Payments to nonparticipating providers

You are responsible for the bills you receive from a nonparticipating provider.

If you use a provider that does not contract with Blue Cross and Blue Shield of Minnesota (a nonparticipating provider) or does not participate in your network, your benefits are usually reduced – often substantially – and you will likely incur significantly higher out-of-pocket expenses. Nonparticipating providers have not agreed to accept the Blue Cross allowed amount as payment in full, nor are they paid directly by Blue Cross.

Although each benefit plan varies, most Blue Cross benefit plans provide some coverage for services received from a nonparticipating provider. However, most benefit plans will have a higher coinsurance or copay for services received from nonparticipating providers. In addition, the allowed amount for services by a non-participating provider is usually less than the allowed amount for the same service by a participating provider. You are responsible for these additional amounts as well as the portion of the bill for which you are reimbursed by Blue Cross. The differences can be significant and the additional expense that you incur may or may not apply toward any out-of-pocket maximum amounts in your benefit plan. To see what applies toward your out of pocket maximum, refer to your plan documents.

In most cases, when you receive services from a nonparticipating provider you most likely will be required to pay up front to the provider and submit the claim to Blue Cross. You can use this Blue Cross subscriber claim form (PDF). Reimbursement for care received from a nonparticipating provider will be sent from Blue Cross directly to the member.

Example of payment for a nonparticipating provider
The following table illustrates the different out-of-pocket costs you may have using a nonparticipating vs. participating provider for most non-emergency services. The example assumes that:

• the member deductible has been satisfied,
  
• the plan covers 80 percent of the allowed amount for participating providers, and
  
• 60 percent of the allowed amount for nonparticipating providers
  
  The example below 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).

   

**The member is responsible to the nonparticipating provider for the provider’s entire charge. This amount represents the member’s out-of-pocket portion of the charge.

What is Blue Cross’ allowed amount for nonparticipating providers?
For physicians, clinics, Ambulatory Surgery Centers (ASC) services, and/or facility services by nonparticipating providers, with some exceptions, the allowed amount for most plans is 100% of the Medicare Allowed Charge that is published at the United States website for Centers for Medicare and Medicaid Services (CMS): http://www.cms.gov/ .

For physicians, clinics, and Ambulatory Surgery Centers (ASC) services, if the Medicare Allowed Charge is not used and the Nonparticipating Provider Professional Services Fee Schedule is used; the allowed amount is the lesser of:

• The Nonparticipating Provider Professional Services Fee Schedule, or
  
• 90 percent of the nonparticipating provider’s billed charges.
  

For facility services, if the Medicare Allowed Charge is not used, the allowed amount will be 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.

Payments are subject to all member contract provisions (including deductibles, copayments, limitations and exclusions) regardless of whether a payment is based upon the Medicare Allowed Charge or a fee schedule.

A procedure listed by CMS or found on a fee schedule does not guarantee payment. The fee schedule or Medicare Allowed Charge that is current at the time of service will be used to determine the allowed amount. Allowances may be greater for emergency services.

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