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.
Preapproval, sometimes referred to as "precertification or preauthorization," is the process used to confirm if a proposed service or procedure is medically necessary. Whenever possible, preapproval should occur before treatment is received.
The doctor who schedules an admission or orders the procedure or service is responsible for obtaining preapproval. Most doctors in your plan will know to contact Anthem at the Provider Services number on the back of your member ID card for benefit coverage information and to obtain preapproval for the care you may be scheduled to receive.
You may also contact Member Services at the number on the back of your member ID card to determine if a proposed test, equipment, service or procedure requires preapproval.
It is important to know if your doctor has obtained preapproval, particularly when visiting a doctor not in your plan who may or may not be familiar with Anthem’s policies and requirements. Failure of your doctor to secure a preapproval when required may result in denial of payment of a claim.
In compliance with State of Connecticut requirements, Anthem makes available its Network Adequacy Survey that lists important details about our provider networks. Links to PDF copies of the current Network Adequacy Survey documents are provided below.
- CT Network Adequacy Survey – Medical Blue Connection PPO
- CT Network Adequacy Survey – Medical Bluecare HMO
- CT Network Adequacy Survey – Medical Bluecare Prime HMO-PPO
- CT Network Adequacy Survey – Medical Century Preferred PPO
- CT Network Adequacy Survey – Medical Pathway HMO (IND)
- CT Network Adequacy Survey – Medical Pathway HMO (SG)
- CT Network Adequacy Survey – Medical Pathway PPO (IND)
- CT Network Adequacy Survey – Medical Pathway PPO (SG)
- CT Network Adequacy Survey – Dental Blue 100 (English)
- CT Network Adequacy Survey – Dental Blue 100 (Spanish)
- CT Network Adequacy Survey – Dental Blue 200 (English)
- CT Network Adequacy Survey – Dental Blue 200 (Spanish)
- CT Network Adequacy Survey – Dental Blue 300 (English)
- CT Network Adequacy Survey – Dental Blue 300 (Spanish)
- CT Network Adequacy Survey – Dental Complete (English)
- CT Network Adequacy Survey – Dental Complete (Spanish)
- CT Network Adequacy Survey – Dental PPO Plus (English)
- CT Network Adequacy Survey – Dental PPO Plus (Spanish)
- CT Network Adequacy Survey – Dental PPO (English)
- CT Network Adequacy Survey – Dental PPO (Spanish)
- CT Network Adequacy Survey – Dental Prime (ACA) (English)
- CT Network Adequacy Survey – Dental Prime (ACA) (Spanish)
- CT Network Adequacy Survey – Dental Prime (Non ACA) (English)
- CT Network Adequacy Survey – Dental Prime (Non ACA) (Spanish)
To help lower your out-of-pocket costs, Anthem offers tiered networks. You can choose to use doctors, hospitals or other health-care providers from Tier 1 or Tier 2, but you’ll find the most savings in Tier 1.
Providers are assigned to Tier 1 because they have agreed to collaborate with us in a quality focused, value-based, patient-care model, and/or because they meet certain minimum quality, cost, and value-based standards. We also consider the provider’s scope of practice, geographic location, cost, and quality as well as any relevant distinctions including but not limited to membership in quality programs, licensure, educational background, and specialty experience.
In general, even though both Tier 1 and Tier 2 providers are both in the network, you’ll have lower copayments, deductibles and coinsurance when using providers in Tier 1. Tier 2 providers are also considered in network, you just may pay more when using them. If you’d like to switch providers, you can at any time. Just use our Find Care tool on anthem.com.
Simply enter the number into the Find Care search bar and hit enter.
A referral is a recommendation by a doctor so that a member can receive health care services from another specialist or facility. Some referrals may require preapproval.
- If you have an HMO Blue New England plan, referrals to doctors in your plan are required.
- If you have Blue Choice New England POS group plan, referrals for doctors whether in your plan or not are required.
- Members with other group products or for members in Individual HMO or PPO products, referrals to doctors in your plan are not required.
- Individual HMO members must obtain preapproval for services outside of your plan.
- If you have a BlueCare Prime HMO individual or group plan, referrals to doctors in your plan are required.
Your PCP will work with you to decide if you need to see a specialist. If referrals are required, your PCP will refer you to a specialist in your plan. If your plan allows self-referrals to a specialist, you can search for a specialist in your plan using our online find care tool.
If you are a PPO Member, you are not required to select a PCP and do not need a referral. If you go to a doctor not in your plan, you will pay a higher cost share for coverage that is available.
Variations to the standard referral rules may apply. To verify the specific requirements for your plan, including preapproval for certain services, check you plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) for details, or call customer service at the number on the back you’re your member ID card.
