I need to have lab services performed. How do I find the nearest network laboratory?
Read Important Information About Our Lab Services and search for a network laboratory.
Do you have any fitness or nutrition programs?
As one of your many benefits, BlueCross BlueShield offers a variety of programs. You may attend any of our BlueLife Health Education and Wellness programs offered throughout the Western New York Community. Program topics range from lifestyle issues such as exercise, nutrition, weight management and smoking cessation as well as health management issues such as diabetes and asthma management. You may also take advantage of our discount network, and receive discounts on massage therapy or acupuncture. For more information, visit the Get Health section of our web site or call Customer Service.
What's the difference between In-Network and Out-of-Network?
"In-network" providers are medical professionals who have agreed to provide services to our members. When you receive care from an "in-network" provider, you pay a low copay and won't need to worry about filing claims.
"Out-of-network" providers do not have a working agreement with our health plan to provide services to our members. If you have an out-of-network benefit, you can seek care from out-of-network providers. You will have a higher out-of-pocket expense.
I was told I needed prior authorization to obtain a service. What does this mean?
Prior Authorization is the process of obtaining coverage approval for a service or medication. Without such prior authorization, the service or medication is not covered. Your physician is responsible for obtaining the prior authorization when required. In additional to certain medical services, select medications are subject to pre-approval to be eligible for coverage under your pharmacy benefit. We review medical information provided by physicians to determine if clinical guidelines have been met and that the medication is being used appropriately. In addition to those drugs noted on the Formulary as requiring prior authorization, most injectable products are subject to prior authorization.
What if I receive a bill?
If you receive care from a non-participating provider, you may be asked to pay for services when you receive them or you may receive a bill. Submit any bills or receipts to:
P.O. Box 80
Buffalo, NY 14240-0080
Be sure that your itemized receipt or bill includes the patient's name, ID number, a description of the service, date of service, diagnosis, dollar amount, provider's name and address and your signature.
What is a Healthcare Proxy?
A healthcare proxy is a legal document that allows you to appoint someone you trust, such as a family member or close friend, as your healthcare agent, to make healthcare decisions for you if you lose the ability to make decisions for yourself.
Appointing a healthcare agent ensures that your healthcare wishes are followed. You may give the person you select as your health care agent as little or as much authority as you want. An agent can be given the right to make all healthcare decisions or only certain ones.
Important decisions about medical treatment, such as nourishment and water by feeding tubes, as well as instructions like requesting or stopping treatment will be carried out as you have requested, if a healthcare proxy is in place.
What is Health Advocate?
Health Advocate is a personal healthcare coaching and patient advocacy service you can call anytime you need help navigating the healthcare system. Health Advocate can help you: find the best doctors and hospitals for complex needs; make appointments with hard-to-reach specialists; locate and research treatments for a medical condition; provide unbiased information; assist with administrative, billing and claims issues; and help with eldercare issues. Call Health Advocate toll-free at 1-800-359-5465.
Can I get my prescriptions mailed to me?
Yes. BlueCross BlueShield offers a mail order option through Medco that provides convenient home delivery of your prescription drugs, and may also save you money. Read more about this mail order benefit in Medco Pharmacy Services.
How do we reimburse our providers?
We support providers in several ways, including sharing with them information about healthcare treatments, helping them to coordinate quality care, and reimbursing them fairly for the care they provide. We have many different ways to pay providers for the care they provide.
Resource Based Relative Value Scale (RBRVS) - We use a method called RBRVS to price medical procedures based on the relative cost of providing a service. RBRVS considers the time a doctor spends on a procedure, how much it costs to run a medical practice, and the cost of medical malpractice insurance. RBRVS also adjusts reimbursement based on how costs vary among different geographic locations. The federal government uses this method to pay doctors across the nation.
Fee for Service - This is the traditional healthcare payment method under which doctors and other providers receive a payment that does not exceed their billed charge for each service they provide. This method of payment can also be used in conjunction with an established fee schedule for our managed care and indemnity plans of coverage.
BlueCard® Program(ITS) - The BlueCross BlueShield Association, a national association of independent Blue Plans, of which our company is a member, developed this program to help pay your claims when you receive care from an out-of-area provider who participates with his or her local BlueCross and BlueShield Plan. The BlueCard® Program processes your claims using the payment agreement the physician has with his or her local plan. The local plan pays the doctor directly for the services you received.
Agreed Upon Amount - This is a negotiated rate agreed to by our company and a medical facility.
Capitation - Capitation means we pay providers a fixed dollar amount in advance, regardless of the number of services they provide to a member. We establish this payment on a per-month basis.
Diagnosis-Related Grouping (DRG) - A method of reimbursing hospitals for providing inpatient hospital care. It takes into account both your diagnosis and the length of time a patient usually stays in the hospital for that particular diagnosis.