July 17, 2024
If you’re a Medicare provider, you may treat Blue Cross Group Medicare Advantage Open Access (PPO) members. This is an open access, non-differential national PPO plan without network restrictions.
You may treat these members regardless of your contract or network status with Blue Cross and Blue Shield of New Mexico. That means you don’t need to participate in our Medicare Advantage networks or in any of our networks to see these members.
The only requirements are that you agree to see the member as a patient, accept Medicare and submit claims to the member’s Blue Cross and Blue Shield plan. Learn more about New Mexico retiree groups with open access plans.
Check Member ID Cards
As with all our members, it’s important to ask to see the member’s ID card before all appointments and to check eligibility and benefits. You can identify these members by the plan type listed on their ID card. Use the entire member ID number, including the alpha prefix, when verifying benefits and submitting claims.
If you have questions, call the customer service number on the member’s ID card.
Open Access Advantages
Blue Cross Group Medicare Advantage Open Access (PPO) is available to retirees of employer groups. It covers the same benefits as Medicare Advantage Parts A and B plus additional benefits depending on the plan. It includes medical coverage and may include prescription drug coverage.
Members’ coverage levels are the same inside and outside their plan service area nationwide for covered benefits. Plan members may have to pay deductibles, copays and coinsurance, depending on their benefit plan.
Referrals aren’t required for office visits. Prior authorization may be required for certain services from Medicare Advantage-contracted providers with BCBSNM.
For Reimbursement
Follow the billing instructions on the member’s ID card. When you see these members, you’ll submit the claims to BCBSNM and not Medicare.
- If you’re a Medicare Advantage-contracted provider with any Blue Cross and Blue Shield plan, you’ll be paid your contracted rate. You’re required to follow utilization management review requirements and guidelines.
- If you’re a Medicare provider who isn’t contracted for Medicare Advantage with any Blue Cross and Blue Shield plan, you’ll be paid the Medicare-allowed amount for covered services. You may not balance bill the member for any difference in your charge and the allowed amount.* You aren’t required to follow utilization management guidelines. However, you may request a review to confirm medical necessity.
* Members may be responsible for cost share for supplemental dental services from non-contracted Medicare providers.
Out-of-network/non-contracted providers are under no obligation to treat Blue Cross Group Medicare Advantage Open Access (PPO) members, except in emergency situations.
Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and their health care provider.