Things to consider:
Where is the physician located? The physician should be located close to where you live or work to ensure that you have reasonable access to care. Generally, Blue Shield will require that the selected Personal Physician be located within 15 miles or 30 minutes from the member's residence or place of employment.
- Is the physician accepting new patients?
- Is the physician affiliated with your preferred hospital? If you know which hospital, medical group, or Independent Practice Association (IPA) you would like to be part of , you can check if your desired physician belongs within that medical group by viewing the doctor’s page on Find a Provider.
- What are the physician's credentials? Check to see if the physician is board certified. All physicians are required to pass an exam in their specialty to obtain board certification.
Questions to ask:
Make yourself a list of questions before meeting with the doctor for the first time:
- Are there other physicians or nurse practitioners in the practice? You may be seen by them if your doctor is unavailable.
- What are the office hours? This is important if your job requires you to schedule doctor's appointments after work or on Saturday.
While you're there, notice:
- Is the office staff courteous and helpful? The way the staff treats patients is often an indication of how a doctor treats patients.
- Do you have to wait a long time past your scheduled appointment? If there is a delay or an emergency, the staff should let you know.
About the doctor:
- Is the doctor warm, polite, and attentive, or rushed and preoccupied?
- Are they attentive? Do they listen to you?
- Do they take the time to make a connection with you?
- Do they both solicit and answer your questions?
- Is everything explained to your satisfaction?
- Do you understand their explanations?
- Does the physician train medical residents, medical students, nurses, or physician assistants? If so, this experience may enhance their ability to explain things more clearly to their patients and be aware of the latest medical research.
Things to consider when choosing a PPO provider
With PPO plans, you have the option to go to a preferred or non-preferred doctor or hospital each time you access care. Preferred providers are in Blue Shield PPO network while non-preferred providers are not within their PPO network. Every plan offers a network of doctors and hospitals to provide you and your family with care. In order to make sure you receive the best value and do not have to pay out of your own pocket at the time of service, you must use doctors and hospitals in your plan’s network. If you choose to use a doctor or hospital that is not in your plan’s network, you will be responsible for all billed charges. Please note that the Exclusive PPO network is not as large as our Full PPO network.
Whenever possible, you should choose a doctor or hospital from the preferred provider network.
When you go to a preferred provider, you can save money and receive the highest level of benefits available to you.
- When you decide to go to a non-preferred provider, you should be aware that Blue Shield of California has no contract with these non-network providers concerning "allowable amounts."
- You'll be responsible for paying a percentage of the amount a non-preferred provider charges you, as well as the amount above Blue Shield's allowable amount for the services you were provided.
- Also, your copayments and deductibles may be higher and your calendar-year copayment maximum is set at the highest level for your PPO plan.
- You'll need to pay the non-preferred provider directly for the entire cost of your care, then you must file a claim with Blue Shield within one year of the month you receive these services. They will keep track of these charges and apply the appropriate amount toward your calendar-year deductible and calendar-year copayment maximum, or reimburse you at the applicable benefit level if you've already met your deductible or copayment maximum for the year. They will notify you of their coverage decision within 30 days of receiving your claim.
For information about allowable amounts, copayments, and deductibles, please refer to your Evidence of Coverage or Certificate of Insurance.
When you need specialist care
Your PPO plan gives you the flexibility of going to a specialist, such as a dermatologist or cardiologist, without a referral.
You also have the option of seeing a specialist who is not in the preferred provider network. However, to keep your medical costs down, it's wise to go to a specialist who is in the preferred provider network.
When you want or need a second opinion
Your PPO plan has the same benefits for second opinions as you do for other physician office visits.
For specific details about your plan benefits, please refer to your Evidence of Coverage or Certificate of Insurance.
The role of your Personal Physician
An HMO plan is different from a PPO plan in that you need to select a Personal Physician (primary care physician) who will be responsible for coordinating your care. Together, you and your physician will decide on the best care for you.
Here are some of the services your Personal Physician will provide for you:
- Provides and coordinates your medical care, including referrals to specialists.
- Orders lab tests, X-rays, and other medical tests.
- Arranges hospital or skilled nursing facility admission.
- Focuses on improving your health through preventive care services, including exams, immunizations, and well-child and well-baby care.
- Assists you in obtaining approval for mental health and substance abuse.
- Assists you in applying for hospice care.
When enrolled in a Blue Shield HMO plan, your medical care will only be covered when it is provided or coordinated by your Personal Physician. The few exceptions include:
Mental health care
Substance abuse care
Access+ SpecialistSM exceptions (see below)
Urgent care delivered outside Blue Shield of California's service area
Obstetrics/gynecology (OB/GYN) care obtained from an OB/GYN or family physician at your Personal Physician's medical group or IPA
For information about available mental health and substance abuse services, please refer to your Evidence of Coverage.
Please also review Choosing a Personal Physician and hospital or Medical Group/IPA.
If you need the care of a medical specialist such as a dermatologist or cardiologist, your Personal Physician can refer you to a specialist.
As an Access+ HMO® member, the Access+ SpecialistSM option allows you to go directly to a specialist within your Personal Physician's medical group or Independent Practice Association (IPA). To use this option, you'll need to select a Personal Physician whose medical group or IPA participates in the Access+ Specialist program.
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