How does the claims payment work for members of the PPO and Part-time & Retiree PPO who live in designated rural counties?
Some areas of the state have limited Preferred Providers. In these counties, PEBB has arranged for resident members to receive the Preferred Provider level of benefit from providers who are either preferred or participating in Regence BCBSO contracts.
This means that if you live in a designated rural county, are enrolled on the Regence PPO plan, and receive care from a Preferred or Participating Provider, you will receive the preferred level of benefits. If you choose to see a non-Participating Provider, you will receive the preferred benefits. However the provider may bill you for any amounts above Regence BCBSO maximum allowable fees.
Designated Rural Counties
The designated rural counties are: Baker, Crook, Curry, Deschutes, Gilliam, Grant, Harney, Jackson, Jefferson, Josephine, Klamath, Lake, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wallowa, and Wheeler.
Claims Payment Examples
The following are examples of claims payment for Regence BCBSO PPO Plan enrollees living in the designated rural counties 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
Rural Counties - Preferred or Participating Provider
Using these charges, if you use a Preferred or Participating Provider and you are enrolled on the PPO Plan, Regence BCBSO pays 85% of $90 or $76.50 and you pay 15% of $90 or $13.50. The physician accepts $90 as paid in full.
Rural Counties - Non-Participating Provider
Using these charges, if you use a non-Participating Provider and you are enrolled on the PPO Plan, Regence BCBSO pays 85% of $90 or $76.50, and you pay 15% of $90 or $13.50 plus the difference between the billed charge and the Participating Provider contracted fee, which is an additional $10. In this instance, you pay $13.50 plus $10, for a total amount of $23.50.