Member Services

Member Services

 
Your Primary Care Provider

At the time you enroll in this health plan, you will be required to choose (or designate) a primary care provider who participates in your health care network. You have the right to choose (or designate) any primary care provider who participates in your health care network and who is available to accept you or your family members. Your Schedule of Benefits will tell you the name of your health care network. The provider directory that is provided for your health plan lists all of the primary care providers who participate in your health care network. You can choose a primary care provider who is an internist, a family practitioner, a pediatrician, a nurse practitioner, or a physician assistant. Your primary care provider will furnish most of your health care and, when it is needed, will arrange for or coordinate other covered services. (Your primary care provider is often referred to as your “PCP.”) Usually, different members of a family have different health care needs. For this reason, each member of a family may choose a different primary care provider. Your choice is important. Your choice will determine who you will see for most of your health care and where you will receive it. This is because a primary care provider will most often send their patients to network specialists who are affiliated with the primary care provider’s network hospital or medical group. Your choice is also important because it may impact the costs that you pay for some health care services. As soon as you enroll and you choose your primary care provider, you should make an appointment with your primary care provider. This will allow your primary care provider to get to know your medical history and to give you medical attention and treatment that is tailored to your needs.

When You Need Help to Choose a Primary Care Provider

Blue Cross and Blue Shield can help you choose your primary care provider. If you need help, call the Blue Cross and Blue Shield customer service office. The toll free phone number to call is shown on your ID card. You can also call the toll free phone number that is shown in the provider directory that applies for your health plan. Or, you can call the Physician Selection Service at 1-800-821-1388.

When You Want To Change Your Primary Care Provider

You may change your primary care provider. All you have to do is call or write to the Blue Cross and Blue Shield customer service office. Or, you can make this change online by using the Blue Cross and Blue Shield member self service option. To change your primary care provider online, log on to the Blue Cross and Blue Shield Web site at www.bluecrossma.com. Just follow the steps to change your “PCP.”

When Your Primary Care Provider Disenrolls From the Network

If your primary care provider disenrolls from the health care network, Blue Cross and Blue Shield will send you a written notice at least 30 days before your primary care provider’s disenrollment date. The notice will tell you how to choose a new primary care provider. (If you do not choose a new primary care provider within 30 days, Blue Cross and Blue Shield may choose one for you. Blue Cross and Blue Shield will let you know if a new primary care provider is chosen for you.)

Your Health Care Network

This health plan consists of two benefit levels: one for PCP/Plan Approved Benefits; and one for Self-Referred Benefits. The costs that you pay for covered services will differ based on the benefit level. To receive the highest benefit level (your PCP/Plan Approved Benefits), you must obtain your health care services and supplies from providers who participate in your health care network. Your Schedule of Benefits will tell you the name of your health care network. The provider directory that is provided for your health plan lists the health care providers who participate in your health care network. The health care providers that participate in your health care network are referred to as “network providers.” (See “covered providers” in Part 2.) If you choose to obtain your health care services and supplies from a covered provider who does not participate in your health care network, you will usually receive the lowest benefit level (your Self-Referred Benefits). See Part 8 in this benefit booklet for the times when PCP/Plan Approved Benefits will be provided if you receive covered services from a covered provider who is not a network provider.

When You Need Help to Find a Health Care Provider

There are a few ways for you to find a health care provider who participates in your health care network. At the time you enroll in this health plan, a directory of health care providers for your health plan will be made available to you at no additional cost. To find out if a health care provider participates in your health care network, you can look in this provider directory. Or, you can also use any one of the following ways to find a provider who participates in your health care network. You can:

  • Call the Blue Cross and Blue Shield customer service office. The toll free phone number to call is shown on your ID card. They will tell you if a provider is in your health care network. Or, they can help you find a covered provider who is in your local area.
  • Call the Blue Cross and Blue Shield Physician Selection Service at 1-800-821-1388.
  • Use the Blue Cross and Blue Shield online physician directory (Find a Doctor). To do this, log on to www.bluecrossma.com. This online provider directory will provide you with the most current list of health care providers who participate in your health care network.

If you or your physician cannot find a provider in your health care network who can furnish a medically necessary covered service for you, you can ask Blue Cross and Blue Shield for help. To ask for this help, you can call the Blue Cross and Blue Shield customer service office. They will help you find providers in your health care network who can furnish the covered service.

When You Are Traveling Outside of Massachusetts

If you are traveling outside of your service area and you need emergency medical care (or urgent care), you can get help to find a health care provider. Just call 1-800-810-BLUE. You can call this phone number 24 hours a day for help to find a health care provider. When you call, you should have your ID card ready. You must be sure to let the representative know that you are looking for health care providers that participate with the local Blue Cross and/or Blue Shield Plan. Or, you can also use the internet. To use the online “Blue National Doctor & Hospital Finder,” log on to www.bcbs.com.

Your Identification Card

After you enroll in this health plan, you will receive an identification (ID) card. The ID card will identify you as a person who has the right to coverage in this health plan. The ID card is for identification purposes only. While you are a member, you must show your ID card to your health care provider before you receive covered services. If you lose your ID card or it is stolen, you should contact the Blue Cross and Blue Shield customer service office. They will send you a new card. Or, you can use the Blue Cross and Blue Shield Web site to ask for a new ID card. To use the Blue Cross and Blue Shield online member self service option, you must log on to www.bluecrossma.com. Just follow the steps to ask for a new ID card.

Your Inquiries and/or Claim Problems or Concerns

Blue Cross and Blue Shield can help you to understand the terms of your coverage in this health plan. They can also help you to resolve a problem or concern that you may have about your health care benefits. You can call or write to the Blue Cross and Blue Shield customer service office. You can call Monday through Friday from 8:00 a.m. to 8:00 p.m. (Eastern Time). The toll free phone number to call is shown on your ID card. To use the Telecommunications Device for the Deaf, call 1-800-522-1254. Or, you can write to: Blue Cross Blue Shield of Massachusetts, Member Service, P.O. Box 9134, North Quincy, MA 02171-9134. A Blue Cross and Blue Shield customer service representative will work with you to resolve your problem or concern as quickly as possible.

When You Need a Language Translator

A language translator service is available when you call the Blue Cross and Blue Shield customer service office. This service provides you with access to interpreters who are able to translate over 140 different languages. If you need these translation services, just tell the customer service representative when you call. Then during your call, Blue Cross and Blue Shield will use the language line service to access an interpreter who will assist in answering your questions or helping you to understand Blue Cross and Blue Shield procedures. (This interpreter is not an employee or designee of Blue Cross and Blue Shield.)