Blue Advantage (PPO) Information

Blue Advantage (PPO) Complete and Premier

This directory provides a list of Blue Advantage’s network providers. To get detailed information about your health care coverage, please see your Evidence of Coverage (EOC).

The network providers listed in this directory have agreed to provide you with your health care and dental services. You may go to any of our network providers listed in this directory. Other providers are available in our network.

For Routine Hearing Exams and Hearing Aids services, you must use a TruHearing provider. Please call 1-855-541-6179 to locate a TruHearing provider and to schedule an appointment. For preventative dental services, a member's cost may be less if services are received from a dentist within network. Please visit www.bcbsalmedicare.com to find an in-network dentist.

Out-of-network providers are under no obligation to treat Blue Advantage's enrollees, except in emergencies. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our Member Service Department at 1-888-234-8266, 8 a.m. to 8 p.m., seven days a week. TTY users should call 711. From April 1 to September 30, on weekends and holidays you may be required to leave a message. Calls will be returned the next business day, or visit www.bcbsalmedicare.com. You may also refer to your Evidence of Coverage (EOC) for more information, including the cost sharing that applies to out-of-network services.

How to get care from out-of-network providers

As a member of our plan, you can choose to receive care from out-of-network providers. Our plan will cover services from either in-network or out-of-network providers, as long as the services are covered benefits and are medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher. Here are other important things to know about using out-of-network providers:

• You can get your care from an out-of-network provider; however, that provider must be eligible to participate in Medicare. We cannot pay a provider who is not eligible to participate in Medicare. If you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. Check with your provider before receiving services to confirm that they are eligible to participate in Medicare.
• You don’t need to get a referral or prior authorization when you get care from out-of-network providers. However, before getting services from out-of-network providers you may want to ask for a pre-visit coverage decision to confirm that the services you are getting are covered and are medically necessary. (See your Evidence of Coverage for information about asking for coverage decisions.) This is important because:
  • Without a pre-visit coverage decision, if we later determine that the services are not covered or were not medically necessary, we may deny coverage and you will be responsible for the entire cost. If we say we will not cover your services, you have the right to appeal our decision not to cover your care. (See your Evidence of Coverage for information on your appeal rights.)
  • It is best to ask an out-of-network provider to bill the plan first. But, if you have already paid for the covered services, we will reimburse you for our share of the cost for covered services. Or, if an out-of-network provider sends you a bill that you think we should pay, you can submit it to us for processing and determination of your liability, if any. (See your Evidence of Coverage for information about what to do if you receive a bill or if you need to ask for reimbursement.)
• If you are using an out-of-network provider for emergency care, urgently needed care, or out-of-area dialysis, you may not have to pay a higher cost-sharing amount. (See your Evidence of Coverage for more information about these situations.)

When you’ve received medical care from a provider who is not in our plan’s network

When you’ve received care from a provider who is not part of our network, you are only responsible for paying your share of the cost, not for the entire cost. (Your share of the cost may be higher for an out-of-network provider than for a network provider.) You should ask the provider to bill the plan for our share of the cost.

• If you pay the entire amount yourself at the time you receive the care, you need to ask us to pay you back for our share of the cost. Send us the bill, along with documentation of any payments you have made.
• At times you may get a bill from the provider asking for a payment that you think you do not owe. Send us the bill, along with documentation of any payments you have already made.
  • If the provider is owed anything, we will pay the provider directly.
  • If you have already paid more than your share of the cost of the service, we will determine how much you owed and pay you back for our share of the cost.
• Please note: While you can get your care from an out-of-network provider, the provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to participate in Medicare. If the provider is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.

When you need out-of-area coverage, urgently needed care, or have a medical emergency

• What is “out-of-area coverage”?
  “Out-of-area coverage” is when you receive covered services that are medically necessary outside of our plan’s service area. If you use an out-of-network provider for these services, your share of the costs for your covered services may be higher.
• What is “urgently needed care”?
  “Urgently needed care” is a non-emergency, unforeseen medical illness, injury, or condition, that requires immediate medical care, but the plan’s network of providers is temporarily unavailable or inaccessible.
• What if you are in the plan’s service area when you have an urgent need for care?
  In most other situations, if you are in the plan’s service area and you use an out-of-network provider, you will pay a higher share of the costs for your care. However, if the circumstances are unusual or extraordinary, and network providers are temporarily unavailable or inaccessible, we will allow you to get covered services from an out-of-network provider at the lower, in-network, cost-sharing amount.
• What if you are outside the plan’s service area when you have an urgent need for care?
  When you are outside the service area and cannot get care from a network provider, our plan will cover urgently needed care that you get from any provider at the lower, in-network, cost-sharing amount.
• What is a “medical emergency” and what should you do if you have one?
  A “medical emergency” is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

If you have a medical emergency:

Get help as quickly as possible. Call 911 for help or go to the nearest emergency room, hospital, or urgent care center. Call for an ambulance if you need it. You do not need to get approval or a referral first from your physician. As soon as possible, make sure that our plan has been told about your emergency. We need to follow up on your emergency care. You, or someone else, should call to tell us about your emergency care, usually within 48 hours. Please call the number on the back of your Member ID Card. Blue Advantage (PPO)/Health Management needs to know about your emergency because we will provide follow-up care.

What is covered if you have a medical emergency?

You may get covered, emergency, medical care whenever you need it, anywhere in the United States or its territories. Our plan covers ambulance services in situations where getting to the emergency room any other way could endanger your health.

If you have an emergency, we will talk with the doctors who are giving you emergency care to help manage and follow up on your care. The doctors who are giving you emergency care will decide when your condition is stable and the medical emergency is over.

After the emergency is over, you are entitled to follow-up care to be sure your condition continues to be stable. Your follow-up care will be covered by our plan. If you get your follow-up care from an out-of-network provider, you will pay the higher, out-of-network, cost-sharing amount. For more information, see your Evidence of Coverage.

What if it wasn’t a medical emergency?

Sometimes it can be hard to know if you have a medical emergency. For example, you might go in for emergency care–thinking that your health is in serious danger–and the doctor may say that it wasn’t a medical emergency after all. If it turns out that it was not an emergency, as long as you reasonably thought your health was in serious danger, we will cover your care.

However, after the doctor has said that it was not an emergency, the amount of cost sharing that you pay will depend on whether you get the care from in-network providers or out-of-network providers. If you get the care from in-network providers, your share of the costs will usually be lower than if you get the care from out-of-network providers. With the exception of emergencies or urgent care, it may cost more to get care from out-of-network providers. As a member of our plan, you can choose to receive care from out-of-network providers. Our plan will cover services from either in-network or out-of-network providers, as long as the services are covered benefits and are medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher.

What is the service area for Blue Advantage?

The counties in our service area are listed below.

How do you find Blue Advantage providers in your area?

To quickly find a plan provider nearest your home, you can search this directory. If you are traveling outside of the service area above, please contact Member Services for help getting additional directories, or finding out if there are in-network providers in that area. Our plan will cover services from either in-network or out-of-network providers, as long as the services are covered benefits and are medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher.

If you have questions about Blue Advantage, please call our Member Service Department at 1-888-234-8266, 8 a.m. to 8 p.m., seven (7) days a week. From April 1 to September 30, on weekends and holidays you may be required to leave a message. Calls will be returned the next business day. TTY users should call 711. You can also visit www.bcbsalmedicare.com.

The hard copy provider directory is available in a different format, including large print. To receive this material in an alternative, large print format, contact member services.

The provider network may change at any time. You will receive notice when necessary.

For Routine Hearing Exams and Hearing Aids services, you must see a TruHearing provider to use these benefits. Please call 1-855-541-6179 to locate a TruHearing provider and to schedule an appointment.

Out-of-network/non-contracted providers are under no obligation to treat Blue Advantage (PPO) members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.