Under this EPO prefix, the member has no out-of-network coverage for routine care. However, unlike HMO plans, no referral is needed to see a specialist within the network. When billing, confirm the provider's network participation status with the plan before submitting the claim.
This is a Point of Service (POS) prefix. POS plans offer flexibility similar to a PPO but incentivize in-network care through lower cost-sharing. Members designate a primary care physician who can issue referrals for the highest level of benefits. Out-of-network claims are covered but at significantly reduced rates.
Medicaid coverage under this prefix means the member's Medicaid benefits are administered by a BCBS managed care plan. Medicaid managed care claims may have different submission requirements, payer IDs, and timely filing deadlines than commercial claims. Verify the specific Medicaid plan details with the payer.
Independent licensee providing commercial, Medicare and Medicaid plans to Texas members.