Member Services

Member Services

 
Your Primary Care Provider

As a member of this health plan, you are not required to choose a primary care provider to coordinate the health care benefits described in this benefit booklet. You may choose any covered provider to furnish your health care services and supplies. But, your choice is important because it will impact the costs that you pay for your health care services and supplies. Your costs will be less when you use health care providers who participate in your PPO health care network to furnish your covered services. These are called your “in-network benefits.” If you choose to use covered health care providers who do not participate in your PPO health care network, you will usually receive a lower level of benefits. In this case, your out-of-pocket costs will be more. These are called your “out-of-network benefits.”

Your Health Care Network

This health plan consists of two benefit levels: one for in-network benefits; and one for out-of-network benefits. The costs that you pay for covered services will differ based on the benefit level. To receive the highest benefit level (your in-network benefits), you must obtain your health care services and supplies from providers who participate in your PPO health care network. These health care providers are referred to as “preferred 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 this PPO health care network, you will usually receive the lowest benefit level (your out-of-network benefits). See Part 8 in this benefit booklet for the times when in-network benefits will be provided if you receive covered services from a covered provider who is not a preferred 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 Living or Traveling Outside of Massachusetts

If you live or are traveling outside of Massachusetts, 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 BlueCard PPO program. Or, you can also use the internet. To use the online “Blue National Doctor & Hospital Finder,” log on to www.bcbs.com. (For some types of covered providers, a local Blue Cross and/or Blue Shield Plan may not have, in the opinion of Blue Cross and Blue Shield, established an adequate PPO health care network. If this is the case and you obtain covered services from this type of covered provider, the in-network benefit level will be provided for these covered services. See Part 8 in this benefit booklet.)

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.)