Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...

Chapter 2
Anthem Blue Cross Blue Shield PPO Plan
How the Plan works
Introduction
This Summary Plan Description (SPD) contains a
summary of the Anthem Blue Cross Blue Shield (BCBS)
PPO Plan coverage option under the Wells Fargo
Health Plan for benefts efective January 1, 2011�
The Plan, fnanced and administered by Wells Fargo &
Company, is a self-insured medical plan� Anthem BCBS
is the claims administrator and provides administrative
services for the medical benefts described in this
chapter only� Anthem BCBS does not assume any
fnancial risk or obligation with respect to claims�
Payment of benefts is subject to all terms and
conditions of this SPD, including medical necessity�
You may choose any eligible provider of health services
for the care you need�
Providers are designated as BlueCard PPO or
out-of-network providers� This designation is
determined by service agreements with the Anthem
BCBS organization(s) in the state in which services
are rendered�
BlueCard PPO providers
These providers have entered into a service agreement
that designates them as a BlueCard PPO provider
with their local Blue Cross Blue Shield organization�
To receive the highest level of benefts for the least
out-of-pocket expense, you must choose BlueCard PPO
providers� These providers will:
• Accept payment based on the allowed amount
as determined by Anthem BCBS� The allowed
amount is the negotiated amount of payment that
BlueCard PPO providers have agreed to accept as
full payment for a covered service based on their
contract with Anthem BCBS� BlueCard PPO physical
therapists, durable medical equipment, chiropractors,
acupuncture and labs use base contracted rates and
then default to Maximum Beneft Allowed (MBA) if
procedure codes are not in their contracts for these
providers� Anthem BCBS prices claims using the
Maximum Beneft Allowed (MBA) amounts� Pricing is
based on 199% of Medicare�
• File claims for you�
For information about the benefts available through
these providers, refer to the “Benefts charts” starting
on page 10� To identify providers who participate
in the BlueCard PPO network, access the Provider
Directory Service through Teamworks or at
geoaccess�com/directoriesonline/wf�
Out-of-network providers
Non-BlueCard PPO providers are providers who have
entered into a service agreement with the local Blue
Cross Blue Shield organization but whose agreement
does not designate them as a BlueCard PPO provider�
When you choose these providers, benefts will be paid
at the out-of-network level� Most of these providers will:
• Accept payment based on the allowed amount as
determined by Anthem BCBS� In most cases, the
allowed amount is the negotiated amount of payment
that BlueCard PPO providers have agreed to accept
as full payment for a covered service based on their
contract with Anthem BCBS (diferent rules may
apply for emergency services)� However, if a provider
does not accept the allowed amount as determined by
Anthem BCBS, you will be required to pay the portion
of the expense above the allowed amount, in addition
to any deductible and coinsurance�
• File claims for you�
For information about the benefts available through
these providers, refer to the “Benefts charts” starting
on page 10�
All other out-of-network providers have not entered
into a service agreement with the local Blue Cross Blue
Shield organization� When you receive services from
out-of-network providers, benefts are based on the
allowed amount as determined by the local Blue Cross
Blue Shield organization or Anthem BCBS (diferent
rules may apply for emergency services)� Therefore,
you will have substantial out-of-pocket expenses when
you use an out-of-network provider because you are
required to pay the portion of the expense that is above
the allowed amount, in addition to any deductible and
coinsurance� Benefts are paid to you directly and you
are responsible for paying the provider� The diference
between the out-of-network provider’s charges and the
allowed amount is not applied toward the deductible,
coinsurance amounts, or out-of-pocket maximum and
is your responsibility� This applies to all out-of-network
Anthem Blue Cross Blue Shield PPO Plan 5