• 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 my clients find a Preferred Provider?
• What is a Nonpreferred Provider?
• What does "in-network" mean?
• What does "out-of-network" mean?
• Can my clients get a second opinion?
• Do my clients need a referral to see a specialist?
• What is prior approval/authorization?
• Are mammograms covered?
• What preventive services are covered?
• Are my clients covered when traveling?
• What is a medical emergency and what are the benefits?
• What do my clients do in an emergency?
• How can my clients get emergency care when traveling?
• What is urgent care and what are the benefits?
• What do my clients do to get urgent care?
• How does Coordination of Benefits work?
• What is an eligible dependent?
A deductible is the amount your clients must pay each year before BCBSNM begins to pay for services. Check the BCBSNM member ID card for the amount of the deductible. If your clients 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 (the 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 your client 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 client's 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 your clients for the difference between the covered charge and the billed charge.
Coinsurance is the percent of covered charges that your clients must pay for covered services after the deductible has been met. With most plans, after your clients have met the deductible, they 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 the Summary of Benefits for the percentage of covered charges they will have to pay for different services.
A copayment is a fixed dollar amount your clients are required to pay for a service at the time they 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 your client will pay for covered services in a calendar year. The amounts your client 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 client's PPO plan will pay 100 percent for most covered charges for the calendar year. See the Summary of Benefits or Benefit Booklet for more information.
For HMO plans, an out-of-pocket limit is usually twice (2X) the annual premium. After the out-of-pocket limit is reached, the HMO plan will pay 100 percent for most covered charges for the calendar year.
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 my clients find a Preferred Provider?
To find a Preferred Provider, they can check the printed network directory or search the Provider Finder® on this Web site. Your clients may also call BCBSNM Customer Service at the number on the back of the ID card for help looking for Preferred Providers. For Preferred Providers outside New Mexico, your clients should 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 your clients have met the deductible for services from a Preferred Provider, they will usually pay a percentage of covered charges for services they receive from Preferred Providers. If the covered charge is less than the amount the provider bills, the provider will "write off" the difference. Preferred Providers will file your clients' claims, and in New Mexico, will obtain any needed prior approvals for them.
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 your clients have met the deductible for services from a Nonpreferred Provider, they will pay a percentage of covered charges for services they receive from Nonpreferred Providers. If the covered charge is less than the amount a Nonpreferred Provider bills, the provider may bill your clients 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 the Summary of Benefits.
Can my clients get a second opinion?
Yes, they may request a second opinion about any procedure or course of treatment recommended. Their physician can recommend a specialist, or your clients can contact BCBSNM Customer Service for assistance.
Do my clients need a referral to see a specialist?
No. However, they should verify that the specialist is in the network and that the services are covered under the plan before making an appointment. Otherwise, your clients will be responsible for costs of services not covered. Even if they don't need a referral for some services with specialists, they may need prior approval. We recommend seeing the primary care physician – your client's family doctor knows his or her medical history and is best qualified to coordinate all 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 your clients receive them, the services will be denied. The list of services that require prior approval is in the Benefit Booklet. To request prior approval, your clients or their 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 the 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.
Yes. Not all radiology and imaging centers offer mammography services. To find a BCBSNM provider that performs mammography services, members can call Customer Service at the number on the back of their ID card.
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, including immunizations, routine testing, and routine vision or hearing screenings (through age 17).
Are my clients covered when traveling?
Yes, with the BlueCard® program your clients have help accessing physicians and hospitals contracted as providers with Blue Cross and Blue Shield companies across the country. If your clients are traveling in the U.S. and need to find a provider when out of the area that BCBSNM serves, they can 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 your clients are outside the U.S. and need emergency medical care, they should 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 they're admitted. They should always carry their BCBSNM member ID card, as it contains important information the provider will need to file claims correctly.
What is a medical emergency and what are the 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.
Your clients 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.
What do my clients do in an emergency?
Whether your clients are at home, out-of-state, or abroad, Blue Cross and Blue Shield of New Mexico wants to ensure they receive proper care in an emergency.
Here's what they need to know about their emergency medical care coverage:
- In an emergency, they should go to the nearest hospital or trauma center.
- They can call 911 or other community emergency resources to obtain assistance in life-threatening situations.
- They must call BCBSNM within 48 hours of the admission or benefits for covered facility services may be reduced. They can check the back of their member ID card and call for admission/prior approval requirements; failing to do so can affect their benefits.
- They do not need authorization for out-of-network emergency services; however, they should call their 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 my clients get emergency care when traveling?
If they are traveling outside the service area and need emergency care, they should go to the nearest participating facility or call the BlueCard® Hotline at 1-800-810-BLUE (2583). The operator will give them the name and telephone number of a local provider who will be able to treat them, call BCBSNM Customer Service for eligibility information, and submit a claim to the local affiliated BCBS Plan. The provider will also call the BlueCard program to arrange follow-up care needed as a result of the sudden illness or injury; approved care will also be covered through the BlueCard program.
What is urgent care and what are the 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 the Summary of Benefits or Benefit Booklet for guidelines on urgent care coverage.
What do my clients do to get urgent care?
If they don't have an emergency condition but feel that they need prompt medical attention, they should go to an urgent care center in our network. If they have coverage for out-of-network services, they will pay higher out-of-pocket costs at a noncontracted urgent care center than they would at a contracted urgent care center. Note: The wait time/treatment time may be shorter than if your clients go to an emergency room. It's important to save the emergency room for emergencies.
If your clients are traveling and need urgent care, they can call the BlueCard® Hotline at 1-800-810-BLUE (2583). The operator will give them the name and telephone number of a local provider who will be able to treat them. Note: If the plan does not have benefits for out-of-network coverage (e.g., they are a BlueNet or HMO Blue member), they must use network providers to receive benefits for nonemergency services.
How does Coordination of Benefits work?
If your client and his or her spouse are covered under each other's group plans, the client's plan is always primary for the client's claims, and the spouse's plan is primary for the spouse's 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 the client's and spouse's group plans, 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 client's spouse*
- Your client's and/or his or her spouse's unmarried, dependent children who are under the limiting age specified on the Summary of Benefits or in the medical/surgical plan Benefit Booklet
- Children who are under your client's legal guardianship**
- Children who are in your client's 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 client's 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.
