2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 16
 
Section 3. How You Get Care
 
Identification cards

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You will need it whenever you receive services from a covered provider, or fill a prescription through a Preferred retail pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call the Local Plan serving the area where you reside and ask them to assist you, or write to us directly at: FEP® Enrollment Services, 840 First Street NE, Washington, DC 20065. You may also request replacement cards through our website, www.fepblue.org.

Where you get covered care

You must use those “covered professional providers” or “covered facility providers” that are Preferred providers for FEP Blue Focus in order to receive benefits. Benefits are not available for care from Non-preferred providers, except in very limited situations. Please refer to page 18 for the exceptions to this requirement. Refer to page 13 for more information about Preferred providers.

You can also get care for the treatment of minor acute conditions (see page 134 for definition), dermatology care (see page 38), and counseling for behavioral health and substance use disorder (see page 87), and nutritional counseling (see pages 42 and 46), using teleconsultation services delivered via telephone by calling 855-636-1579, TTY: 855-636-1578, or via secure online video/messaging at www.fepblue.org/telehealth.

 
  • Covered professional providers
We provide benefits for the services of covered professional providers, as required by Section 2706(a) of the Public Health Service Act. Covered professional providers are healthcare providers who perform covered services when acting within the scope of their license or certification under applicable state law and who furnish, bill, or are paid for their healthcare services in the normal course of business. Covered services must be provided in the state in which the provider is licensed or certified. Your Local Plan is responsible for determining the provider’s licensing status and scope of practice. As reflected in Section 5, the Plan does limit coverage for some services, in accordance with accepted standards of clinical practice regardless of the geographic area.
 
  • We cover any licensed professional provider who is Preferred for covered services performed within the scope of that license.

Covered professional providers are physicians and other healthcare providers, when they provide covered services and meet the state’s applicable licensing or certification requirements. If the state has no applicable licensing or certification requirement, the provider must meet the requirements of the Local Plan.

If you have questions about covered providers or would like the names of PPO (Preferred) providers, please contact the Local Plan where services will be performed.

 
  • Covered facility providers
Covered Preferred (PPO) facilities include those listed below, when they meet the state’s applicable licensing or certification requirements.

Hospital – An institution, or a distinct portion of an institution, that:

 
  1. Primarily provides diagnostic and therapeutic facilities for surgical and medical diagnoses, treatment, and care of injured and sick persons provided or supervised by a staff of licensed doctors of medicine (M.D.) or licensed doctors of osteopathy (D.O.), for compensation from its patients, on an inpatient or outpatient basis;
     
  2. Continuously provides 24-hour-a-day professional registered nursing (R.N.) services; and
     
  3. Is not, other than incidentally, an extended care facility; a nursing home; a place for rest; an institution for exceptional children, the aged, drug addicts, or alcoholics; or a custodial or domiciliary institution having as its primary purpose the furnishing of food, shelter, training, or non-medical personal services.