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 of Illinois (BCBSIL). When you use a contracting PPO doctor or hospital, you will receive a higher level of benefits for most services than if you go outside the network.
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 Blue Cross and Blue Shield to participate in the PPO network
- Look up PPO doctors and hospitals in the Provider Finder®
- Call the BCBSIL Customer Service Center at (800) 311-0419.
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 BCBSIL Customer Service Center at (800) 311-0419. 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.
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 benefits. 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 BCBSIL PPO Plus reasonable and customary allowable amounts.
Am I covered if I travel outside the United States?
As a BCBSIL 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 Blue Card Worldwide doctor or hospital?
If you receive care from a non Blue Card Worldwide doctor or hospital, your benefits will be paid at the PPO level.
Do I need to prenotify for care?
As a member of BCBSIL, 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.
What services require prenotification?
The following services require prenotification:
- Inpatient Admissions
- Coordinated Home Care
- Private Duty Nursing
- Skilled Nursing Facility Services
What do I need to do if I need to be hospitalized?
Before any scheduled inpatient hospitalization and within two business days of an emergency hospitalization or maternity admission, members must call the BCBSIL Customer Service Center at (800) 311-0419 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
The BCBSIL 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 have their benefits reduced by 50%.
Where can I get information about the prescription drug benefits?
Members can contact Medco with questions about prescription drug benefits. The
toll-free number for the Customer Service Center is (800) 311-0419. Members can also access the Medco Rx Web site for more information.
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) 311-0419. 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 say they should file with their local Blue Cross and Blue Shield plan.
If the BCBS PPO is 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 BCBSIL 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 BCBSIL Customer Service Center 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 BCBSIL Customer Service Center at (800) 311-0419.
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.
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, and if prenotification is required.
Will my family members receive their own identification cards?
If you elect single coverage, you will receive one ID card. If you need additional cards, contact the BCBSIL Customer Service Center at (800) 311-0419. Members can also request additional ID cards by visiting Blue Access for Members.
