Tag: Insurance Cards
Information relating to Insurance cards
ERISA or maybe TPA?
Let’s play pretend:
Some one gives you this card and wants to make an appointment.
They seem to want an answer right now.
You know your physician takes Blue Choice, but have never seen this card before. How would you know?
Look at the front of the card. Blue Cross is written all over it. BCBS must be the insurer? STOP!
Do you see any insurance regulation language? Is “TDI” or “DOI” on this card?
NO. This is your 1st clue. The employer may be the insurer.
Scan the front of the card intently. Are there any other clues. Look for what you know, not what you don’t know.
If not flip it over. What do you see? READ ALL THE TINY WRITING.
On this card: phone numbers, addresses, where to file, prior auth info. But what else?
“This coverage is self-funded Excellus BlueCross BlueShield, and independent licensee of the BlueCross BlueShield Association provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims.”
What does that mean:
- The employer is the insurer (self-funded plan)
- Excellus BCBS is acting as a Third-Party Administrator (TPA)
Is this a Lease Network?
Very likely — yes.
On the front of the card it says:
“To verify participation, please call the BlueCard Provider Network.”
That suggests:
- The plan is using the BlueCard network
- Excellus is providing network access + claims processing. The employer is leasing the BCBS network
That’s what we commonly call a lease network arrangement.
But — this is important — don’t assume, Verify
Why you may still get a “Yes” when you call
When you call provider services:
- The rep may simply see “In Network”
- They may not understand lease networks
- They may not understand the difference between:
- Payor
- TPA
- Repricer
- Network administrator
So we need to ask better questions.
Instead of just asking “Is Dr. Smith in network?”
Tell the representative you would like to check network participation.
Ask:
- Is this plan self-funded? (if it is self-funded it is not a lease network)
- Is Excellus the payor, or the administrator?
- Is this a leased network?
- Who bears the financial risk?
- Is Excellus repricing the claims?
- What network applies to this patient?
And always get:
✔ Representative name
✔ Date/time
✔ Call reference number
If the claim denies, that reference number becomes your leverage.
Why this matters
In lease network plans:
- The employer controls the benefits.
- The employer may carve out services.
- The employer may override network rules.
- The plan can be patient-specific.
Basically they can make up their own rules.
In practical terms — They have more flexibility than a fully insured DOI-regulated plan.
Protect Yourself when speaking to the patient.
Never speak in absolutes.
Use language like:
- “It looks like this is a self-funded plan…”
- “Based on the card wording…”
- “According to the representative I spoke with…”
- “At the time of verification…”
Never say:
- “Yes, you are definitely covered.”
- “This will pay.”
- “You are in network.”
HealthSpring Plans by County
POET staff has done everything short of a full skeletal reconstruction to make the HealthSpring county page in the provider manual legible. They’ve stretched it. They’ve shrunk it. They’ve even converted it to Word and back to a PNG. It just didn’t have the backbone it needed.
If we were tibia honest, nothing worked.
So I, Sir Seymore Bones — resident WordPress writer and part-time osteo-optimizer — took pen in hand (metacarpals and all) to give everyone a little relief. When the formatting started rattling, I decided it was time to get to the bare bones of the issue.
I hope the map below helps you Sey-more, and make sense of the plans offered in our counties. We femur-ly believe this version is better. If it doesn’t… well, I promise I didn’t bone it up on purpose.
Stay humerus,
Sir Seymore Bones
Employer Group PPO/EPO Hybrid
Interpreting insurance cards has never been easy, but with the constant changes in today’s insurance landscape, it has become nearly impossible.
Every week seems to bring a new insurance company—or an established insurer that has acquired several others, rebranded, and rewritten the rules.
On top of that, there are hybrid plans like POS and EPO, along with discount cards, medical cost-sharing programs, limited-benefit plans, and the growing model of Direct Primary Care.
The one pictured below is an ultimate example!
It takes hybrid to a new level of complexity.
By mixing the rules of PPO and EPO in one plan.
Therefore, I, Sir Seymore, have taken my red pen in hand in an effort to make sense of it all.
Feel free to download this card for your records.
Do Not Be Fooled
MultiPlan
Has Changed It's Name to:
Claritev
The company, which spent much of past year navigating rising debt and antitrust lawsuits, said Tuesday the rebrand will have no affect on its existing services.
Help Identifying BCBS cards
The following Network IDs only apply to cards that show the TDI indicator.
This shows the plan is fully funded and regulated by TDI (Texas Department of Insuarnce).
- Blue Choice PPOSM= BCA.
- Blue EssentialsSM = HMO.
- Blue Advantage HMOSM = BAV.
- Blue PremierSM = HMH.
- MyBlue HealthSM = BFT.
- Blue High Performance (BlueHPN) = HPN
Example of Blue EssentialsSM
Note the red letters “HMO” and blue letters “TDI” on the card. This is what makes it a Blue Essentials Card.
However, with the ever-changing insurance landscape,
We highly encourage you to check Eligibility and Benefits.
It is advisable to retain any information you view, for your office to have the documentation you
need when a claim does not pay correctly or does not pay at all.
REMEMBER: IT HAS TO HAVE THE TDI INDICATOR
CHI Has A New Card
It has been reported that CHI has a new name on their card.
Angelina Co. Vs. City of Lufkin
Angelina County
City of Lufkin
VS
POET holds a direct contract with the employer group: Angelina County
If you are unsure your physician has opt’ed into this POET contract, give us a call.
POET is working to obtain a direct contract with employer group: City of Lufkin.
POET will email opt in to physicians, when and if a contract is obtained.
YES
YES
PHCS is on both cards. But if you will look closely the card states PHCS is the “Medical Plan Network Access”. This means Angelina County is accessing physicians through a “lease network”. Angelina county employees are not insured by PHCS.
Imagine 360 is also on both cards. Imagine 360 is NOT an insurance company. They are a “third party administrator” (TPA). A third-party administrator (TPA) provides administrative services for self-funded health plan.
If you have opt’ed in to POET’s Angelina Co. agreement, please do not turn away your patients. Nothing has changed with the Angelina Co. contract. The only difference is GPA has changed it’s name to Imagine 360. However, that does not affect the current contract.
Angelina County New Card
We apologize these are not the best pictures, but we wanted to get this out to you, asap.
Some of you have already seen this new card from Angelina County. POET’s contract is with Angelina County not GPA or Imagine 360. POET has reached out to both Angelina County and Imagine 360. Imagine 360 told POET the benefits have not changed. We have asked if your representative will remain the same and are waiting for that response. As information comes in, we will keep you informed. Please let POET know if you are not paid according to contract
Just a Reminder-Cigna MA Plans
The below list is for Provider use only. Not to be distributed to Patients.
HMO Customer Benefit Plans for Our Service Area
PPO Customer Benefit Plans for Our Service Area
Cigna Preferred Medicare HMO, H4513-061
Cigna True Choice Medicare PPO, H7849-038
Cigna Preferred Savings Medicare HMO, H4513-066
Cigna True Choice Plus Medicare PPO, H7849-062
Cigna Fundamental Medicare HMO, H4513-009
Cigna TotalCare HMO D-SNP, H4513-060
Virtual Insurance Cards
With Virtual Insurance Cards on the rise, it can become an issue for your staff at check in.
The usual method of scanning in the insurance card, is not an option with virtual cards.
This may open up the possibility for human error in capturing the data off the card.
One office suggest you have the patient email the card from their phone to the office.
Then the card can be uploaded into the patient chart.
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