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In-Network vs. Out of Network

IT PAYS TO STAY IN-NETWORK

You save time and money. There’s less hassle with paperwork. As you may be aware, beginning January 1, 2018, the PWGA reimburses out-of-network care at 60% of the bill. The maximum out-of-pocket for out-of-network is $20,000 as opposed to 85% and $1,500 for in-network services.

Going out-of-network also means you get more paperwork, and the price controls obtained by the PWGA for in-network services aren’t applicable. Thus, if a provider wants to charge an outrageous amount for a particular service, the PWGA will pay for 60% of the Reasonable and Customary rate for the service. You will be responsible for the difference – what the industry calls “balance-billing”.

IN-NETWORK PROVIDERS OUT-OF-NETWORK PROVIDERS
How much do you pay? LESS The PWGA contracts with providers so they agree on how much (a discounted rate) you pay when you see them. MORE Because there is no contract with the PWGA or negotiation on price, they can charge any amount they want.
Are you protected from balance billing? YES Providers can’t bill you for more than they have agreed to accept from the PWGA(assuming you have met the annual deductible and coinsurance amounts). NO The out-of-network provider can charge any amount they want, and bill you for the difference between what the PWGA allows for and their price. You get “balance-billed” for the difference.
Do you have to fill out and send claims forms? NO The provider does the paperwork for you. The PWGA pays the providers directly. You are only responsible for any remaining balance. MAYBE If your provider doesn’t file a claim for you then you’ll have to file one after you receive the bill. You’ll have to go the PWGA website to get the proper form.

HOW IN-NETWORK CLAIMS ARE PAID

The paperwork and forms are all handled by the provider and the PWGA; you don’t have to fill out any forms. The process looks like this:

HOW OUT-OF NETWORK CLAIMS ARE PAID

While some out-of-network providers may file a claim for you, more often than not, this responsibility will fall to you, the patient. The process looks like this:

HOW DO I FIND AN IN-NETWORK PROVIDER?

The quickest way to find an in-network provider is to go to the PWGA website by clicking here, going to the Anthem website, using Anthem’s mobile App on your smartphone, or calling the numbers on the back of your healthcare identity card.

Online Physician: www.livehealthonline.com
Note: When submitting claims or correspondence, always include the fill 12-digit participant identification number listed on the front of this card. Possession or use of this card does not guarantee payment.

Claims:

All California Claims:
Anthem Blue Cross
P.O. Box 60007
Los Angeles, CA 90060-0007

Non California Claims:
Submit to local BCBS office.
(See PWGA.org)

Electronic ID:
47198 (CA Claims only)

Dental Claims*:
Delta Dental
P.O. Box 997330
Sacramento, CA 95899

Contact:

PWGA Eligibility and
Benefit Inquiries
(818) 846-1015
(800) 227-7863

Locate a Medical Provider
(800) 810-2583

Pre-Authorization or
Pre-Service Review
(800) 274-7767

Anthem Provider Services
(CA only)
(800) 688-3828

Express Scripts*
(800) 987-6551

Delta Dental*
(Group# 0825)
(800) 765-6003

BlueCard Worldwide
(Traveling or living abroad)
(800) 810-2583

* Contracts directly with the group
Note: Anthem Blue Cross Life and Health Insurance Company provides administrative services only and does not assume any financial risk or obligation with respect to claims. Blue Cross of California, using the trade name Anthem Blue Cross, administers claims on behalf of Anthem Blue Cross Life and Health Insurance Company and is not liable for benefits payable. Independent licensees of the Blue Cross Association.

CONCLUSION

Every way you look at it, in-network makes sense. It gives you the best price. It never leaves you with “balance-billing”. It saves you a whole lot of paperwork. The next time you’re getting ready to see a healthcare provider, make sure they’re in-network. You’ll be glad you did.