Common Insurance FAQs

A deductible is the amount of covered charges your clients must pay each calendar year before BCBSNM begins to pay for its share of the applicable covered charges the member incurs during the rest of the same calendar year. 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, coinsurance, copayment, and/or penalty amount), 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 percentage of covered charges that your clients must pay for certain covered services after the deductible has been met. With most plans, after your clients have met the deductible, they will pay a percentage of covered charges for services from a Preferred Provider and a percentage of covered charges for services from a Nonpreferred Provider. Check the Summary of Benefits for the specific percentage of covered charges they will have to pay for different services.

A copayment is a fixed dollar amount your clients pay for a service at the time they receive care.

For PPO plans, an out-of-pocket limit is the maximum amount of coinsurance that your client will pay for covered services in a calendar year. After the out-of-pocket limit is reached, your client's PPO plan will pay 100 percent of most of the Preferred Provider and Nonpreferred Provider covered charges for the rest of that 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 of most covered charges for the calendar year, not to exceed any benefit limits.

A provider is a physician, hospital, or other health care professional or facility, licensed when required, that provides medical services and care, and performs within their scope of licensure.

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 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, they can 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 to request a printed network directory or to ask for help looking for Preferred Providers. For Preferred Providers outside New Mexico, your clients should call 1-800-810-BLUE (2583).

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

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.

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.

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.

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.

Covered preventive services include routine annual physicals, gynecological exams, related testing (includes routine Pap tests, mammograms, cholesterol tests, urinalysis, etc.), well child care, including immunizations, routine testing, and routine vision or hearing screenings (through age 17).

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.

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.

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 (or a family member) 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.

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.

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.

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.

If your client and his or her spouse are covered under each other's 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 plans, the plan of the parent whose birthday (month and day) occurs first in the calendar year will be considered primary.

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 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.