to receive health care coverage in most areas of the U.S. To learn more information about the BlueCard Program, access details through http://www.bluecares.com/ the Blue Cross Blue Shield Association's Web Site. Simply click on the BlueCard Doctor & Hospital Finder hotlink and complete the requested information to locate a PPO provider as close as five miles away from your location. You can also call 1-800-810-BLUE to locate a provider. For your convenience, this number is also printed on the back of your member ID card.
5. How often can I change benefit plans?
You may only change benefit plans during your company's open enrollment period, unless you have a life event change either through marriage, or the birth or adoption of a child. Changes in family status allow persons to enroll who were not previously enrolled.
6. How long can my children remain covered?
Your children remain covered if they are unmarried, under 19 years old, or until age 26 if they are full-time students at an accredited school. Please see your Certificate Booklet for more details.
7. How long can my child be covered if he or she has disabilities?
If your child has a physical handicap or mental retardation and reaches the age limits (19 years, 26 years if in college), your child can continue coverage if he or she is: covered under this plan, still dependent on you or your spouse, not able to get a job to self-support him or herself because of the handicap or mental retardation. Please see your Certificate Booklet for more details.
ID Cards
1. How do I order additional ID cards?
Simply visit the Member Access portion of this Web site. If you do not have a username and password to the service, request one today and then call customer service to request a replacement member ID card(s), or request one by emailing us at websupport@bcbsga.com.
2. Do I need to carry my ID card with me at all times?
While it's not a requirement, it is good practice to have your member ID card with you in the event of an emergency. However, if you do have an emergency and do not have your member ID card, do not worry, your provider of care can call Blue Cross Blue Shield Healthcare Plan of Georgia to verify your benefits.
Providers
1. How do I find a network provider?
You have three options:
Visit our on-line Provider Directory and follow the steps to find the provider of your choice.
Look in the printed BlueChoice Healthcare Plan/BlueChoice Option Provider Directory.
Call the toll-free customer service number on your member ID card.
2. What is a primary care physician?
A Primary Care Physician (PCP) is the doctor you choose to provide and/or coordinate most of your medical care. Under the PPO plan, you are not required to select a Primary Care Physician (PCP) and no referral is needed to see a specialist.
3. What are the advantages of using network providers?
By using a PPO network provider, your covered services will be paid at the higher in-network benefit level. Additionally, the network provider will file your claims for you. Check your member ID card, Benefit Summary or Certificate Booklet to review your co-payment amount and the level of coverage allowed for the use of network providers.
4. What happens if my current physician is not a network provider?
Under the PPO plan, you may continue to see your current physician. However, you will receive the greatest benefit when you use a network provider. You also have the opportunity to nominate your physician to become apart of our network by calling the customer service number listed on your member ID card.
5. Can I go to a non-network provider?
Yes, when visiting a non-network provider the services received are paid under the out-of-network deductible and coinsurance provisions of your coverage. However, you will receive the greatest benefit when you use a network provider.
Approvals and Referrals
1. What services require prior approval or a referral?
When you use a network physician or hospital, they are responsible for ensuring that any surgical procedure or inpatient admissions receive the necessary prior approval. When using an out-of-network physician and hospital, it is your responsibility to receive prior approval from Blue Cross and Blue Shield of Georgia for home health care services and inpatient care (excluding maternity related care) prior to these services being rendered.
2. How do I get prior approval or a referral?
You or your physician can obtain prior approval for all hospital admissions and selected outpatient surgical procedures by calling our Pre-Admission Certification (PAC) line at 1-800-722-6614.
3. What if I don't get prior approval or a referral?
If you are admitted to a network hospital and receive treatment and the hospital did not obtain prior approval, they, the hospital is liable for all charges. If you are admitted to a non-network hospital and receive treatment and did not receive prior approval, you are liable for all denied charges.
Emergency Care
1. What do I do in case of an emergency?
Call 911 or go to the nearest hospital emergency room. You, or someone else, should call your PCP the next business day to inform him/her of the visit and arrange follow-up care.
2. Do you cover emergency care?
Yes. If you or a covered family member has a medical emergency, you should call 911 or go to the nearest emergency room for immediate care.
A medical emergency is defined as "a condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that failure to obtain immediate medical care could result in their health being in serious jeopardy, serious impairment of bodily functions, or serious dysfunctions of any bodily organ."
Non-emergency use of the emergency room is covered at 90%, after a co-pay and deductible.
Travel Coverage
1. What do I do if I need care while traveling?
If you have an emergency while traveling, you should call 911 or go to the nearest hospital emergency room for treatment. If you become ill or need urgent care, call BlueCard Access at 1-800-810-BLUE (2583). When you arrive at the participating doctor's office or hospital, simply present your member ID card.
2. What routine coverage do I have while I am traveling?
Specific benefits vary from plan to plan but rest assured that if you have an emergency or need urgent care, you are covered. If you have a specific question, please call customer service at the number listed on your member ID card.
3. What emergency coverage do I have while I am traveling?
If you have a medical emergency while away from home, you are covered. All you need to do is call 911 or go to the nearest hospital emergency room for treatment.
Pharmacy
PPO members have prescription drug coverage through an extensive pharmacy network that includes select local pharmacies and many national chains. Coverage is provided according to our Preferred Drug Benefit.
Please check your Benefit Summary or Contract Booklet to be sure that you have prescription drug coverage through BCBSGA.
1. How do I get prescriptions filled through a mail order pharmacy?
Fill out a mail order form and return it to PrecisionRx at P.O. Box 961025, Fort Worth, Texas, 76161-9863. Their toll-free number is (866) 274-6825. You may order refills via their Web site at precisionrx.com. The processing of your prescriptions will take 10-14 days.
Special Note: Please confirm with your employer or review your Certificate Booklet to ensure you have the mail order pharmacy benefit. Mail order is available for maintenance drugs only, as classified by the Federal Data Bank.
2. What is the difference between generic and brand name drugs and how does that difference affect my benefits?
Brand name drugs are those drugs that are marketed under a specific trade name by a pharmaceutical manufacturer. In most cases, these drugs are still under patent protection, meaning the manufacturer is the sole source for the product. Generic drugs are safe, effective and equivalent to brand name medications that may cost considerably less than the brand name medications. Generic drugs must meet the same high standards of quality as brand name drugs and are formulated to have the same effect in the body as the brand name version. Generic drugs often become available when a brand name drug's patent expires.
The difference in your benefits is the amount of your copay. Generally, the cost of your copay for generic drugs is less than that of brand name drugs.
3. Can I get reimbursed for drugs I got from a pharmacy not in the network?
It will cost you more if you go to an out-of-network pharmacy. Take a claim form with you to the out-of-network pharmacy. If you need a claim form, you can download one from our Forms section of this Web site. Once completed, fax the claim form to 1.877.868.7950 or by mailing to P.O. Box 9907, Columbus, GA 31908-6007.
4. If I am going to be out of town for an extended time, how do I get an extra supply of drugs to cover me through that period?
If you are out of state and you need medicine, call the customer service number on your member ID card to find a nearby participating national pharmacy. If there is not a national pharmacy, pay for the prescription and send us a claim form. If you are planning to go out of the country, go to your local network pharmacy prior to your trip. Pay for the extra supply and send us a claim form. If you should need to purchase drugs while out of the country, pay for drug, and send us a copy of the letter indicating your prescription, receipt and a claim form.
5. What is a drug formulary (or preferred drug list) and how does that affect me?
A prescription drug formulary is used to help your doctor make prescribing decisions. This list of drugs is updated quarterly by a committee of doctors and pharmacists so that the list includes drugs that are safe and effective in the treatment of disease. The goal of the formulary list of prescription drugs, as established for the Pharmacy Program, is to identify and promote prescription drugs which are therapeutically appropriate and cost-effective.
Claims
1. How do I file a claim?
If you visit a network provider, they will file the claim for you. In the HMO plan, there are no covered benefits if you visit a non-network provider.
Under the POS plan, if you visit an out-of-network provider, you may need to pay for the services in full at the time they are rendered. You will then need to file a claim with Blue Cross Blue Shield Healthcare Plan of Georgia for reimbursement. Visit our Forms section to download and print a claim form. Simply complete and fax to 1.877.868.7950.
2. How long do I have to file a claim?
Claim forms submitted by the member or a provider must be received by us within 90 days of the date the expense is incurred in order to be eligible for benefits. If it is not reasonably possible to submit the claim within that time frame, an extension of up to twelve months will be allowed. We are not liable for the benefits of the plan if claims are not filed within this time period.
3. A provider has billed me; how do I know how much of the bill to pay?
As a PPO plan member, you are responsible for the charges incurred minus your co-insurance when using an out of network provider. Please call customer service at the number listed on your member ID card for assistance.
4. How can I check the status of my claim?
Visit the Member Access page of this Web site. To safeguard your personal information, you must have a username and password to use Member Access. If you do not already have one, you can request one be sent to you. You can also call customer service at the number listed on your member ID card to check on the status of your claim.
5. What are copayments?
A copayment is a cost-sharing arrangement in which a member pays a specified charge for a covered service, such as $20 for an office visit. The member is usually responsible for payment of the copayment at the time the health care is rendered. Typical copayments are fixed or variable flat amounts for physician office visits, prescription drugs or hospital services. Copayments are distinguished from coinsurance as flat dollar amounts rather than percentages of the charges for services rendered.
6. What is Coordination of Benefits (COB)?
Coordination of Benefits (COB) is the anti-duplication provision to limit benefits for multiple group health insurance in a particular case to 100% of the covered charges and to designate the order in which the multiple carriers are to pay benefits. Under a COB provision, one Plan is determined to be primary and its benefits are applied to the claim. The unpaid balance is usually paid by the secondary Plan to the limit of its liability. Benefits may be coordinated between two contracts at the same Blue Plan, different Blue Plans or between a Blue Plan and a commercial carrier.
7. Why did I receive a Coordination of Benefit questionnaire and do I have to return it?
The Coordination of Benefit Questionnaire is used to determine if you are covered by more than one group health insurance carrier. Please fill it out and return to us so that we may process your claims correctly.
8. What do I do with a foreign medical bill for care I received outside of the U.S.?
When receiving services in a foreign country, the member should ask for the claim to be written in English and:
Submit the itemized bill with the policyholder's ID number clearly displayed. A claim form may also be submitted with the itemized bill if it is available, but it is not required.
Use a separate form for each enrolled family member and each provider of service.
Submit the form to the customer service address printed on your member ID card.
BCBSHP is not able to pay benefits in the local currency of the claims submission site. The claims amounts are converted into dollars using the Wall Street Journal exchange rate on the day services were rendered.
Grievances and Appeals
1. What is the procedure for lodging a grievance against a provider or against the Plan?
Fax the details of your grievance to 1.877.868.7950 or call the customer care number on your member ID card. Your inquiry should be resolved within 21 calendar days.
2. How do I express dissatisfaction regarding a denial of services?
As a member, you have a right to express dissatisfaction and to expect fair resolution of your issues. BCBSGa established the inquiry, formal complaint, and appeal process to be used any time you are displeased with any aspect of services rendered:
Inquiry: You may call customer care at the phone number listed on your member ID card. Describe your concern and we will make every effort to respond within 21 calendar days.
Formal complaint: If you are not satisfied with our response, you may file a formal complaint, preferably, in writing. Fax the details of your request, along with supporting documentation, to 1.877.868.7950 or you may call customer care number on your member ID card.
Appeal: If you choose to appeal, your written request with comments, documents, records, or other relevant information should be faxed to 1.877.868.7950. The request may also be mailed to BCBSGa, PO Box 9907, Columbus GA 31908.
At the conclusion of this appeal review, a written response addressing your specific concerns will be provided within 30 calendar days of receiving your request.
3. What if waiting for you to decide on my appeal would harm my health?
If your condition is of emergent or urgent nature, you, along with your physician will decide on the most appropriate treatment plan.
4. My Explanation of Benefits (EOB) says I received services that I did not have. What should I do?
Call the customer service number located on your member ID card. Our associates will review your EOB and fix any errors that may have occurred.
General Information
1. What happens to my coverage if I move out of the area?
Please call customer service and request that your information is updated with your new address. You may also need to change your PCP is his/her location is no longer convenient to your home or office.
2. What happens to my coverage if I quit my job or I'm laid off or fired?
For companies with more than 20 full time employees, you can pay to continue, for a limited time, exactly the same benefits you have while employed, through a federal law called COBRA. Your employer must provide you with detailed information regarding the terms, cost and duration of COBRA benefits upon termination of your employment. For companies with 2-19 full time employees, you may receive Georgia Continuation Rights for 90 days.
3. What happens to my coverage if I turn 65?
If you are age 65 or over and eligible for Medicare, you will get the benefits of this plan without taking into account Medicare unless you've chosen Medicare as your primary plan. If you've chosen Medicare as your primary health plan, you won't be able to get any benefits under this plan.
4. What happens to my coverage if I retire?
You may be able to continue your coverage for a limited time. See answer number 3 (General Information) above. Ask your employer for more information. Your employer will let you know that you may have a right to keep your health plan under COBRA. You should know that you might have to pay the whole cost of staying on the health plan.
5. What if I become disabled?
If you are a totally disabled subscriber or a totally disabled family member and under the treatment of a physician on the date of discontinuance of the Group Benefit Agreement issued by us to your company, your benefits will be continued for treatment of the totally disabling condition. Please refer to your Certificate Booklet for more details.
6. What if my spouse and I divorce?
Your family members may continue coverage for a limited time, through COBRA, if you are divorced or legally separated. Ask your employer for more information.
7. Is my child covered while in college?
Your unmarried child is covered until his or her 26th birthday while in college, provided that he or she is enrolled as a full-time student.
8. Do I have coverage for pre-existing conditions?
Until a member has had "creditable coverage" for 12 consecutive months, benefits for service shall not be available for any illness, injury or condition for which medical advice or treatment was recommended by, or received from, a health care provider within six months preceding the effective date of coverage (excepting maternity services, for which the pre-existing condition limitation is not applicable.)
9. How do I know what benefits are non-covered?
The following items represent a generic list of non-covered items. For a complete list, please refer to your Certificate Booklet.
Acupuncture- Although not covered, BCBSGa does offer discounted health and wellness services.
Blood pressure monitor correct
Smoking cessation and add weight loss programs. Although not covered, BCBSGa does offer several wellness programs to assist with your goals.
Eye refraction
Air filters
Central or unit air conditioners, Hepa-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 and or sauna's
Special toilet seats
Routine physical exams, screenings, procedures and immunizations necessitated by employment, foreign travel, participation in school athletic programs, recreational camps or retreats
Services rendered by public health department, nurse midwife, social worker and or professional counselors
Physical fitness, exercise, massage, ultraviolet and or tanning equipment
Hypo-allergenic pillows, mattresses and or waterbeds
Escalators, elevators, ramps, stair glides, emergency alert equipment, motor-driven chairs or beds, and or handrails
Note, even if these services are deemed as medically necessary, if it is excluded from your contract, your benefits do not provide coverage of these items.
Please review your Certificate Booklet or contact your Employer Representative with questions.
Members Rights and Responsibilities
1. As a Blue Cross and Blue Shield of Georgia (BCBSGA) BlueChoice PPO member, you have the right to:
Recommend changes to the Member’s Rights and Responsibilities policy.
Receive information about the Plan, its services, its providers and about your rights and responsibilities as a member.
Choose your personal physician from the Plan’s network directory listing participating providers and change your personal physician.
Receive considerate and courteous service with respect for personal privacy and human dignity through the Plan in a timely manner.
Expect the Plan to implement policies and procedures to ensure the confidentiality of all your personal health information.
Understand where your consent is required and when you are unable to give consent, the Plan will seek your designated and/or guardian/representative to provide this consent.
Participate in full discussion with your provider concerning the diagnosis, appropriate or medically necessary treatment options, and the prognosis of your conditions, regardless of whether or not the information represents a covered treatment or benefit.
Receive and be informed about where, when and how to obtain all benefits to which you are entitled under your contract, including access to routine services, as well as after-hours and emergency services.
Be informed of your premiums, deductibles, copays and any maximum limits on out-of-pocket expenses for items and services.
Receive Plan rules regarding copays and pre-certification including, but not limited to, pre-certification, concurrent review, post-service review or post-payment review that could result in your being denied coverage for a specific service.
Participate with providers in the decision-making process concerning your health care.
Refuse treatment and be informed by your physician of the medical consequences.
Receive specific information, upon your request, from network providers including, but not limited to, accreditation status, accessibility of translation or interpretation services, and credentials of providers of direct care (limited to contracted providers). BCBSGA encourages network providers to disclose such information upon member request.
Receive, upon request, a summary of how physicians, hospitals and other providers are compensated using a variety of methodologies, including capitation, fee-for-service, per diem, discounted charges and global reimbursement.
Express your opinions, concerns, or complaints about the Plan and the care provided by network providers in a constructive manner to the appropriate people within the Plan and be given the right to register your complaints and to appeal Plan decisions.
Receive, upon request, a summary of the number, nature and outcome of all formally filed grievances filed with the Plan in the previous three years.
Receive timely access to medical records and health information maintained by the Plan in accordance with applicable federal and state laws.
2. As a BCBSGA, BlueChoice PPO member, you have the responsibility to:
Understand your health problems and participate in developing mutually agreed upon goals—to the degree possible.
Maintain your health and participate in the decisions concerning treatment.
Ask questions and make certain that you understand the explanations and instructions you are given by your physician, and comply with those conditions.
Identify yourself as a member when scheduling appointments or seeking specialty care, and pay any applicable physician office copay at the time of service and coinsurance or out-of-pocket expenses in a timely manner.
Keep scheduled appointments or give adequate notice of delay or cancellation.
Furnish information regarding other health insurance coverage.
Treat all network physicians and personnel respectfully and courteously as partners in good health care.
Permit BCBSGA to review your medical records as part of quality management initiatives in order to comply with regulatory bodies.
Provide, to the extent possible, information that the Plan and its providers need in order to care for you.
Follow the plans and instructions for care that you have agreed on with your physician(s).
 contact or email us!
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