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Out of Network Reimbursement

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Network dentists and x-ray laboratories (“Participating Providers”) who treat members agree to accept contracted rates as payment for the services they provide. 
For services provided by dentists and x-ray laboratories who have not contracted to treat members (“Non-Participating Providers”), the amounts that will be allowed for such services and processed for payment (“Non-Participating Provider Reimbursement Amounts”) are based on the member contracts. These amounts may be determined based on fee schedules or a database produced by FAIR Health, Inc., as supported by member certificates, and also may be subject to deductibles, co-pays, and other limitations. 
Because there is no Provider contract or participating agreement, a Non-Participating Provider has not agreed to a reimbursement rate for services provided to members. Therefore, absent a regulation or law, the Non-Participating Provider can bill the member for the difference between the amounts they charge and the Non-Participating Provider Reimbursement Amount. Members are responsible for paying Non-Participating Providers this difference. Depending on the service, this difference can be substantial. 
At this time, Non-Participating Provider Reimbursement Amounts will continue to be determined as described above. This page will be updated if there are any changes to the methods used to determine Non-Participating Provider Reimbursement Amounts. 
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Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use