• What is a deductible?
• What is a billed charge?
• What is a covered charge?
• What is coinsurance?
• What is a copayment?
• What is an out-of-pocket limit?
• What is a provider?
• What is a participating provider?
• What is a Preferred Provider?
• Where can I find a Preferred Provider?
• What is a Nonpreferred Provider?
• What does "in-network" mean?
• What does "out-of-network" mean?
• Can I get a second opinion?
• Do I need a referral to see a specialist?
• What is prior approval/authorization?
• Are mammograms covered under my plan?
• What preventive services are covered?
• Am I covered when traveling?
• What is a medical emergency and what are my benefits?
• What do I do in an emergency?
• How can I get emergency care when traveling?
• What is urgent care and what are my benefits?
• What do I do to get urgent care?
• How does Coordination of Benefits work?
• What is an eligible dependent?
• How do I add an eligible dependent to my health insurance coverage?
• Why isn't my dependent's name listed on my ID card?
• What should I do if I lose my ID card?
• How does my prescription drug plan work?
A deductible is the amount you must pay each year before BCBSNM begins to pay for services. Check your BCBSNM member ID card for the amount of your deductible. If you have a PPO plan, there is a separate higher deductible for using Nonpreferred Providers (out-of-network providers).
The billed charge is the amount a provider bills for a service. Sometimes the billed charge is more than the covered charge (amount BCBSNM will pay to contracted providers). Preferred Providers (in-network providers) will "write off" the balance, but Nonpreferred Providers (out-of-network providers) may bill you for the difference between the covered charge and the billed charge.
The covered charge is the amount that BCBSNM determines is a fair and reasonable allowance for a particular covered service. After your share of a covered charge has been calculated (deductible and coinsurance), BCBSNM pays the remaining amount of the covered charge, up to maximum benefit limitations, if any. The covered charge may be less than the billed charge for a covered service. Preferred Providers will "write off" this balance, but Nonpreferred Providers may bill you for the difference between the covered charge and the billed charge.
Coinsurance is the percent of covered charges that you must pay for covered services after the deductible has been met. With most plans, after you have met the deductible you will pay 20 percent of covered charges for services from a Preferred Provider and 40 percent of covered charges for services from a Nonpreferred Provider. Check your Summary of Benefits for the percentage of covered charges you will have to pay for different services.
A copayment is a fixed dollar amount you are required to pay for a service at the time you receive care.
What is an out-of-pocket limit?
For PPO plans, an out-of-pocket limit is the total amount of coinsurance ONLY that you will pay for covered services in a calendar year. The amounts you may pay for deductibles, drug plan copayments, penalty amounts, or noncovered charges are not included in this out-of-pocket limit. After the out-of-pocket limit is reached, your PPO plan will pay 100 percent for most covered charges for the calendar year. See your Summary of Benefits or Benefit Booklet for more information.
For HMO plans, an out-of-pocket limit is usually twice (2X) your annual premium. After the out-of-pocket limit is reached, your HMO plan will pay 100 percent for most covered charges for the calendar year. Contact your group benefits administrator for more information.
A provider is a licensed health care facility, program, agency, ambulance company, doctor (including Doctor of Medicine, Doctor of Osteopathy, Doctor of Oriental Medicine, Doctor of Chiropractic, and Doctor of Podiatric Medicine), or other health professional that delivers health care services.
What is a participating provider?
A participating provider is a provider that has a written agreement with BCBSNM or another Blue Cross and Blue Shield company to provide services to members through a designated health plan. Participating providers are sometimes called contracting providers.
A Preferred Provider (in-network provider) is a health care professional or a facility that has a "preferred" or "PPO" contract with BCBSNM or a Blue Cross and Blue Shield (BCBS) company in another state.
Where can I find a Preferred Provider?
To find a Preferred Provider, check the printed network directory or search the Provider Finder® on this Web site. You may also call BCBSNM Customer Service at the number on the back of your ID card for help looking for Preferred Providers. For Preferred Providers outside New Mexico, call 1-800-810-BLUE (2583).
What is a Nonpreferred Provider?
A Nonpreferred Provider (out-of-network provider) does not have a "preferred" or "PPO" contract with BCBSNM or a Blue Cross and Blue Shield (BCBS) company in another state.
In-network services are services provided by doctors and hospitals that have contracted with BCBSNM or with other Blue Cross and Blue Shield companies. For most benefits, after you've met the deductible for services from a Preferred Provider, you will usually pay a percentage of covered charges for services you receive from Preferred Providers. If the covered charge is less than the amount a provider bills, the provider will "write off" the difference. Preferred Providers will file your claims, and in New Mexico, will obtain any needed prior approvals for you.
What does "out-of-network" mean?
Out-of-network services are services provided by doctors and hospitals that have not contracted with BCBSNM or with other Blue Cross and Blue Shield companies. Out-of-network providers may have other contracts with their local BCBS, but not "preferred" or "PPO" contracts. For most benefits, after you've met the deductible for services from a Nonpreferred Provider, you will pay a percentage of covered charges for services you receive from Nonpreferred Providers. If the covered charge is less than the amount a Nonpreferred Provider bills, the provider may bill you for the balance. (Some Nonpreferred Providers may have other types of contracts with BCBSNM and will also write off the amount over the covered charge.) Some BCBSNM plans do not cover services from Nonpreferred Providers, except for emergency services. See your Summary of Benefits.
Yes, you may request a second opinion about any procedure or course of treatment recommended. Your physician can recommend a specialist, or contact BCBSNM Customer Service for assistance.
Do I need a referral to see a specialist?
No. However, you should verify that the specialist is in your network and that the services are covered under your plan before making an appointment. Otherwise, you will be responsible for costs of services not covered. Even if you don't need a referral for some services with specialists, you may need prior approval. We recommend seeing your primary care physician – your family doctor knows your medical history and is best qualified to coordinate all your medical care, including visits to specialists.
What is prior approval/authorization?
Certain services require approval from BCBSNM before being received; if approval is not obtained before you receive them, the services will be denied. The list of services that require prior approval is in your Benefit Booklet. To request prior approval, you or your provider must call BCBSNM Health Services (505-291-3585 in Albuquerque, or toll-free at 1-800-325-8334), Monday through Friday, from 8 a.m. to 5 p.m. Mountain Time.
Note: If your plan includes mental health, alcoholism, and drug abuse services, prior approval must be requested from the BCBSNM behavioral health services administrator. Call 505-816-6790 in Albuquerque, or toll-free at 1-800-583-6372. Phones are open 7 days a week, 24 hours a day.
Are mammograms covered under my plan?
Yes, but not all radiology and imaging centers offer mammography services. Please search under Ancillary Services – Mammography Centers on our Provider Finder®, or check the Mammography Provider List (PDF) to locate a BCBSNM provider in your area that performs mammography services.
What preventive services are covered?
Covered preventive services include: routine adult physicals, gynecological exams, related testing (includes routine Pap tests, mammograms, cholesterol tests, urinalysis, etc.) and well child care, immunizations, routine testing, routine vision or hearing screenings (through age 17).
Yes, with the BlueCard® program you have help accessing physicians and hospitals contracted as providers with Blue Cross and Blue Shield companies across the country. If you are traveling in the U.S. and need to find a provider when out of the area that BCBSNM serves, contact the local Blue Cross and/or Blue Shield company, call the BlueCard Doctor and Hospital Information Line toll-free at 1-800-810-BLUE (2583), or search the BlueCard Doctor and Hospital Finder. If you are outside the U.S. and need emergency medical care, go to the nearest hospital; call the BlueCard Worldwide® Service Center at 1-800-810-BLUE (2583) or call collect at 1-804-673-1177 if you're admitted. Always carry your BCBSNM member ID card, as it contains important information your provider will need to file claims correctly.
What is a medical emergency and what are my benefits?
An emergency is the sudden onset of a medical condition with symptoms of sufficient severity, including severe pain, whereby the absence of immediate medical attention could result in jeopardy to the member's health; serious impairment of bodily functions; serious dysfunction of any bodily organ or part; or disfigurement. Examples of emergency conditions are heart attack, poisoning, severe allergic reaction, convulsions, unconsciousness, and uncontrolled bleeding.
You must seek initial treatment within 48 hours of the accidental injury, or onset of the condition, for the visit to qualify as an emergency. Services received in an emergency room or other trauma center must meet the definition of "emergency" to be covered. Services received in a doctor’s office or urgent care facility are not considered emergencies.
Whether you're at home, out-of-state, or abroad, Blue Cross and Blue Shield of New Mexico wants to ensure you receive proper care in an emergency.
Here's what you need to know about your emergency medical care coverage:
- In an emergency, go to the nearest hospital or trauma center.
- You can call 911 or other community emergency resources to obtain assistance in life-threatening situations.
- You must call BCBSNM within 48 hours of the admission or benefits for covered facility services may be reduced. Check the back of your member ID card and call for admission/prior approval requirements; failing to do so can affect your benefits.
- You do not need authorization for out-of-network emergency services; however, you should call your doctor as soon as reasonably possible after receiving emergency room care or being admitted as an inpatient in order to arrange for follow-up care.
Note: Services are reviewed and if they are determined to be nonemergency services, coverage may be denied.
How can I get emergency care when traveling?
If you are traveling outside the service area and need emergency care, go to the nearest participating facility or call the BlueCard® Hotline at 1-800-810-BLUE (2583). The operator will give you the name and telephone number of a local provider who will be able to treat you, call BCBSNM Customer Service for eligibility information, and submit a claim to the local affiliated BCBS Plan. You will also call the BlueCard program to arrange follow-up care needed as a result of your sudden illness or injury; approved care will also be covered through the BlueCard program.
What is urgent care and what are my benefits?
Urgent care refers to a necessary medical treatment or service for an unforeseen condition that is not life threatening. The condition does, however, require prompt medical attention to prevent a serious deterioration in your health (e.g., sprains, high fever, cuts that require stitches).
See your Summary of Benefits or Benefit Booklet for guidelines on urgent care coverage.
What do I do to get urgent care?
If you don't have an emergency condition but feel that you need prompt medical attention, go to an urgent care center in our network. If you have coverage for out-of-network services, you will pay higher out-of-pocket costs at a noncontracted urgent care center than you would at a contracted urgent care center. Note: Your wait time/treatment time may be shorter than if you go to an emergency room. It's important to save the emergency room for emergencies.
If you're traveling and need urgent care, call the BlueCard® Hotline at 1-800-810-BLUE (2583). The operator will give you the name and telephone number of a local provider who will be able to treat you. Note: If your plan does not have benefits for out-of-network coverage (e.g., you are a BlueNet or HMO Blue member), you must use network providers to receive benefits for nonemergency services.
How does Coordination of Benefits work?
If you and your spouse are covered under each other's group plans, your plan is always primary for your claims, and your spouse's plan is primary for his or her claims. The primary plan will pay first. The secondary plan may then pay an additional amount toward the claim, depending on its rules. If dependent children are covered under both your group plan and your spouse's, the plan of the parent whose birthday (month and day) occurs first in the calendar year will be considered primary.
What is an eligible dependent?
Generally, eligible dependents for group or individual plans include:
- Your spouse*
- Your and/or your spouse's unmarried, dependent children who are under the limiting age specified on your Summary of Benefits or in your medical/surgical plan Benefit Booklet
- Children who are under your legal guardianship**
- Children who are in your custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first
*The spouse of a covered employee is an eligible dependent. Typically, if there is a divorce, the spouse no longer meets the previously stated description of an eligible dependent. His or her coverage will end as of the date of the divorce.
**Typically, children who are also employees of your group are not eligible dependents under your coverage. Coverage for unmarried children will end on the last day of the calendar month in which the limiting age birthday falls or on their date of marriage, whichever occurs first.
How do I add an eligible dependent to my health insurance coverage?
To add a dependent to your health insurance coverage, please call us at the number on your BCBSNM member ID card.
Why isn't my dependent's name listed on my ID card?
As a subscriber, only your name is listed on an ID card. However, any dependent listed in your health care benefits plan will be covered according to your policy, and your dependent will receive an ID card that includes your name as the subscriber (main policyholder).
What should I do if I lose my ID card?
You can log in to Blue Access® for Members and request a new member ID card. It will take up to two weeks to receive a new card. If you need a new card immediately, you can print a temporary ID card to use until your permanent card arrives.
How does my prescription drug plan work?
If you have prescription drug coverage through BCBSNM, please see your medical plan-specific FAQs and the separately issued Prescription Drug Plan Rider for more information.
