2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 3. How You Get Care
Page 19
Section 3. How You Get Care
Page 19
For listings of Blue Distinction Centers, visit https://www.bcbs.com/about-us/programs-initiatives/blue-distinction-specialty-care/centers-and-physicians-search; access our National Doctor & Hospital Finder via www.fepblue.org/provider/; or call us at the customer service phone number listed on the back of your ID card.
Cancer Research Facility – A facility that is:
FACT-Accredited Facility
A facility with a transplant program accredited by the Foundation for the Accreditation of Cellular Therapy (FACT). FACT-accredited cellular therapy programs meet rigorous standards. Information regarding FACT transplant programs can be obtained by contacting the transplant coordinator at the customer service phone number listed on the back of your ID card or by visiting www.factglobal.org.
Skilled Nursing Facility (SNF)
A SNF is a freestanding institution or a distinct part of a hospital which customarily bills insurance as a skilled nursing facility and meets the following criteria:
To be covered, skilled nursing facility care cannot be maintenance or custodial care. The term skilled nursing facility does not include any institution that is primarily for the care and treatment of mental diseases. If you have questions about treatment at a SNF, or need assistance coordinating this care, please contact us at the customer service phone number listed on the back of your ID card.
Other facilities specifically listed in the benefits descriptions in Section 5(c).
What you must do to get covered care
Under Standard Option, you can go to any covered provider you want, but in some circumstances, we must approve your care in advance.
Under Basic Option, you must use Preferred providers in order to receive benefits, except under the situations listed below. In addition, we must approve certain types of care in advance. Please refer to Section 4, Your Costs for Covered Services, for related benefits information.
Exceptions:
Cancer Research Facility – A facility that is:
- A National Cooperative Cancer Study Group institution that is funded by the National Cancer Institute (NCI) and has been approved by a Cooperative Group as a blood or marrow stem cell transplant center;
- An NCI-designated Cancer Center; or
- An institution that has a peer-reviewed grant funded by the National Cancer Institute (NCI) or National Institutes of Health (NIH) to study allogeneic or autologous blood or marrow stem cell transplants.
FACT-Accredited Facility
A facility with a transplant program accredited by the Foundation for the Accreditation of Cellular Therapy (FACT). FACT-accredited cellular therapy programs meet rigorous standards. Information regarding FACT transplant programs can be obtained by contacting the transplant coordinator at the customer service phone number listed on the back of your ID card or by visiting www.factglobal.org.
Skilled Nursing Facility (SNF)
A SNF is a freestanding institution or a distinct part of a hospital which customarily bills insurance as a skilled nursing facility and meets the following criteria:
- Is Medicare-certified as a skilled nursing facility;
- Is licensed in accordance with state or local law or is approved by the state or local licensing agency as meeting the licensing standards (where state or local law provides for the licensing of such facilities);
- Has a transfer agreement in effect with one or more Preferred hospitals; and
- Is primarily engaged in providing skilled nursing care and related services for patients who require medical or nursing care; or rehabilitation services for the rehabilitation of injured, disabled or sick persons.
To be covered, skilled nursing facility care cannot be maintenance or custodial care. The term skilled nursing facility does not include any institution that is primarily for the care and treatment of mental diseases. If you have questions about treatment at a SNF, or need assistance coordinating this care, please contact us at the customer service phone number listed on the back of your ID card.
Other facilities specifically listed in the benefits descriptions in Section 5(c).
What you must do to get covered care
Under Standard Option, you can go to any covered provider you want, but in some circumstances, we must approve your care in advance.
Under Basic Option, you must use Preferred providers in order to receive benefits, except under the situations listed below. In addition, we must approve certain types of care in advance. Please refer to Section 4, Your Costs for Covered Services, for related benefits information.
Exceptions:
- Medical emergency or accidental injury care in a hospital emergency room and related ambulance transport as described in Section 5(d), Emergency Services/Accidents;
- Professional care provided at Preferred facilities by Non-preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, neonatologists, emergency room physicians, and assistant surgeons;
- Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred laboratories, radiologists, and outpatient facilities;