Our nonparticipating provider policy and fee schedules are provided for your information. We are providing similar information to our members. If you require information that is not addressed here, you may contact Provider Services at 1-800-262-0820.

When our members use a provider that does not contract with a Blue Cross and Blue Shield plan* (a nonparticipating provider) for most services, benefits are substantially reduced and our members will likely incur significantly higher out-of-pocket expenses.

Nonparticipating providers have not agreed to accept the Blue Cross and Blue Shield plan allowed amount as payment in full.

The allowed amount for most services from a nonparticipating provider is usually less than the allowed amount for a participating provider. The allowed amount for nonparticipating providers is not a reflection of the usual, customary or reasonable charge from a provider. For most services, members must pay the difference between the Blue Cross allowed amount and the nonparticipating provider’s billed charges. This amount can be significant and does not apply toward any out-of-pocket maximum contained in the plan.

Blue Cross will, in most cases, pay the benefits for any covered health care services received from a non-participating provider directly to the member, based on the allowed amounts described below and subject to other applicable limitations in the plan. An assignment of benefits from a member to a nonparticipating provider generally will not be recognized.

Cost-sharing amounts for members that receive services from a nonparticipating provider are usually higher than for participating providers.

Although each plan varies, most Blue Cross and Blue Shield of Minnesota plans provide some coverage for nonparticipating provider services. Most plans also have higher coinsurance or copayments for services received from nonparticipating providers. Members are responsible for these amounts in addition to the difference between the nonparticipating provider’s billed charge and the plan’s allowed amount.

Example of payment for nonparticipating provider

The following table illustrates the different out-of-pocket costs a member may incur using nonparticipating vs. participating providers for most non-emergency services. The example assumes that the member deductible has been satisfied and that the plan covers 80 percent of the allowed amount for participating providers and 60 percent of the allowed amount for nonparticipating providers. It also assumes that the allowed amount for a nonparticipating provider will be less than for a participating provider. The difference in the allowed amount between a participating and nonparticipating provider could be more or less than the 40 percent difference in the example below.

What is Blue Cross and Blue Shield of Minnesota’s allowed amount for nonparticipating providers?***

For physicians, clinics or Ambulatory Surgery Centers (ASC) services by nonparticipating providers in Minnesota, with some exceptions, the allowed amount is most commonly the amount in the Nonparticipating Provider Professional Services in Minnesota Fee Schedule.****

» Provider professional services sample fee schedule (PDF)
» Chiropractic provider sample fee schedule (PDF)
» Ambulatory Surgery Center (ASC) fee schedule (PDF)

The allowed amount is the lesser of (1) the Nonparticipating Provider Professional Services in Minnesota Fee Schedule, or (2) 90 percent of the nonparticipating provider’s billed charges. The determination of the allowed amount is subject to all Blue Cross business rules as defined in the Blue Cross Provider Policy and Procedure Manual (PDF). As a result, Blue Cross could bundle services, take multiple procedure discounts and/or take other reductions as a result of the procedures performed and billed on the claim. No fee schedule amounts include any applicable tax.

Payments using these fee schedules are subject to all member contract provisions (including deductibles, copayments, limitations and exclusions). A procedure listed on a fee schedule does not guarantee payment. The fee schedule that is current at the time the services are provided will be used for determining the allowed amount. Allowances may be greater for emergency services.

The allowed amount for all other nonparticipating providers (facility services) in Minnesota***

The Blue Cross and Blue Shield of Minnesota allowed amount for nonparticipating provider facility services is 40 percent of the facility’s billed charges, with certain exceptions and subject to business rules established in the Blue Cross Provider Policy and Procedure Manual (PDF). As a result, certain procedures billed by a nonparticipating provider facility may be combined into a single procedure or denied as not a covered service for purposes of determining what the 40 percent will be applied against. Examples of facility-based provider types include, but are not limited to, hospitals, skilled nursing facilities and renal dialysis centers.

The allowed amount for nonparticipating provider professional services (physicians or clinics) outside Minnesota***

For nonparticipating provider physician or clinic services outside of Minnesota, with certain exceptions, the allowed amount is determined by the local Blue Cross and/or Blue Shield Plan, unless that amount is greater than the nonparticipating provider’s billed charge, or no allowed amount is provided by the local Blue plan. In that case, the allowed amount will be based on a percentage of pricing obtained from a nationwide provider reimbursement database that considers various factors, including the ZIP code of the place of service and the type of service provided. If this database pricing is not available for the service provided, Blue Cross and Blue Shield of Minnesota will use the allowed amount for nonparticipating providers in Minnesota.

The allowed amount for all other nonparticipating providers (facility services) outside Minnesota***

For nonparticipating provider facility services outside of Minnesota, with certain exceptions, the allowed amount is determined by the local Blue Cross or Blue Shield Plan, unless that amount is greater than the nonparticipating provider’s billed charge, or no amount is provided by the local Blue plan. In that case, the allowed amount is determined from a Medicare-based fee schedule. If such pricing is unavailable, payment will be based on a percentage of the nonparticipating provider’s billed charges.

*Each Blue Cross or Blue Shield plan is an independent licensee of the Blue Cross and Blue Shield Association.

** Blue Cross will in most cases pay the benefits for any covered health care services received from a non-participating provider directly to the member based on the allowed amounts described here and subject to the other applicable limitations in the plan. An assignment of benefits from a member to a nonparticipating provider generally will not be recognized. This figure, therefore, represents the net cost to the member after being reimbursed by Blue Cross.

***The above summaries for determining allowed amounts are not followed in all cases. Certain plan sponsors, for example, for their group coverage simply defer to the nationwide provider reimbursement database for determining allowed amounts for services provided by nonparticipating providers to their members.

****These proprietary fee schedules are for the information of Blue Cross and Blue Shield of Minnesota members only and are not to be used for any other purpose. They are subject to change without notice.