Po box 60007 los angeles ca 90060

Blue Cross PPO

QUESTION: Who do I contact for information on benefits or if I have questions about a claim?

ANSWER: Contact Anthem Blue Cross of Southern California at: (800) 543-3037 or PO Box 60007, Los Angeles, CA 90060.

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QUESTION: Do I have to select a Prudent Buyer doctor?

ANSWER: No. You can use any Prudent Buyer doctor at any time. If you already have a personal physician, we suggest you determine if your physician is a Prudent Buyer member by checking the directory or calling their office. You can also locate Prudent Buyer doctors online. Refer to the "Online Internet Website-Anthem Blue Cross". Recognizing that there are sometimes changes in between directory printings, it is your responsibility and in your best financial interest, to verify current Prudent Buyer Participating Provider status before your obtain services. This is simple to do. Just call the physician's office, hospital admissions office, Administrative Office, or the 800 number listed on your Identification Card. Refer to section entitled "Online Internet Website - Anthem Blue Cross."

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QUESTION: How can using the services of a Prudent Buyer provider save me money?

ANSWER: Prudent Buyer providers have agreed to give members health care at a special low cost. Because of these savings, the Health Plan can provide increased benefits when you choose to get your health care from a Prudent Buyer doctor, hospital, or other provider.

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QUESTION: What are the differences in Plan benefits when using a Prudent Buyer provider versus a non-participating provider?

ANSWER: When you use a Prudent Buyer participating provider, you are responsible for only ten percent (10%) of covered charges (subject to Plan deductibles and benefit maximums) of the special PPO contract rate. When you use a non-participating provider, you will be responsible for twenty percent (20%) of covered charges (subject to Plan deductibles and benefit maximums) of the charges as determined reasonable by the Plan. In addition, all hospitalizations in other than Prudent Buyer hospitals will be subject to a separate $200 hospital deductible per confinement.

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QUESTION: Can you provide an example of the above?

ANSWER: Assume after satisfying the $200 calendar year deductible, that you have a combined doctor and hospital bill for covered charges in the amount of $10,000. By way of illustration, your out-of-pocket expense may be as follows: If you use Prudent Buyer doctors and hospital: $10,000 of covered charges reduced to special, contract rate of $7,000. Your out-of-pocket cost would be ten percent of $7,000 or $700. If you use non-contracting doctors and hospital: $10,000 of covered charges is reduced to $9,000, which is the amount determined by the Health Trust to be reasonable and customary charges. From the $9,000 there is deducted a $200 hospital deductible, applicable to hospitals which are not part of the Prudent Buyer network. You will be reimbursed by the Plan, eighty percent of $8,800, or $7,040. Your out-of-pocket expense will be $2,960, which is the difference between total charges of $10,000 and Plan benefits of $7,040.

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QUESTION: Will I have to complete a claim form if I use a Prudent Buyer provider?

ANSWER: No. Prudent Buyer providers will submit your bills directly to Anthem Blue Cross of California. However, if you do not use a Prudent Buyer provider, you are required to submit your claims to Blue Cross at: Anthem Blue Cross of California Claims Department P.O. Box 60007 Los Angeles, CA 90060-0007

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QUESTION: If I go to a Prudent Buyer provider, will I need to make a payment at the time of service?

ANSWER: Generally, you will not make a payment until you receive a statement of the claim, called an Explanation of Benefits or EOB for short, from the Anthem Blue Cross. However, in some instances, a Prudent Buyer provider can collect a payment for services up to the amount necessary to satisfy the deductible. To receive benefits, you must meet the eligibility rules of the Health Plan and be eligible for benefits.

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QUESTION: Is there a mandatory Hospital Medical Review Cost Containment Program in the Plan?

ANSWER: Yes. To receive full benefits, the Plan requires all non-emergency hospitalizations to be approved in advance. When you use a Prudent Buyer Doctor and Hospital, the pre-certification will take place with no action required on your part. If you choose to go to a non-participating doctor or hospital, be certain that your hospital stay is approved before admission. The number for utilization review is shown on your Prudent Buyer Identification Card.

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QUESTION: Must non-emergency elective surgery be approved in advance?

ANSWER: Yes, for inpatient hospital confinement. Benefits are provided only for medically necessary and appropriate services. For example, many elective surgeries are considered cosmetic, for which no Plan benefits are payable. If you have questions as to whether a particular elective surgery is covered by the Plan, you or your doctor should contact Anthem Blue Cross.

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QUESTION: Will the Plan cover a second opinion prior to having elective surgery?

ANSWER: Yes, subject to Plan benefits (deductibles and coinsurance), a second doctor's opinion for elective surgery is a covered benefit.

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QUESTION: Why does the Plan maintain a Hospital Cost Containment Review Program?

ANSWER: Cost containment provides you with valuable information, so that unexpected out-of-pocket costs can be avoided. When the hospital cost containment program is properly used, you will know in advance whether the proposed services are medically necessary and appropriate, and therefore eligible for Plan benefits.

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QUESTION: Is there a penalty if my non-emergency hospitalization is not approved in advance?

ANSWER: Yes. Plan benefits otherwise payable may be reduced up to $500. In addition, Anthem Blue Cross utilization review will perform a retrospective review of your hospital stay. No Plan benefits will be provided for days in the hospital, which are not determined to be medically necessary.

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QUESTION: Is the Indemnity Plan insured by Anthem Blue Cross?

ANSWER: No. Plan benefits are self-funded, and the Board of Trustees may change the benefits of the Plan at any time by providing written notice of the changes.

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QUESTION: Are there chiropractors who are members of the Prudent Buyer network?

QUESTION: Explain the basics of the Anthem Blue Cross Prudent Buyer Plan Directory.

ANSWER: By reading the first couple of pages of the directory, you will be familiar with how to access the Prudent Buyer network. There is a separate listing of Prudent Buyer hospitals. There is a listing of Prudent Buyer physicians, which is broken down by specialty. For example, internists, family practice, and pediatrician doctors. After each physician's name, there is a listing of the hospitals where the physician is affiliated.

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