Attention Medicare Advantage PPO Contracted Providers:

Medicare Advantage PPO Network Sharing
Provides In-Network Access to Out-Of-Area Blue Plan Medicare Advantage PPO Members

Medicare Advantage PPO Network Sharing Provides In-Network Access to Out-Of-Area Blue Plan Medicare Advantage PPO MembersAll Highmark Blue Cross Blue Shield, Highmark Blue Shield, and/or Highmark West Virginia Blue Cross Blue Shield Medicare Advantage PPO Plans participate in reciprocal network sharing. This allows all Blue Plan Medicare Advantage PPO patients to obtain in-network benefits when traveling or living in the service area of any other Blue Medicare Advantage PPO Plan if the patient sees a contracted Blue Medicare Advantage PPO provider.

If you have a Medicare Advantage PPO contract with Highmark, you should provide the same access to care for patients of other Blue Medicare Advantage PPO Plans as you do for Highmark’s Medicare Advantage PPO patients. Below are answers to questions you may have about Medicare Advantage PPO Network Sharing.

Q How does Medicare Advantage PPO Network Sharing work?
A If you are a contracted Medicare Advantage PPO provider with Highmark and you see Medicare Advantage PPO patients from another Blue Plan, you must give them the same contractual access to care as other Highmark patients and you will be reimbursed in accordance with your negotiated rate under your Highmark contract. Your patients will receive in-network benefits in accordance with their benefit plan. If you are not a contracted Medicare Advantage PPO provider with Highmark and you provide services for out-of-area Blue Medicare Advantage PPO patients, you will receive the Medicare allowed amount for covered services based on where the services were rendered and according to the patient’s out-of-network benefit level. For emergency and urgent care, you will be reimbursed at the patient’s in-network benefit level.
Q How do I recognize an out-of-area patient from one of the Plans participating in this program?
A The “MA” in the suitcase on the patient’s Blue Plan Medicare Advantage PPO ID card indicates a patient who is covered under the Medicare Advantage PPO Network Sharing Program. Patients should be asked to show their Blue Cross and/or Blue Shield ID card when receiving services (and not their standard Medicare ID card).
Q Do I have to provide services to Medicare Advantage PPO patients from other Blue Plans?
A

If you are a contracted Medicare Advantage PPO provider with Highmark, you should provide the same access to care as you do for Highmark Medicare Advantage PPO patients. 

If you are not a contracted Medicare Advantage PPO provider with Highmark, you may see other Blue Plan Medicare Advantage PPO patients; however, you are not required to do so.

Q What if my practice is closed to new local Medicare Advantage PPO patients?
A If your practice is closed to accepting new Highmark Medicare Advantage PPO patients, you are not required to provide care for out-of-area Blue Plan Medicare Advantage PPO patients.
Q How do I verify eligibility and benefits?
A You can verify eligibility and benefits for Medicare Advantage PPO patients from other Blue Plans via Highmark’s NaviNet® provider portal. Select BlueExchange® (Out-of-Area) under Workflows for this Plan, and then click on BX Eligibility and Benefits Inquiry. You can also call the BlueCard® Eligibility line at 1-800-676-BLUE (2583) and provide the patient’s 3-character prefix located on the patient’s ID card.
Q Where do I submit the claim?
A Submit the claim to Highmark under your current billing practices. Once you submit the claim, Highmark will work with the out-of-area patient’s Blue Plan to determine benefits, and then Highmark will send you the payment.

Please do not bill traditional Medicare for any services rendered to a Medicare Advantage member.

Q What is the member cost-sharing level and copayments?
A When out-of-area Blue Plan Medicare Advantage PPO patients see Medicare Advantage PPO contracted providers in Highmark’s service areas, covered services and copayments will be at the patient’s in-network level of benefits. You may collect the copay amounts at the time of service.
Q May I balance bill the out-of-area patient the difference between my charge and the allowance?
A No, you may not balance bill the out-of-area patients for this difference. Patients may be billed for any applicable deductibles, coinsurance, and/or copays.
Q What if I disagree with the reimbursement amount that I received?
A If there is a question concerning the reimbursement you received, please contact Highmark Freedom Blue PPO Provider Services.
Q Who do I contact if I have a question about Medicare Advantage PPO Network Sharing?
A

If you have any questions about the Medicare Advantage PPO Network Sharing Program, please contact Highmark Freedom Blue PPO Provider Services at 1-866-588-6967

Information on the Medicare Advantage PPO Network Sharing Program is available in the Highmark Provider Manual. Please see Chapter 2.2: Medicare Advantage Products & Programs and Chapter 2.6: The BlueCard Program .


Disclaimer: BlueCard is a registered mark of the Blue Cross Blue Shield Association. Health benefits or health benefit administration may be provided by Highmark Blue Cross Blue Shield, Highmark Blue Cross, Highmark Blue Cross Blue Shield West Virginia, or Highmark Senior Solutions Company, which are independent licensees of the Blue Cross and Blue Shield Association.

 

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