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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.
No, you can select a PPO doctor and hospital each time you need care.
No, but to receive the highest level of benefits, members should use PPO network doctors and hospitals whenever possible. You 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.
There are several ways:
You can search the online list of contracting doctors and hospitals. 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.
If you are having trouble finding a PPO doctor or hospital, please contact the BCBSIL Customer Service Center at 1-800-311-0419. Customer Service Representatives can help you locate a PPO network doctor or hospital.
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.
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.
If you receive care from a non-Blue Card Worldwide doctor or hospital, your benefits will be paid at the PPO level.
As a member of BCBSIL, you do not need to pre-notify for routine care from your doctor, such as when you seek care in your doctor's office. However, you do need to pre-notify any inpatient hospital care.
The following services require pre-notification:
Before any scheduled inpatient hospitalization and within 2 business days of an emergency hospitalization or maternity admission, you must call the BCBSIL Customer Service Center at 1-800-311-0419 to pre-notify the hospitalization with Blue Care Connection. This call can be made by:
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%.
Your prescription coverage is provided by a third-party pharmacy benefits manager. Contact your company’s pharmacy benefits.
You can check claim status several different ways. You can call a Customer Service Representative toll-free at 1-800-311-0419. 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 MembersSM.
Most doctors are familiar with the BlueCard® program and know to file claims with their local Blue Cross and Blue Shield plan. These instructions are on the back of your member ID card.
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 BCBSIL.
You will receive an Explanation of Benefits (EOB) from BCBSIL 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.
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 1-800-311-0419.
When receiving care in-network there is no paperwork to fill out — all you need to do is show your member 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.
You must present your member 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 pre-notification is required.
If you elect single coverage, you will receive one ID card. If you need additional cards, contact the BCBSIL Customer Service Center at 1-800-311-0419. Members can also request additional ID cards by visiting Blue Access for Members.
To request a replacement member ID card, call the BCBSIL Customer Service Center at 1-800-311-0419. You can also print a temporary ID card and obtain a replacement ID card by visiting Blue Access for Members.