Monthly Archives: February 2016

Why you are out of network for Covered CA

I have two providers who are both out of network for the Blue Shield Covered CA Silver plan. They were both surprised and displeased by this. And so were their patients. As a result, I was tasked with “looking into this, please.” Which, as an aside, I was happy to do, seeing as it is my job.

So, it turns out, the first provider was out of network with the Blue Shield Covered CA Silver plan because in late 2013 when he was sent the application for the three tiers of Covered CA plans, he chose to sign up with only the platinum and gold plans, and specifically opted out of the silver plan. Then he promptly forgot that he signed that paper and in Jan 2014 when he started seeing Covered CA people, Blue Shield told Silver patients that he was a provider. They came to him and he saw them and then they had 50% coinsurances applied to every visit. And no one was happy.

Since I learned my lesson with that situation, when it came time to contract the second doctor in this story with Blue Shield, I MADE SURE to check all three boxes for all three tiers of the Covered CA plans. So, at the end of 2014 when he started seeing Covered CA people, Blue Shield told Silver patients that he was a provider. They came to him and he saw them and then they had 50% coinsurances applied. When I called Blue Shield with a copy of the application in my hand the provider enrollment representative told me that since the HOSPITAL my doctor had rights in was not contracted with the Blue Shield Covered CA Silver plan, Blue Shield could not give him a contract that included that plan.

So, if you are having issues with large deductibles, large coinsurances, and your claims are being processed as out of network, call provider enrollment. The issue is probably either something that seemed insignificant and has been forgotten, or completely out of your hands, and something the doctor needs to address.

The contact info for Blue Shield provider enrollment is (800) 258-3091 or BSCproviderinfo@blueshieldca.com

 

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Filed under Billing, Blue Shield, Contracting, Medical Billing