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Out-of-Network Benefits and Provider Reimbursement

All BlueCross health plans include out-of-network benefits. This includes individual plans that feature Blue Network E. It’s important to remember that members get more from their health plan by visiting in-network providers.

Providers will be reimbursed up to the Maximum Allowable Charge (MAC), which is based on a statewide standard out-of-network reimbursement schedule. We are not able to release this information publicly.

Emergency situations

All Marketplace plans feature the same medical emergency benefits as any other commercial network.

If a Blue Network E member uses an out-of-network Emergency Room for an emergency situation, the claim will process as in-network, subject to the MAC. To provide our members with additional peace of mind, we have a higher out-of-network reimbursement schedule for true medical emergencies. These typically include life-threatening situations or accidents, and are defined by diagnosis codes.

If a Blue Network E member uses an out-of-network Emergency Room and it is not an emergency situation, the claim will process as out-of-network, subject to the standard MAC.

Provider Reimbursement

The provider reimbursement fee schedule for patients with coverage through the Marketplace remains the same as your currently-contracted fee schedule with BlueCross.

Your patients with BlueCross individual health plans may feature BlueCross Networks P, S or E.
If you are a provider in any of these networks, you will be reimbursed at your current contracted rate.

Remittance advice

The same information that appears today on your remittance advices will also appear on those for members who have purchased health plans through the Marketplace.