Doctors, hospitals, facilities (such as labs) and other professionals who give health care services may have a contract with us. If they do, they're in our network - also called in-network providers. That means they've shown they provide quality care and they accept our payment rates when our members go to them for care. If they don't have a contract with us, they're outside of our network - or out of network providers.
Many of our networks are made up of providers who meet high quality standards. Network providers are responsible for getting any needed preauthorization (approval) of your care. They also file your claim for you and will seek payment from us for covered services. When you see network providers, you only have to pay the copays, deductibles and coinsurance required by hour health plan.
If you get treatment from a provider outside the network, you may be responsible for getting preauthorization for a proposed service. You could have to pay more for services done outside of your network. Check your plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) for details.
If you have questions or to check if your treatment needs preauthorization call the Member Services number listed on the back of your ID card.
Yes, although it does not make the most of your benefits and may end up costing you more. Check your plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) to learn more.
NOTICE: There are hospitals, health care facilities, physicians or other health care providers who are not included in every plan network. Your financial responsibilities for payment of covered services may differ if you use a network provider or a non-network provider. Please refer to the online Find Care tool to determine if a particular provider is in the network, or contact customer service for assistance.
You could ask your doctor to call us and apply to join the network. Until your doctor becomes a provider in the network, changing to a network doctor will help you pay less and make the most of your benefits.
A primary care physician (PCP) is your main doctor. Always try to go to your PCP first for health concerns or questions.
Your PCP coordinates any other care you need, such as a visit to a specialist or a hospital stay. You may need to contact your PCP to get an OK (prior authorization) before you get certain services.
Most PCPs are family or general practitioners, internists or pediatricians. These types of doctors have gone to school to learn about all areas of health. That way, they can get a strong, overall picture of your health.
Not all health plans require you to have a PCP. Check your plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) for details.
In emergencies, call 9-1-1 or go to the nearest hospital - you don’t need an OK from us or your PCP. But be careful not to use the emergency room unless it really is an emergency.
If it’s not an emergency, you can see a doctor right away online, using your phone or computer at livehealthonline.com. Depending on your plan, it’s likely about the same cost as your doctor.
You can also use our Find Care tool to look for an urgent care center - or a clinic in a retail shopping store. You can usually walk in without an appointment needed. And they can handle lots of urgent health issues like a flu or cold, allergies, prescribing medication, even small fractures and X-rays.
If it’s not an emergency, you can see a doctor right away online, using your phone or computer at livehealthonline.com. Depending on your plan, it’s likely about the same cost as your doctor.
You can also use our Find Care tool to look for an urgent care center - or a clinic in a retail shopping store. You can usually walk in without an appointment needed. And they can handle lots of urgent health issues like a flu or cold, allergies, prescribing medication, even small fractures and X-rays.
You may need to contact your Primary Care Physician (PCP) to get an OK (prior authorization) before you get certain services, including behavioral health services. Your PCP will work with you to decide if you need to see a specialist. If so, your PCP will refer you to a network specialist. If you have to refer yourself to a specialist, you can search for a network specialist in our online directory. Check your plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) for details.
If your primary doctor can’t see you that day or the next, you should find an urgent care clinic nearby. Under Find Care, select Find Urgent Care for one in your network.
It can take up to 10 business days or two weeks.
Call them. They should always have someone available, or a recorded message to help you get the care you need.
Please visit www.anthem.com/co/networkaccess to view your network’s access plan.
In building and evaluating possible additions to its provider networks or tiers of providers within given networks, Anthem considers several criteria. We consider the service area of the products and plans utilizing the network and the nature of services covered under the products/plans. We also consider the ability of existing network providers to adequately deliver covered services, considering the relative demand and utilization of covered services and the number and types of providers that can provide the covered service, either in person or via telehealth, and the relative cost we, our groups and individual consumers would bear with either including or excluding a provider.
When Anthem develops a network, the following factors, among others, are considered:
- Which and how many providers work in the area.
- Which providers meet Anthem’s quality and credentialing standards.
- Which providers want to contract with Anthem.
- The number of members we anticipate enrolling in the network.
- Which providers are important to specific employer groups or other groups of members.
- What are the PCP referral patterns in the area, i.e., who do PCPs normally send their patients to for specialty care.
In considering a provider for inclusion in our narrowed Pathway and Mountain Enhanced Networks, we will consider the provider’s ability to provide Covered Services. In some areas, such as in the Front Range, this may be dependent on the provider’s ability to treat or deliver services through designated in-network hospital systems.
In considering a provider for inclusion in Blue Priority PPO and HMO, we consider whether the provider is a part of a PCP group and whether that PCP group meet the following criteria:
- Highly organized.
- Have fully implemented or are in the process of implementing electronic medical records (EMRs).
- Have achieved NCQA level III Patient Centered Medical Home (PCMH) designation or are in the process of getting this designation.
- Meet pre-defined set of quality metrics.
- Have the resources needed to work with Anthem and our members differently to evaluate cost of care opportunities (i.e. sharing of actionable data).
- Interest and participation in shared savings / risk opportunities.
- Have demonstrated the ability to provide better value to our members through improved quality and lower costs.
We selected Blue Priority specialists based upon their expertise and willingness to work toward coordination of care with the Blue Priority PCPs. Most have established working relationships with the Blue Priority PCPs.
With respect to developing our plans’ pharmacy networks or the tiers of providers within given networks, our pharmacy vendor may consider the above factors as well as assess our (and our groups’ and members’) need for both savings and access. The networks are designed to provide groups and members with a wide range of flexibility in pharmacy access, choice, and price. In addition, participating network pharmacies must meet rigorous credentialing and re-credentialing requirements and agree to standard contract and pricing terms. These credentialing and recredentialing policies for participating network pharmacies help ensure member safety, meet government agency requirements and help provide optimal member care services. All prospective network pharmacies are required to complete all forms and provide all required documentation during the credentialing and recredentialing process. Additionally, if and where we or our pharmacy vendor believes that there is a network inadequacy - either due to geographic constraints or lack of ability to offer a covered service - we will undertake good faith efforts to expand existing network or mail order capabilities or, as needed, contract with pharmacy providers to improve the networks’ strength and access.
Simply enter the number into the Find Care search bar and hit enter.
