HMO coverage means this member must use providers within the plan's network. A primary care physician serves as the care coordinator and must authorize specialist referrals. Emergency services are the primary exception to the network requirement. Always verify referral status before providing non-emergency specialty care.
This is a Preferred Provider Organization (PPO) prefix. PPO plans are the most common BCBS plan type. Members have the freedom to self-refer to specialists. Claims for in-network services are typically processed faster and reimbursed at higher rates than out-of-network claims.
Under this prefix, the member may have Medicare Advantage coverage administered by this BCBS plan. MA claims are subject to CMS regulations in addition to the plan's own policies. Balance billing restrictions apply. Verify the member's specific MA plan details and confirm the correct payer ID for electronic submission.
This prefix includes Medicaid managed care coverage. The BCBS plan administers Medicaid benefits on behalf of the state. Claims submission, prior authorization, and reimbursement rules may follow state Medicaid guidelines rather than the plan's standard commercial policies. Confirm the correct payer ID for Medicaid claims.
Nonprofit health plan providing 6 million Californians with affordable healthcare coverage including HMO, PPO, dental, and vision plans for individuals, families, and employers.