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 requires that the primary care physician (PCP) is located within 15 miles or 30 minutes of the member’s residence or place of employment. 
• Is the physician accepting new patients?
• Is the physician part of the medical group, or Independent Practice Association (IPA) you would like to be part of? You can check if your desired physician’s medical group(s) by viewing the doctor’s page on find a doctor.
• Does the physician have admitting privileges with a participating hospital? You can check the physician’s hospital admitting on privileges by viewing the doctor’s page on find a doctor.
• 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 a doctor's appointment after work or on Saturday.

While you're there, notice:

• Are 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. 

PPO plans

Things to consider when choosing a provider

With PPO plans, you have the option to go to a participating or non-participating doctor or hospital each time you access care. Participating providers are in the Blue Shield PPO network while non-participating providers are not in the PPO network. Every plan offers a network of doctors and hospitals to provide you and your family with care. If you have questions about your out-of-pocket expenses and what is covered, review your Summary of Benefits or Evidence of Coverage.

Participating providers

Whenever possible, you should choose a doctor or hospital in the network.

When you go to a participating provider, your out-of-pocket costs may be less and the quality of your care may also be better.

Non-participating providers

• Non-participating providers do not have a contract to provide health care services to members. When you receive covered services from a non-participating provider, you are responsible for: the copayment or coinsurance (once any calendar year deductible has been met), and
• any charges above the allowable amount. “Allowable amount” is defined in the Evidence of Coverage (EOC). 

In addition:

• Coinsurance is calculated from the allowable amount, which is subject to any stated benefit maximum.

Charges above the allowable amount do not count towards the out-of-pocket maximum, and are your responsibility for payment to the provider. This out-of-pocket expense can be significant. For information about allowable amounts, cost-shares/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 network. However, to keep your out-of-pocket costs down, it's wise to go to a specialist who is in the 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.

HMO, including Access + and Trio plans (excluding Medicare-eligible plans)

Every Blue Shield HMO member has a primary doctor, also known as a primary care physician or PCP. They help coordinate your care and guide you through your health journey. 

• After you apply and your enrollment is processed, you will receive a welcome kit that provides information for you to create an account on blueshieldca.com
• After creating an account you can select a or update your selection. Non-participating providers do not have a contract with Blue Shield to accept Blue Shield’s allowed charges as payment in full for covered services. Except for emergency services, urgent services, and services received at a participating provider facility (hospital, ambulatory surgery center, laboratory, radiology center, imaging center, or certain other outpatient settings) under certain conditions, this plan does not cover services from non-participating providers.
• Utilize the unified search page to easily find doctors, specialists, and services.
• If you do not choose a primary care physician for yourself or other family members, each individual will be automatically assigned a PCP.

Covered California or On Exchange HMO members only  

• Upon completion of your application and if you selected primary care physicians for yourself and family and have made your initial payment if required, you will receive a welcome kit in the near future after the information is processed.

Medicare Advantage HMO plans

If you are a Medicare Advantage HMO member, you’ll choose your PCP on your enrollment form. Blue Shield will assign one to you if you don’t pick one. You can’t enroll and register without a PCP.

The role of your HMO PCP

An HMO plan is different from a PPO plan in that you must select and use a PCP 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 PCP provides:

• Coordinates and provides 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 PCP. 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 PCP's medical group or IPA

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

Specialists

If you need the care of a medical specialist such as a dermatologist or cardiologist, your PCP 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 PCP's medical group or Independent Practice Association (IPA). To use this option, select a PCP whose medical group or IPA participates in the Access+ Specialist^SM program.

Types of PCPs

• 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 PCP, go to find a doctor and choose primary care 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 PCP

• 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 requires that your primary care physician (PCP) is located within 15 miles or 30 minutes of your residence or place of employment.
• Number of specialists – since PCPs 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 PCP.
• 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 doctor.
• Board certified and board eligibility – most Access+ HMO PCPs are board certified or board eligible for their type of practice or specialty. 

How to find a PCP

• Go to blueshieldca.com and select find a doctor.
• Follow the steps and choose a location, plan, sub-plan, and specialization.
• Blue Shield will show you a list of available providers that fit your criteria.

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 the information on the doctor’s page on find a doctor.

Please note on your application if you are an existing patient to avoid getting assigned to another doctor.

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^SM option

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

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

Updates to your primary care physician (PCP)

• If you’ve created your account on blueshieldca.com you can change your primary care physician at any time.
• If your new physician is in the same medical group and you choose to change doctors, it takes 24 hours to update.
• If you change your physician to one outside of your current medical group, your new selection becomes active the first day of the following month. Our system takes this time to update transactional records within our provider network.
• Avoid this type of change if you are undergoing care for critical conditions or have upcoming procedures.
• If the provider selected is not accepting new patients, but you are an existing patient, you may call customer care at the number on the back of your ID card to confirm you are current patient.

You can change your PCP at any time for any reason by creating an account on blueshieldca.com/register. Change your PCP from your dashboard, my plan, or profile page.

Timing is important

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

• hospitalized
• in the third trimester of pregnancy
• undergoing certain types of treatment

In these instances, plan to change PCPs 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, please contact customer care at the number on your Blue Shield member ID card, for further review.

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

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