Reminder: Out-of-Network Medicare Providers can Treat Group Medicare Advantage Open Access (PPO) Members

Dec. 18, 2019

As a Medicare provider, you do not need to have a contract with Blue Cross and Blue Shield of Montana (BCBSMT) to treat Blue Cross Group Medicare Advantage Open Access (PPO)SM members.

As we announced in October, Blue Cross Group Medicare Advantage Open Access (PPO) is the new name of Blue Cross Medicare Advantage (PPO) Employer GroupSM. This plan offers members access to care from any providers nationwide who accept Medicare assignment and are willing to bill BCBSMT. Members’ coverage levels are the same in and out of network, and you will be paid the Medicare allowed amount.

What you need to know

  • Referrals are not required for office visits
  • Prior authorization may be required for certain Medicare-covered services.
  • Out-of-network providers will be paid the Medicare allowed amount for covered services as defined by Medicare, less any member cost-sharing. In-network providers will be paid their contracted rate.
  • For eligibility, prior authorization or claims inquiries, call 877-299-1008.

Member ID card
Group Medicare Advantage Open Access (PPO) members will have this ID card. Look for “Open Access” on the front.

Details about Group Medicare Advantage Open Access (PPO), available on the flier.

Questions?Contact us.

Out-of-network/non-contracted providers are under no obligation to treat Blue Cross Group Medicare Advantage Open Access (PPO) members, except in emergency situations.

It is important to check eligibility and benefits for each patient before every scheduled appointment. Eligibility and benefit quotes include membership confirmation, coverage status and applicable copayment, coinsurance and deductible amounts. The benefit quote may also include information on applicable benefit prior authorization/pre-notification requirements. Ask to see the member’s BCBSMT ID card and a driver’s license or other photo ID to help guard against medical identity theft.

Checking eligibility and benefits and/or obtaining benefit prior authorization/pre-notification or predetermination of benefits is not a guarantee that benefits will be paid. Payment is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations and exclusions set forth in your patient’s policy certificate and/or benefits booklet and/or summary plan description. Regardless of any benefit determination, the final decision regarding any treatment or service is between you and your patient. If you have any questions, please call the number on the member’s ID card.