2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 3. How You Get Care
Page 20
Section 3. How You Get Care
Page 20
- Services of assistant surgeons;
- Care received outside the United States, Puerto Rico, and the U.S. Virgin Islands; or
- Special provider access situations, other than those described above. We encourage you to contact your Local Plan for more information in these types of situations before you receive services from a Non-preferred provider.
Unless otherwise noted in Section 5, when services are covered under Basic Option exceptions for Non-preferred provider care, you are responsible for the applicable coinsurance or copayment, and may also be responsible for any difference between our allowance and the billed amount.
• Transitional care
Specialty care: If you have a chronic or disabling condition and
- lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan, or
- lose access to your Preferred specialist because we terminate our contract with your specialist for reasons other than for cause,
you may be able to continue seeing your specialist and receiving any Preferred benefits for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.
If you are pregnant and you lose access to your specialist based on the above circumstances, you can continue to see your specialist and your Preferred benefits will continue until the end of your postpartum care, even if it is beyond the 90 days.
• If you are hospitalized when your enrollment begins
We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call us immediately. If you have not yet received your Service Benefit Plan ID card, you can contact your Local Plan at the phone number listed in your local phone directory. If you already have your new Service Benefit Plan ID card, call us at the phone number on the back of the card. If you are new to the FEHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage.
However, if you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
- you are discharged, not merely moved to an alternative care center;
- the day your benefits from your former plan run out; or
- the 92nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.
You need prior Plan approval for certain services
The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for Other services (called prior approval) are detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us before you receive medical care or services. In other words, a pre-service claim for benefits may require precertification and prior approval. If you do not obtain precertification, there may be a reduction or denial of benefits. Be sure to read all of the following precertification and prior approval information. Our FEP medical policies may be found by visiting www.fepblue.org/policies.