| Frequently Asked Questions: Claims / Benefits |
| Q: |
What are the plan benefits for a member that goes out-of-network? |
| A: |
Out-of-network benefits are defined in the member’s benefit plan booklet.
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| Q: |
I am a participating BlueChoice Solutions PCP. What happens if I am out of town and one of my PPO BlueChoice Solutions patients sees one of my back-up physicians that is not a participating BlueChoice Solutions physician. How will my back-up physician’s claim be paid? |
| A: |
The back-up physician’s claim will be paid at the ParPlan allowable, if the physician is in the ParPlan, subject to member’s deductible and coinsurance. Otherwise, non-network fee schedule applies.
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| Q: |
I am a participating BlueChoice Solutions PCP. What happens if I am out of town and one of my POS BlueChoice Solutions patients sees one of my back-up physicians that is not a participating BlueChoice Solutions physician. How will my back-up physician’s claim be paid? |
| A: |
The back-up physician’s claim will be paid at the out-of-network benefit level subject to member’s deductible and coinsurance.
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| Q: |
I am a participating BlueChoice Solutions PCP. What happens if I am out of town and one of my POS BlueChoice Solutions patients sees one of my back-up physicians that is a participating BlueChoice Solutions physician. How will my back-up physician’s claim be paid? |
| A: |
If your back-up physician is listed in the BCBSTX system as your back-up, the claim will be paid at the in-network benefit level.
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| Q: |
If an out-of-network physician/professional provider is approved for a member, how will the physician/professional provider be paid? Will the member have to pay anything to the physician/professional provider? |
| A: |
If an out-of-network authorization is granted, the member will only by responsible for any applicable deductible and/or coinsurance/copayment amount.
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