Out-of-network liability and balance billing

Preferred Provider Organization (PPO) coverage is most effective and advantageous for a member when the member receives covered healthcare services from a preferred or "in-network" provider. Claims for services provided by preferred providers may have a more advantageous deductibles, coinsurance and copays than claims for services that are performed by non-preferred, or "out-of-network" provider.

PPO or in-network deductibles, coinsurance and copays are applied to allowable charges for services and supplies members receive from preferred providers, unless the Schedule of Benefits or a policy shows a different deductible, coinsurance or copay for the particular service.

Reimbursement for services by non-preferred providers generally will be less than payment for the same services if they had been provided by a preferred provider, and could result in substantial additional out-of-pocket expense to the member. Non-PPO or out-of-network deductibles, coinsurance and copays are applied to allowable charges for services and supplies members receive from non-preferred providers, unless:

1. Plan Provision. The Schedule of Benefits or a policy provides a different deductible, coinsurance or copay for the particular service or supply that is the subject of the claim
2. Emergency Services. The intervention is for emergency care, in which case the in-network deductible, coinsurance and copay apply.
3. Provider Leaves the PPO Network. A member can notify Arkansas Blue Cross and Blue Shield that a non-preferred provider was formerly a preferred provider during ongoing treatment of the member for an acute condition, which treatment began before the provider left the PPO network, and request that PPO benefits be paid for the continuation of the ongoing treatment. If Arkansas Blue Cross approves PPO coverage for the ongoing treatment, in-network deductibles, coinsurance and copays will apply to claims for services and supplies rendered by the non-preferred provider for such condition after Arkansas Blue Cross's approval until the end of the current episode of treatment or until the end of ninety (90) days, whichever occurs first.
4. Provider Leaves PPO During Member Pregnancy. A member can notify Arkansas Blue Cross that a non-preferred provider was formerly a preferred provider while the member was receiving obstetrical care for a pregnancy covered under the terms of the plan, and that the member was in the third trimester of the pregnancy on the date that the provider left the PPO. In such cases, the member can request PPO benefits for continuation of such obstetrical care from this non-preferred provider. If Arkansas Blue Cross approves PPO coverage for the requested obstetrical care, in-network deductible, coinsurance and copay will apply to services and supplies received from this non-preferred provider after Arkansas Blue Cross's approval and will continue to apply to claims for services and supplies rendered by the non-preferred provider until the completion of the pregnancy, including two (2) months of postnatal visits.
5. Arkansas Blue Cross and Blue Shield Approval. A member can notify Arkansas Blue Cross prior to receiving a health intervention from a non-preferred provider and, if Arkansas Blue Cross determines that the required covered services or supplies associated with the health intervention are not available from a preferred provider and provide a written approval of in-network coverage for such services or supplies, in-network deductibles, coinsurance and copays will apply to the claims for the services received from the non-preferred provider.

Notification to Arkansas Blue Cross and Blue Shield of requests for payment of out-of-network services or supplies at in-network benefit level should be made by writing to:

Arkansas Blue Cross and Blue Shield
Attention: Medical Audit and Review Services
PO Box 3688
Little Rock, AR 72203

Requests should be received at least 15 working days prior to your receipt of such services or supplies.

No Balance Billing from Preferred Providers and Contracting Providers. Preferred providers and contracting providers are physicians or hospitals who are paid directly by Arkansas Blue Cross and have agreed to accept Arkansas Blue Cross's payment for covered services as payment in full except for your deductible, coinsurance, copay and any specific benefit limitation, e.g. home health visits are limited to 50 per year. A covered person is responsible for a provider’s billed charges in excess of Arkansas Blue Cross's payment when non-preferred or non-contracting providers render covered services, except in specific circumstances. This is sometimes referred to as “balance billing” by non-preferred and non-contracting providers, and these excess charges could amount to thousands of dollars in additional out-of-pocket expenses to the covered person.

Members have a choice to receive covered dental services from either a participating or non-participating dentist in our dental network

USAble Mutual Insurance Company has a contracted network of participating dentists. These dentists have signed an agreement with us to accept the allowance established for covered dental procedures as payment in full up to the member's calendar-year maximum, plus any deductibles, coinsurance or copayments due from the member per the policy.

Non-participating dentists have not signed an agreement with us to accept our allowance as payment in full and may balance bill a member for any amounts in excess of our allowance in addition to any deductibles, coinsurance, copayments due (or after the member's calendar-year maximum has been met) from the member per the policy.

Emergency services received from a non-participating dentist are not exempt from balance billing and any cost sharing as described above.