January 4, 2023
If you’re a Medicare provider, you may treat Blue Cross Group Medicare Advantage Open Access (PPO)SM and Blue Cross Medicare Advantage Flex (PPO)SM members.
You may treat these members regardless of your contract or network status with Blue Cross and Blue Shield of Illinois (BCBSIL). That means you don’t need to participate in BCBSIL’s Medicare Advantage networks or in any other BCBSIL networks to see these members.
The only requirements are that you:
- Agree to see the member as a patient;
- Accept Medicare assignment; and
- Will submit claims to BCBSIL.
Flex and Open Access Advantages
These plans cover the same benefits as Medicare Advantage Parts A and B plus additional benefits per plan. Members’ coverage levels are the same inside and outside their plan service area nationwide for covered benefits.
- Blue Cross Medicare Advantage Flex (PPO) is available to individuals. It includes medical coverage and prescription drug coverage. It doesn’t require member cost share.
- Blue Cross Group Medicare Advantage Open Access (PPO) is available to retirees of employer groups. It includes medical coverage and may include prescription drug coverage. Plan members may have to pay deductibles, copays and coinsurance, depending on their benefit plan. Call the number on the member ID card for details.
Referrals aren’t required for office visits. Prior authorization may be required for certain services from Medicare Advantage-contracted providers with BCBSIL.
How To Identify Members
Look for Blue Cross Medicare Advantage Flex (PPO) or Blue Cross Group Medicare Advantage Open Access (PPO) on the front of member ID cards. It’s always important to check eligibility and benefits before providing care. See sample member ID cards.
For Reimbursement
Follow the billing instructions on the member’s ID card. When you see these members, you’ll submit the claims to BCBSIL and not Medicare.
- If you’re a Medicare Advantage-contracted provider with any Blue Cross and Blue Shield (BCBS) plan, you’ll be paid your contracted rate. You’re required to follow utilization management review requirements and guidelines.
- If you’re a Medicare provider who isn’t contracted for Medicare Advantage with any BCBS plan, you’ll be paid the Medicare-allowed amount for covered services. You may not balance bill the member for any difference in your charge and the allowed amount.* You aren’t required to follow utilization management guidelines. However, you may request a review to confirm medical necessity.
Questions? Call the number on the member’s ID card.
*Blue Cross Group Medicare Advantage Open Access (PPO) members may be responsible for cost share for supplemental dental services from non-contracted Medicare providers.
Out-of-network/non-contracted providers are under no obligation to treat Blue Cross Medicare Advantage Flex (PPO) or Blue Cross Group Medicare Advantage Open Access (PPO) members, except in emergency situations.
Verification of eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, any claims received during the interim period and the terms of the member’s certificate of coverage applicable on the date services were rendered.