My MD said they that they are a participating provider with Blue Shield. Turns out they are for some plans, but not the plan that I have. Must the MD accept Blue Shield’s rate and not make me pay the difference. It was their mistake!

This is beyond the scope of my duties as an Insurance Agent.  Please check with legal counsel. Did the doctor  make a binding contract with you, guaranteeing that they would accept Blue Shield’s payment as payment in full? The Blue Shield policy – says it’s the members responsibility to make sure a provider is on the list.

 

Choice of Providers

This Blue Shield health plan is designed for Members to obtain services from Blue Shield Participating Providers and MHSA Participating Providers. However, Members may choose to seek services from Non-Participating Providers for most services. Covered Services obtained from Non-Participating Providers will usually result in a higher share of cost for the Member. Some services are not covered unless rendered by a Participating Provider or MHSA Participating Provider.

Please be aware that a provider’s status as a Participating Provider or an MHSA Participating Provider may change. It is the Member’s obligation to verify whether the provider chosen is a Participating Provider or an MHSA Participating Provider prior to obtaining coverage.

Call Customer Service or visit www.blueshieldca.com to determine whether a provider is a Participating Provider. Call the MHSA to determine if a provider is an MHSA Participating Provider. See the sections below and the Summary of Benefits for more details. See the Out-of-Area Services section for services outside of California  Blue Shield Evidence of Coverage Page 14

 

Blue Shield Participating Providers

Blue Shield Participating Providers include primary care Physicians, specialists, Hospitals, and Alternate Care Services Providers that have a contractual relationship with Blue Shield to provide services to Members of this Plan. Participating Providers are listed in the  Participating Provider directory.

Participating Providers agree to accept Blue Shield’s payment, plus the Member’s payment of any applicable Deductibles,  Copayments, and Coinsurance or amounts in excess of specified Benefit maximums as payment-in-full for Covered Services, except as provided under the Exception for Other Coverage and the Reductions-Third Party Liability sections. This is not true of NonParticipating Providers.

If a Member receives services from a Non Participating Provider, Blue Shield’s payment for that service may be substantially less than the amount billed. The Subscriber is responsible for the difference between the amount Blue Shield pays and the amount billed by the Non Participating Provider.

If a Member receives services at a facility that is a Participating Provider, Blue Shield’s payment for Covered Services provided by a health professional at the Participating Provider facility will be paid at the Participating Provider level of Benefits, whether the health professional is a Participating Provider or Non-Participating Provider. The Member’s share of cost will not exceed the Copayment or Coinsurance due to a Participating Provider under similar circumstances.

Some services are covered only if rendered by a Participating Provider. In these instances, using a Non-Participating Provider could result in a higher share of cost to the Member or no payment by Blue Shield for services received

Payment for Emergency Services rendered by a Physician or Hospital that is not a Participating Provider will be based on Blue Shield’s Allowable Amount and will be paid at the Participating level of Benefits. The Member is responsible for notifying Blue Shield within 24 hours, or as soon as reasonably possible following medical stabilization of the emergency condition.

The Member should contact Member Services if the Member needs assistance locating a provider. The Plan will review and consider a Member’s request for services that cannot be reasonably obtained in network. If a Member’s request for services from a Non-Participating Provider or MHSA Non-Participating Provider is approved  at an in-network benefit level, the Plan will pay for Covered Services at a Participating Provider level.

Please call Customer Service or visit www.blueshieldca.com to determine whether a provider is a Participating Provider  Blue Shield Evidence of Coverage Page 15 

 

Bibliography

A breach of contract is the failure of a party to the contract to do what he or she agreed to do under the contract. A party’s breach of contract gives rise to certain remedies in the non-breaching party, in particular

(1) an action for money damages, and

(2) in certain circumstances, a suit for specific performance of the contract.   https://gehreslaw.com/part-ii-remedies-for-breach-of-contract-in-california/

kinseylaw.com/breach of contract Jury instruction #302 for if a contract was actually formed…  .justia.com/trials-litigation/

Blue Shield Provider Finder – Shows detailed instructions

plainfield dental.com/does-do-you-take-my-insurance-equal-are-you-in-network/

See page 24 of Blue Shield PPO Evidence of Coverage – Choice of Providers

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