Your BCBSIL Hospital/Doctor PPO
The Trustees of your Plan have a contract with the Blue Cross and Blue Shield of Illinois Preferred Provider Organization (BCBSIL PPO) which allows you and your covered dependents to receive inpatient and outpatient care from BCBSIL PPO doctors and hospitals (“in-network providers”) at negotiated rates. You don’t have to use in-network providers – the choice of a doctor or hospital is solely up to you. However, if you do, both the Plan and you will save money because of the PPO’s negotiated rates. Also, you will save money because you will avoid the out-of-network hospital penalty, and your out-of-pocket expenses will, in most cases, be lower. Also, non-network providers may balance bill you for amounts above the Allowable Charge covered by the Plan. (In any event, the fact that a doctor or hospital is in-network or out-of-network is not a statement as to the ability of the provider).
FINDING PROVIDERS IN THE BCBSIL PPO NET-WORK
For a current list of in-network hospitals or doctors near you, you can:
- Call BCBSIL at 1 (800) 810-BLUE (2583), or
- Visit the BCBSIL website at www.bcbsil.com
Since In-network providers change from time to time, you should call the provider to verify their continued participation in the BCBSIL PPO before receiving the services.
A penalty will apply if you use a hospital that does not participate in the BCBSIL PPO.
USING BCBSIL PPO PROVIDERS
- Be sure to show the doctor or hospital your BCBSIL PPO I.D. card. Failure to show your I.D. card could cause a delay in claim processing.
- In-network providers should not ask you to make payment up front unless you have failed to show your I.D. card. (If you show your card and an in-network provider asks for payment, please con-tact the Fund Office immediately.)
Because of the negotiated rates, you will not be able to determine the amount you are responsible for before the claim has been processed by BCBSIL. Wait until you receive an Explanation of Benefits showing the amount you are responsible for before paying a bill from an in-network provider.
All doctors and hospitals must send their bills directly to Blue Cross and Blue Shield of Illinois at the address shown on your BCBSIL I.D. Card.
- The rules of the Medical Care Review Program apply whether or not the provider is in the BCBSIL PPO network.
WHAT HAPPENS IF YOU USE AN OUT-OF-NETWORK (NON-PPO) PROVIDER
Out-of-Network Hospitals
Each time you or a covered family member goes to an out-of-network hospital for a non-emergency inpatient stay or for non-emergency outpatient care, an additional penalty ($250 under the Active Plan and $300 under the Retiree Comprehensive Plan) will apply to the covered medical expenses incurred for the care. This penalty does not apply if the treatment was due to an emergency, or if the person lives outside the state of Illinois.
Services Received at an In-Network Hospital
Covered hospital-based services provided at an in-network hospital will be paid as in-network claims even if the provider is out-of-network (example, a pathologist or radiologist).
*Important* Out-of-Network Surgical Facilities
The Plan excludes all charges by surgical facilities that are not in the BCBSIL PPO network.
All Other Out-of-Network Providers
When you use a provider that is not in the BCBSIL PPO network, your out-of-pocket share of the expenses will most likely be higher because:
- Out-of-network providers can charge you more than the BCBSIL negotiated rates, and you will be responsible for the excess amounts.
- In addition, your co-payment percentage shares for out-of-network hospital and doctor expenses will not apply to your out-of-pocket limit, and the Plan will not pay 100% for out-of-network expenses after your out-of-pocket limit is met.