PPO coverage under this prefix means the member can access any provider. In-network providers have negotiated rates with the plan, while out-of-network providers are reimbursed based on usual and customary charges. Prior authorization is generally not required for routine services but may be needed for high-cost procedures.
This is a Health Maintenance Organization (HMO) prefix. HMO plans have stricter routing requirements than PPO plans. Members select a PCP who manages their care and issues referrals. Claims for specialist services should include the referral number. Out-of-network claims will typically be denied unless emergency criteria are met.
Under this prefix, the member may have Medicaid coverage managed by this BCBS plan. Medicaid claims have specific rules around cost-sharing, balance billing, and timely filing that override the plan's standard commercial policies. Contact the plan's Medicaid provider services line for submission details.
Independent licensee providing commercial, Medicare and Medicaid plans to North Carolina members.