All Blue Cross and/or Blue Shield Medicare Advantage PPO Plans participate in reciprocal network sharing. This network sharing allows all Blue Plan Medicare Advantage PPO members to obtain in-network benefits when traveling or living in the service area of any other Blue Medicare Advantage PPO Plan, as long as the member sees a contracted Blue Medicare Advantage PPO provider.
If you have a Medicare Advantage PPO contract with Highmark, you should provide the same access to care for members of other Blue Medicare Advantage PPO Plans as you do for Highmark’s Medicare Advantage PPO members. Below are answers to questions you may have about Medicare Advantage PPO Network Sharing.
| How does Medicare Advantage PPO Network Sharing work? |
If you are a contracted Medicare Advantage PPO provider with Highmark and you see Medicare Advantage PPO members from other Blue Plans, these members are to be given the same contractual access to care as Highmark members and you will be reimbursed in accordance with your negotiated rate under your Highmark contract. These members will receive in-network benefits in accordance with their benefit plan. If you are not a contracted Medicare Advantage PPO provider with Highmark and you provide services for out-of-area Blue Medicare Advantage PPO members, you will receive the Medicare allowed amount for covered services based on where the services were rendered and according to the member’s out-of-network benefit level. For emergency and urgent care, you will be reimbursed at the member’s in-network benefit level. |
| How do I recognize an out-of-area member from one of the Plans participating in this program? |
| The “MA” in the suitcase on the member’s Blue Plan Medicare Advantage PPO ID card indicates a member who is covered under the Medicare Advantage PPO Network Sharing Program. Members should be asked to show their Blue Cross and/or Blue Shield ID card when receiving services (and not their standard Medicare ID card). |
| Do I have to provide services to Medicare Advantage PPO members from other Blue Plans? |
If you are a contracted Medicare Advantage PPO provider with Highmark, you should provide the same access to care as you do for Highmark Medicare Advantage PPO members. If you are not a contracted Medicare Advantage PPO provider with Highmark, you may see other Blue Plan Medicare Advantage PPO members; however, you are not required to do so. |
| What if my practice is closed to new local Medicare Advantage PPO members? |
If your practice is closed to accepting new Highmark Medicare Advantage PPO members, you are not required to provide care for out-of-area Blue Plan Medicare Advantage PPO members. |
| How do I verify eligibility and benefits? |
You can verify eligibility and benefits for Medicare Advantage PPO members from other Blue Plans via Highmark’s NaviNet® provider portal. Select BlueExchange® (Out-of-Area) under Workflows for this Plan, and then click on BX Eligibility and Benefits Inquiry. You can also call the BlueCard® Eligibility line at 1-800-676-BLUE (2583) and provide the member’s 3-character prefix located on the member’s ID card. |
| Where do I submit the claim? |
Submit the claim to Highmark under your current billing practices. Once you submit the claim, Highmark will work with the out-of-area member’s Blue Plan to determine benefits, and then Highmark will send you the payment. Please do not bill traditional Medicare for any services rendered to a Medicare Advantage member. |
| What is the member cost-sharing level and copayments? |
| When out-of-area Blue Plan Medicare Advantage PPO members see Medicare Advantage PPO contracted providers in Highmark’s service areas, covered services and copayments will be at the member’s in-network level of benefits. You may collect the copay amounts at the time of service. |
| May I balance bill the out-of-area member the difference between my charge and the allowance? |
| No, you may not balance bill the out-of-area member for this difference. Members may be billed for any applicable deductibles, coinsurance, and/or copays. |
| What if I disagree with the reimbursement amount I received? |
| If there is a question concerning the reimbursement you received, please contact Highmark Freedom Blue PPO Provider Services. |
| Who do I contact if I have a question about Medicare Advantage PPO Network Sharing? |
| If you have any questions about the Medicare Advantage PPO Network Sharing Program, please contact Highmark Freedom Blue PPO Provider Services at 1-866-588-6967. |
Information on the Medicare Advantage PPO Network Sharing Program is available in the Highmark Provider Manual. Please see Chapter 2.2: Medicare Advantage Products & Programs 
and Chapter 2.6: The BlueCard Program .
BlueCard is a registered mark of the Blue Cross Blue Shield Association
