Choosing a provider

Things to consider:

Where is the physician located? The physician should be located close to where you live or work to ensure that you have reasonable access to care. Generally, Blue Shield will require that the selected Personal Physician be located within 15 miles or 30 minutes from the member's residence or place of employment. 

• Is the physician accepting new patients?
  
• Is the physician affiliated with your preferred hospital? If you know which hospital, medical group, or Independent Practice Association (IPA) you would like to be part of , you can check if your desired physician belongs within that medical group by viewing the doctor’s page on Find a Provider.
• What are the physician's credentials? Check to see if the physician is board certified. All physicians are required to pass an exam in their specialty to obtain board certification.

Questions to ask:

Make yourself a list of questions before meeting with the doctor for the first time:

• Are there other physicians or nurse practitioners in the practice? You may  be seen by them if your doctor is unavailable.
  
• What are the office hours? This is important if your job requires you to schedule doctor's appointments after work or on Saturday.

While you're there, notice:

• Is the office staff courteous and helpful? The way the staff treats patients is often an indication of how a doctor treats patients.
  
• Do you have to wait a long time past your scheduled appointment? If there is a delay or an emergency, the staff should let you know.

About the doctor:

• Is the doctor warm, polite, and attentive, or rushed and preoccupied?
  
• Are they attentive? Do they listen to you?
• Do they take the time to make a connection with you?
• Do they both solicit and answer your questions?
• Is everything explained to your satisfaction?
• Do you understand their explanations?
• Does the physician train medical residents, medical students, nurses, or physician assistants? If so, this experience may enhance their ability to explain things more clearly to their patients and be aware of the latest medical research. 

Things to consider when choosing a PPO provider

With PPO plans, you have the option to go to a preferred or non-preferred doctor or hospital each time you access care. Preferred providers are in Blue Shield PPO network while non-preferred providers are not within their PPO network. Every plan offers a network of doctors and hospitals to provide you and your family with care. In order to make sure you receive the best value and do not have to pay out of your own pocket at the time of service, you must use doctors and hospitals in your plan’s network. If you choose to use a doctor or hospital that is not in your plan’s network, you will be responsible for all billed charges. Please note that the Exclusive PPO network is not as large as our Full PPO network.

Preferred providers

Whenever possible, you should choose a doctor or hospital from the preferred provider network.

When you go to a preferred provider, you can save money and receive the highest level of benefits available to you.

Non-preferred providers

• When you decide to go to a non-preferred provider, you should be aware that Blue Shield of California has no contract with these non-network providers concerning "allowable amounts."
  
• You'll be responsible for paying a percentage of the amount a non-preferred provider charges you, as well as the amount above Blue Shield's allowable amount for the services you were provided.
• Also, your copayments and deductibles may be higher and your calendar-year copayment maximum is set at the highest level for your PPO plan.
• You'll need to pay the non-preferred provider directly for the entire cost of your care, then you must file a claim with Blue Shield within one year of the month you receive these services. They will keep track of these charges and apply the appropriate amount toward your calendar-year deductible and calendar-year copayment maximum, or reimburse you at the applicable benefit level if you've already met your deductible or copayment maximum for the year. They will notify you of  their coverage decision within 30 days of receiving your claim.

For information about allowable amounts, copayments, and deductibles, please refer to your Evidence of Coverage or Certificate of Insurance.

When you need specialist care

Your PPO plan gives you the flexibility of going to a specialist, such as a dermatologist or cardiologist, without a referral.

You also have the option of seeing a specialist who is not in the preferred provider network. However, to keep your medical costs down, it's wise to go to a specialist who is in the preferred provider network.

When you want or need a second opinion

Your PPO plan has the same benefits for second opinions as you do for other physician office visits. 

For specific details about your plan benefits, please refer to your Evidence of Coverage or Certificate of Insurance.

The role of your Personal Physician

An HMO plan is different from a PPO plan in that you need to select a Personal Physician (primary care physician) who will be responsible for coordinating your care. Together, you and your physician will decide on the best care for you.

Here are some of the services your Personal Physician will provide for you:

• Provides and coordinates your medical care, including referrals to specialists.
  
• Orders lab tests, X-rays, and other medical tests.
• Arranges hospital or skilled nursing facility admission.
• Focuses on improving your health through preventive care services, including exams, immunizations, and well-child and well-baby care.
• Assists you in obtaining approval for mental health and substance abuse.
• Assists you in applying for hospice care.

When enrolled in a Blue Shield HMO plan, your medical care will only be covered when it is provided or coordinated by your Personal Physician. The few exceptions include:

Emergency care

Mental health care

Substance abuse care

Access+ Specialist^SM exceptions (see below)

Urgent care delivered outside Blue Shield of California's service area

Obstetrics/gynecology (OB/GYN) care obtained from an OB/GYN or family physician at your Personal Physician's medical group or IPA

For information about available mental health and substance abuse services, please refer to your Evidence of Coverage.

Please also review Choosing a Personal Physician and hospital or Medical Group/IPA.

Specialists

If you need the care of a medical specialist such as a dermatologist or cardiologist, your Personal Physician can refer you to a specialist.

As an Access+ HMO® member, the Access+ Specialist^SM option allows you to go directly to a specialist within your Personal Physician's medical group or Independent Practice Association (IPA). To use this option, you'll need to select a Personal Physician whose medical group or IPA participates in the Access+ Specialist program. 

Types of Personal Physicians

Family/general practice – Specializes in the diagnosis and treatment of general medical conditions of all age groups.

Internal medicine – Specializes in the medical diagnosis and non-surgical treatment of diseases or disorders.

Obstetrics/gynecology – Specializes in the medical and surgical treatment of diseases and disorders of the female reproductive system and the care of pregnancy and childbirth. To see if a specific OB/GYN can be your Personal Physician, go to Find a Provider and choose “HMO Personal Physician.” 

Pediatrics – Specializes in the diagnosis and treatment of diseases and medical conditions, as well as management of the health of children.

Things to consider when choosing a Personal Physician 

Is the physician accepting new patients – Contact the physician’s office to verify if they are accepting new patients. Although the provider database is updated as frequently as possible, if a physician changes their status to not accepting patients before the database is updated, Blue Shield will assign a physician to you based on your ZIP code.

Location – To ensure that you have reasonable access to care, Blue Shield generally will require your selected Personal Physician be located within 15 miles or 30 minutes from your residence or place of employment.

Number of specialists – Since Personal Physicians typically refer patients to specialists within their own medical group or IPA, look at the type and number of specialists within a physician's medical group or IPA before deciding whether to select that physician as your Personal Physician.

Hospital – If you know which hospital, medical group, or IPA you would like to be a part of, check if your desired physician belongs with that medical group by viewing the doctor’s detail page on Find a Provider.  

Board certified and board eligibility – Most Access+ HMO Personal Physicians are board certified or board eligible for their type of practice or specialty. 

How to find an HMO personal physician  

• Go to blueshieldca.com and select Find a Provider.
  
• Next to Select a Plan, click on the Select button.
• Choose the medical plan and subplan, then click Set Plan.
• Under “Provider Types,” select Doctor. 
• In the “Doctor type or specialty” field, enter “HMO Personal Physicians.”
• Enter your city, county, state, or ZIP code, then click Find Now.
• Find a Provider will display all the HMO Personal Physicians nearest your location.

Key information needed for selecting a physician on your application

First and last name of the physician

Physician’s 9-digit provider number

Medical group/IPA’s  6-digit number

You can find all of the information from the doctor’s page on Find a Provider.

To avoid physician assignment, please note on your application that you are an existing patient.

Medical groups and IPAs

For business purposes, many physicians have joined together into medical groups and Independent Practice Associations (IPAs).

Medical groups are organizations of physicians, generally located in the same facility, who provide a range of services to health plan members.

IPAs are groups of physicians with individual offices who have formed organizations to contract, manage and, share financial responsibilities for providing services to health plan members.

Access+ Specialist option

If you are an Access+ HMO® member, the Access+ Specialist^SM option allows you to go directly to a specialist within your Personal Physician's medical group or IPA.

To use this option, you'll need to select a Personal Physician whose medical group or IPA participates in the Access+ Specialist program.

You can change your Personal Physician at any time for any reason by registering at blueshieldca.com/register. Once registered, you can log in at the website, and at the home page, select Changing Personal Physician and Medical Group under the Plan Overview tab.

Your request to change a Personal Physician and designated medical group or IPA will take effect on the first day of the following month.

Timing is important

Because continuity of your care is important to us, you should delay a change in your Personal Physician if you are:

Hospitalized

In the third trimester of pregnancy

Undergoing certain types of treatment

In these instances, your change in Personal Physician should take place on the first day of the month following your discharge from the hospital, the delivery of your baby, or when it is medically appropriate for you to transfer your care. If this delay is not acceptable to you, please contact Member Services at the number on your Blue Shield member ID card, for further review.

When your Personal Physician is no longer in the Blue Shield of California network

If your Personal Physician retires or leaves the network, Blue Shield will select another Personal Physician for you and notify you in writing. If you are not satisfied with the selection, you can select a different Personal Physician.