What is a PPO?
PPO stands for Participating Provider Option, a plan that includes a large network of doctors and hospitals that contract with a health plan like Blue Cross and Blue Shield. When you use a contracting PPO doctor or hospital you will receive a higher benefit for most services than if you go outside the network.
What is the difference between PPO and POS Wisconsin (WI) Blue Preferred?
The POS WI BluePreferred is an open access network with greater savings and discounts, same level of quality, with slightly less providers.
Do I need to choose a PPO doctor and hospital when I enroll?
No, you can select a PPO doctor and hospital each time you need care.
Do I have to use a PPO contracting doctor or hospital?
No, but in order to receive the highest level of benefits, members should use PPO network doctors and hospitals whenever possible. Members can seek treatment from non network PPO doctors and hospitals. However, benefits will be paid at the non network PPO benefit level and will be subject to reasonable and customary allowable amounts. Additionally, doctors and hospitals who are not contracted are allowed to balance-bill you for fees that exceed reasonable and customary amounts.
How can I find a contracting PPO doctor in my area?
There are several ways:
- Ask if your doctor contracts with the Blue Cross and Blue Shield PPO network
- Look up PPO doctors and hospitals in the Provider Finder®
- Call the BCBS Customer Service Center at (800) 671-1210
How can I find a PPO network doctor or hospital?
You can search the online list of Doctors & Hospitals for information on contracting doctors and hospitals. With it, you can search for PPO doctors and hospitals in your area, or search for a specific doctor by name. You can also print out your search results in a customized report.
What if I can't find a PPO doctor or hospital in my area?
If you are having difficulty locating a PPO doctor or hospital, please contact the BCBS Customer Service Center at (800) 671-1210. Customer Service Representatives can help you locate a PPO network doctor or hospital.
What if my doctor is not in the network?
If you do not find a doctor you are looking for you can nominate a doctor for inclusion into the contracting network.
If my PPO doctor has suggested a specific treatment, will it be covered?
Benefits are determined according to the terms of your plan. If you have questions about availability of benefits for a specific service, please contact the BCBS Customer Service Center at (800) 671-1210 and speak with a Customer Service Representative.
What if I do not use a contracting doctor in the PPO network?
If you use the PPO network, you will receive a higher level of coverage. If you receive services from a non network doctor or hospital, your benefits are covered at the non-network level. You may also be responsible for paying any difference between the non-network doctor's charges and the BCBS reasonable and customary allowable amounts.
If my PPO doctor refers me to a non-network doctor, what level of reimbursement will I receive for the non network doctor's services?
You will receive the lower level of benefit for non-network doctors. Ask your doctor to help you find an in-network specialist. Remember you do not need referrals from your primary care doctor; you may see any specialist and if you use a PPO specialist, your benefits will be paid at a higher level.
If I receive services with a non PPO doctor, do the charges above the PPO allowance apply to my annual deductible or out-of-pocket maximum?
Expenses and charges over the reasonable and customary limits do not apply to your annual deductible or out-of-pocket maximum.
Am I covered if I travel outside the United States?
As a BCBS member, you have access to the BlueCard® PPO network, which links you to a network of doctors and hospitals throughout the United States. You also have access when traveling or working abroad to BlueCard Worldwide® doctors and hospitals in more than 200 countries.
What if I receive care outside the United States from a non BlueCard Worldwide doctor or hospital?
If you receive care from a non BlueCard Worldwide doctor or hospital, your benefits will be paid at the PPO level (80%).
Do I need to prenotify for care?
As a BCBS member, you do not need to prenotify for routine care from your doctor, such as when you seek care in your doctor's office. However, you do need to prenotify any inpatient hospital care and prenotify some outpatient hospital procedures. In addition, infertility services must be prenotified.
What services require prenotification?
The following services require prenotification:
- Accidental Dental Services
- Blepharoplasty (upper lid surgery)
- Breast Reconstruction (other than following surgery for breast cancer)
- Breast Reduction
- Cancer Treatment (inpatient or outpatient)
- Coordinated Home Care
- Durable Medical Equipment>$1,000
- Hospice
- Infertility Treatment, please view the Reproductive Resource Services (RRS) flier
- Inpatient Admissions
- Lap Band
- Ligation, Vein Stripping
- Private Duty Nursing
- Reconstructive Surgery
- Sclerotherapy Skilled Nursing Facility services
- Transplant Services
What do I do if I need to be hospitalized?
Before any scheduled inpatient hospitalization and within two business days of an emergency hospitalization, members must call the Customer Service Center at (800) 671-1210 to prenotify the hospitalization with Blue Care Connection. This call can be made by:
- The member
- The doctor
- The hospital
- Family or friends of the patient
Blue Care Connection is staffed with knowledgeable professionals who will help you determine what is the most appropriate and cost-effective ways to meet your health care needs and maximize available benefits.
What happens if the prenotification call is not made?
Members who do not make the call — or have it made on their behalf — for an inpatient stay within the appropriate time frame will be assessed a $250 charge.
What do I do in case of an emergency?
In the event of a medical emergency, contact 911. Members should seek treatment at the nearest facility. For emergency care, benefits will be paid at the in-network benefit level, regardless of the facility used.
How does the $100 emergency room visit charge work?
For each visit to the emergency room, you will be responsible for paying a $100 copayment. The emergency room visit charge is waived if the patient is admitted to the hospital from the emergency room. It is not applied to the deductible or toward satisfying the out-of-pocket expense limits.
What is a medical emergency?
A medical emergency is generally defined as a medical condition that has symptoms of an injury or illness serious enough to make you, as a prudent layperson with an average knowledge of health and medicine, believe that any delay in seeking care may result in significant impairment or death.
Where can I get information about the prescription drug benefits under the BCBS Plan?
Members can contact Caremark with questions about prescription drug benefits at (866) 293-8009. Representatives are available Monday - Friday from 7 a.m. to 9 p.m. CT and Saturday from 8 a.m. to 12 p.m. CT. For more information, members can also access the Caremark Web site for Abbott employees or retirees.
Where can I get information about the behavioral health care benefits under the BCBS Plan?
Members can review a summary of their behavioral health care benefits or contact Magellan with questions. The toll-free number for Magellan is (800) 240-6227. Members located in Hawaii or Altavista should contact Magellan at (800) 851-7498 for information about the providers available in their network. Representatives are available 24 hours a day, 7 days a week.
What number should I call to reach a BCBS Customer Service Representative?
You can reach the BCBS Customer Service Center at (800) 671-1210. Customer Service Representatives are available Monday - Friday, 7 a.m. to midnight C.T., and Saturday, 8 a.m. to 6 p.m. C.T.
How can I check the status of my claim?
You can check claim status several different ways. You can call a Customer Service Representative toll-free at (800) 671-1210. They can advise you on the status of any processed claims, as well as those that are still being considered. You can also check claim status via Blue Access for Members.
Where should my doctor file my claim?
Most doctors are familiar with the BlueCard® program and know how to file claims. The doctor should follow the filing instructions on the back of your member ID card — which states that all claims should be filed with their local Blue Cross and Blue Shield plan.
If the BCBS Plans offerd through Abbott are affiliated with Blue Cross and Blue Shield of Illinois, why does my doctor file my claims with the local Blue Cross and Blue Shield plan?
Blue Cross Plans negotiate discounted rates with local doctors and hospitals. To help you benefit from those discounts, doctors and hospitals may file claims with the local plan. The local plan then exchanges benefit payment information with Blue Cross and Blue Shield of Illinois.
How will I know that my claim has been paid?
You will receive an Explanation of Benefits (EOB) from Blue Cross and Blue Shield of Illinois once your claim has been processed. The EOB will provide details of what was covered, the level of coverage, and the amount you owe. To view your EOBs online, log on to Blue Access for Members.
Can I contact my local Blue Cross and Blue Shield office to check status of my claim or to question benefits?
Your local Blue Cross and Blue Shield plan will not be able to assist you. The BCBS Customer Service Center for Abbott employees is trained on your plan's benefits and will be able to assist you with questions regarding the processing of your claims. To ensure you receive a prompt and accurate response to any questions you may have regarding your claims or benefits, please contact the BCBS Customer Service Center at (800) 671-1210.
How do I get a Blue Cross and Blue Shield of Illinois claim form and where do I mail it?
When receiving care in-network there is no paperwork to fill out — all you need to do is show your ID card to receive benefits. Your doctor will file your claims directly with the local Blue Cross and Blue Shield plan. For some out-of-network care, you may need to download a copy of our claim form.
Mail your completed claim form to the following address:
Blue Cross and Blue Shield of Illinois
P.O. Box 805107
Chicago, IL 60690-1220
What information does my ID card contain?
The ID card will provide information about the BCBS network for Abbott employees. Please present your ID card when obtaining services from doctors and hospitals.
Why do I need to carry my ID card?
You must present your ID card to your doctor so that he or she knows who to contact for eligibility, what medical benefits are available to you under the Abbott BCBS Plan, and if prenotification is required.
Will my family members receive their own identification cards?
BCBS PPO Plus participants with "Employee Only" coverage are sent one identification (ID) card. Participants with "Employee plus Spouse", "Employee plus Children" or "Employee plus Family" coverage receive two ID cards. If you need additional cards, please contact the BCBS Customer Service Center at (800) 671-1210. Members can also request additional ID cards by visiting Blue Access for Members.
I've lost my ID card. What do I do?
Contact the BCBS Customer Service Center at (800) 671-1210 to request a replacement ID card. Members can also print a temporary ID card and obtain a replacement ID card by visiting Blue Access for Members.
How do I change my personal information?
- To change your name or address, contact myHRTeam at 877-228-4707.
How do I add a dependent to my coverage?
To add a new dependent to your coverage, you need to go to the Abbott Benefits Web site at www.benefits.ehr.com or contact myHRTeam at 877-228-4707. Newly acquired dependents must be added within 31 days of the qualifying event.
What is Blue Care Connection®?
Blue Care Connection makes it easier for you to manage your health care and health care benefits. The suite of online resources and support services provide you with personalized attention, health advocacy and health and condition-specific information.
Who can use Special Beginnings®?
Special Beginnings® is a maternity program for pregnant members. It provides prenatal and postnatal health education and support, pregnancy risk factor identification assessment and ongoing communication monitoring.
When can I call the Nurseline?
You can access the 24/7 Nurseline at (800) 671-1210 to get answers to your health-related questions 24 hours a day, 7 days a week.
What is the Personal Health Manager?
The Personal Health Manager (PHM) is a resource of online tools and information that helps you better manage your health. You can set up a personal health record, access online health content such as videos and interactive tutorials, receive targeted wellness information and set up reminders about medical appointments and screenings.
Who has access to my personal health record?
Members can decide who has access to their personal health records within the Personal Health Manager. With your permission, health care providers, Blue Cross and Blue Shield of Illinois nurses and family members can access the information and facilitate care.
If I have questions about fitness, weight management or nutrition, who can I e-mail?
Via secured e-mail, members can ask registered nurses health-related questions with the E-Mail Ask A Nurse feature; ask personal trainers for exercise advice at E-Mail Ask A Trainer; ask registered dietitians for nutrition advice at E-Mail Ask A Dietitian; and get help on managing stress and other issues with E-Mail Ask A Life Coach.
