Emergency Care Emergency care received from a non-participating provider may, under certain circumstances, be paid at the in-network benefit level. However, the participant is still responsible for amounts charged by the non-participating provider that exceed the allowable charge.
If a claim for emergency care is processed at the out-of-network benefit level, the participant may appeal the percentage paid on the claim for emergency services by making a written appeal to Blue Cross & Blue Shield. Only emergency services payable at the 60% coverage level may be appealed for the in-network coverage level.
Specialty Services Performed by a Non-participating Provider If a Plan participant needs specialty services that are not available from participating providers, he should call Intracorp and request a review of the availability of the needed services. This is called an “out-of-network review” and must be requested prior to receiving medical services. If Intracorp certifies that the service is not available in the Network, that service is covered at the in- network benefit level, even if provided by a non-participating provider. Services approved through an out-of-network review are subject to the in-network calendar year deductible and coinsurance. Although approval to use a non-participating provider may be granted, the participant is responsible for amounts charged by the provider that exceed the Plan’s allowable charge.
Out-of-network review requests will not be approved for follow-up testing after active treatment is complete.
Only services that have a 60% coverage level are eligible for an out-of-network review. area participants are not eligible to request an out-of-network review.
Medical Management/Utilization Review Utilization review is a process to make sure that medical services are medically necessary, delivered in the most appropriate setting, reflective of the correct length of stay, and consistent with generally accepted medical standards. Certification requirements apply, regardless of whether a participant uses a participating or non-participating provider. Intracorp performs medical management/utilization review for the Plan. The following services must be certified by Intracorp:
Inpatient Hospital Admissions Specified Outpatient Diagnostic Tests Private Duty and Home Health Nursing Services Solid Organ and Bone Marrow/Stem Cell Transplants Home Infusion Therapy
Outpatient diagnostic tests requiring certification
CAT Scan Colonoscopy MRI Scan UGI Endoscopy/EGD