Frequently Asked Questions About the National PPO Plan

The National PPO Plan lets you see the providers you want to see. You do not have to choose a primary care provider and do not need a referral to see a specialist. Providers are classified as "Preferred" (in-network) or "Nonpreferred" (out-of-network), and your choice of provider will determine the amount of your out-of-pocket costs. You will pay a higher deductible and higher out-of-pocket costs if you visit Nonpreferred Providers, but it is your choice to receive most covered health care services from any licensed provider. For most services, you will have a deductible to meet and will then be responsible for paying coinsurance (a percentage of covered charges).

A Preferred Provider (in-network provider) is a health care professional or facility that has contracted with BCBSNM, a BCBSNM contractor or subcontractor, or with a Blue Cross and Blue Shield (BCBS) company in another state. To find a Preferred Provider, search the Provider Finder^®. You may also call BCBSNM Customer Service at the number on the back of your member ID card to request a printed network directory or to ask for help looking for Preferred Providers. For Preferred Providers outside New Mexico, call 1-800-810-BLUE (2583).

A Nonpreferred Provider (out-of-network provider) has not contracted with BCBSNM or another Blue Cross and Blue Shield (BCBS) company, either directly or indirectly, to be part of the preferred or PPO provider network.

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.

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.

You will use the Blue Cross and Blue Shield of New Mexico PPO provider network to access contracted doctors, hospitals, and other health care professionals within New Mexico. To find contracted providers in New Mexico, search our Provider Finder^®. National PPO Plan members also have access to PPO providers when outside New Mexico – search the Blue National Doctor and Hospital Finder^®.

The office visit copayment covers only the office visit charge. You will pay deductible and coinsurance for other related services you receive during the visit.

Certain services require approval from BCBSNM. If approval is not obtained, BCBSNM will not pay for them. This approval is called "preauthorization." The list of services that require preauthorization is in the Benefit Booklet. To request preauthorization, you or your provider must call BCBSNM Health Services. Call 1-505-291-3585 in Albuquerque, or toll-free at 1-800-325-8334, Monday through Friday, from 8 a.m. to 5 p.m. Mountain time.

Note: Your plan includes behavioral health and chemical dependency services. Preauthorization is required for inpatient, residential treatment, partial hospitalization and some outpatient services. Request preauthorization from the BCBSNM behavioral health services administrator. Call toll-free at 1-888-898-0700. Phones are open 7 days a week, 24 hours a day.

Yes, with the BlueCard^® Program you have help accessing physicians and hospitals contracted as providers with Blue Cross and Blue Shield companies across the United States, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands (also called the “BlueCard Service Area”). 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 Blue National Doctor and Hospital Finder. Always carry your BCBSNM member ID card, as it contains important information your provider will need to file claims correctly.

If you are outside the United States, Puerto Rico, and the U.S. Virgin Islands, you may be able to take advantage of the Blue Cross Blue Shield Global^® Core Program when accessing Covered Services. Blue Cross Blue Shield Global Core is unlike the BlueCard Program available in the BlueCard Service Area in certain ways. Although Blue Cross Blue Shield Global Core assists you with accessing a network of inpatient, outpatient, and professional providers, the network is not served by a Host Blue Plan. When you receive care from providers outside the BlueCard Service Area, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. For services received in foreign countries, BCBSNM will use the exchange rate in effect on the date of service in order to determine the covered charge.

Go to the Global Core website and register to search for providers outside the U.S., as well as access other emergency information. If you need medical assistance services (including locating a doctor or hospital) outside the BlueCard Service Area, call the Blue Cross Blue Shield Global Core service center at 1-800-810-BLUE (2583), 24 hours a day, 7 days a week. An assistance coordinator, working with a medical professional, can arrange a physician appointment or hospitalization, if necessary.

BCBSNM's customer service representatives are available to answer your questions 6 a.m. to 8 p.m. MT, Monday through Friday, and 8 a.m. to 5 p.m. MT on weekends and holidays (closed Thanksgiving and Christmas Day). If you call after hours, you can leave a message and we will return your call by the next business day. Call BCBSNM Customer Service toll-free at 1-877-878-LANL (5265). Please have your member ID card available when you call.