How does the claims payment work for members of the PPO and Part-time & Retiree PPO who live in Benton, Clackamas, Clatsop, Columbia, Coos, Douglas, Hood River, Lane, Lincoln, Linn, Marion, Multnomah, Polk, Umatilla, Wasco, Washington and Yamhill counties?
Providers
The Regence BlueCross BlueShield of Oregon (Regence BCBSO) PPO Plan provides coverage for eligible expenses with any licensed provider. However, you receive a better benefit and you pay less if you use Preferred Providers. A Preferred Provider has an agreement with Regence BCBSO to accept discounted fees as payment in full for covered services.
A Participating Provider files its fees with Regence BCBSO and discounts those fees, but to a lesser degree than a Preferred Provider. A Participating Provider accepts the terms and conditions of Regence BCBSO and agrees not to bill the participating members for the balance of charges above the fees filed with Regence. Participating Providers are considered non-Preferred Providers.
Non-Participating Providers have no contract or agreement with Regence BCBSO. Non-Participating Providers generally bill participating members for all balances up to the billed charge that are not paid by the plan. Non-Participating Providers are also considered non-Preferred Providers.
You can determine whether providers are Preferred or Participating using the Regence BCBSO provider.
Claims Payment Examples
The following are examples of claims payment based on whether you use a Preferred, Participating or non-Participating Provider:
- Physician's Billed Charge = $100 Preferred provider contracted fee for this service = $80
- Participating provider contracted fee for this service = $90 Preferred Provider -- Using these charges, if you use a
- Preferred Provider and you are enrolled on the PPO Plan, Regence BCBSO pays 85% of $80 or $68 and you pay 15% of $80 or $12. The physician accepts $80 as paid in full.
Participating Provider
Using these charges, if you use a Participating Provider (non-preferred) and you are enrolled on the PPO Plan, Regence BCBSO pays 70% of $90 or $63 and you pay 30% of $90 or $27. The physician accepts $90 as paid in full.
Non-Participating Provider
Using these charges, if you use a provider that is neither preferred nor participating (non-preferred) and you are enrolled on the PPO Plan, Regence BCBSO pays 70% of $90 or $63. You pay 30% of $90 or $27 plus the difference between the billed charge and the Participating Provider contracted fee, which is an additional $10. In this instance, you pay the $27 plus the $10 for a total of $37.
