What is a Blue Shield of California non-participating provider?

Healthcare providers who do not have a contract with Blue Shield are called non-participating providers. These providers charge their usual rates for services, which can be substantially higher than the rates allowed by providers in our network. As a Blue Shield member, you can see non-participating providers. However, you will typically have a higher cost share for their services.

What should I consider before seeing a non-participating provider for covered services?

If you see a non-participating provider, you will usually have to pay your plan’s coinsurance amount, as well as the difference between the non-participating provider’s cost and the amount Blue Shield allows for that service. Non-participating providers may also require you to pay the full amount owed when you receive the service.

What should I do after receiving care from a non-participating provider for covered services?

After you receive care from a non-participating provider, you will need to submit an out-of-network claim form.* To request reimbursement, submit a claim form and itemized bill to Blue Shield within one year of the service date.

You can ask the provider to give you the itemized bill, which must include the following information:

• Patient information
• Date of service
• Charges for each individual procedure
• Diagnosis code(s)
• Procedure code(s)
• Place of treatment
• Provider name
• Provider tax ID
• Provider national provider identifier (NPI)
• Amount paid by patient
• A note indicating the service was an “out-of-network self-referral”

Blue Shield will review your claim and notify you of its coverage determination within 30 days after receipt. If the service is eligible for reimbursement and you have met your calendar year deductible, Blue Shield will send you an Explanation of Benefits (EOB), as well as a reimbursement check for a portion of the costs. If you have not yet met your deductible, the Blue Shield allowed amount will be applied to the deductible and no reimbursement will be issued to you. The EOB will provide details of the claim.

How do I submit an out-of-network claim?

You can use either of the options below.

Online

• Visit blueshieldca.com/login and log in to your account.
• In the top panel, select Coverage and Benefits.
• Then choose Claims.
• Go to the “Out-of-network claims” feature box and select File a claim. Follow the steps to file your out-of-network claim online.

IMPORTANT: Make sure you select Yes as the answer to the question “Is this service an out-of-network self-referral?”

Mail

• Visit blueshieldca.com/login and log in to your account.
• Under the “Quick Links” section, select Download forms.
• You can also call the Blue Shield Customer Service number on the back of your ID card to request a claim form.
• Mail your completed form to Blue Shield of California, P.O. Box 272540, Chico, CA 95927.

IMPORTANT: Make sure you select Yes as the answer to the question “Is this service an out-of-network self-referral?”

How can I avoid accidentally using a non-participating provider?

Follow these tips to make sure you’re using in-network providers, so you pay the lowest out-of-pocket costs:

• Before you make an appointment with any new doctors, including specialists, ask them to verify that they are in your plan’s provider network or call Blue Shield Customer Service at (855) 256-9404 (TTY: 711).
• If your doctor refers you to a specialist, laboratory, X-ray lab, or other provider, before your visit, ask that provider to verify that they are in your plan’s provider network or call Blue Shield Customer Service at (855) 256-9404 (TTY: 711).
• Any time you are considering getting care from a non-participating provider, before the visit, ask them how much your total charges will be – and if you will have to pay in full at the time of the visit. Then, refer to your plan’s Evidence of Coverage and Disclosure Form to see the amount that you will be responsible for based on your plan’s benefits. Note: You may pay more for Level II (PPO) and Level III (out-of-network) services than for Level I (HMO) services.

Want to make sure you’re using an in-network provider?

For help locating a doctor, specialist, or facility in your plan’s network:

• For HMO network (Level I) benefits, go to blueshieldca.com/networkhmo.
• For PPO network (Level II) benefits, go to blueshiedca.com/pponetwork.
• Call Blue Shield Customer Service at (855) 256-9404 (TTY: 711).