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.
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/
Jury instruction #302 for if a contract was actually formed… .justia.com/trials-litigation/
Blue Shield Provider Finder – Shows detailed instructions
See page 24 of Blue Shield PPO Evidence of Coverage – Choice of Providers
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 Programs section for services outside of California.
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
If a Member receives services from a NonParticipating
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 NonParticipating
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
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 in
the Member’s Service Area. 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 NonParticipating
Provider or MHSA NonParticipating
Provider is approved at an innetwork
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