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Northeast Georgia Health System (NGHS): Update on Your Health Plan’s Network

October 10, 2019
 

Effective October 1, 2019, Northeast Georgia Health System (NGHS) is no longer available as an in-network care provider with Anthem Blue Cross and Blue Shield (Anthem).

This means NGHS services received on or after October 1, 2019 will be considered out-of-network and may be reimbursed as out-of-network under the terms of your health plan with some exceptions noted below in the Common FAQs section.

Our long history of partnership with NGHS gives us hope that we will get NGHS back into our network. 
We're committed to reaching an agreement that continues to give you access to affordable care – and also makes sure that NGHS is compensated fairly. Our members are our top priority, so we’re hoping to sign a contract soon so you can regain access to in-network care from NGHS.
 
Need more Information?
Read over some common questions and answers below. If you have other questions or need help finding a doctor or hospital, you can call the Member Services number on your Anthem ID card. For a complete list of providers, log on to anthem.com and select Find a Doctor.
 
Common FAQs
Q: How can I stay up-to-date on NGHS’s status?
 
A: For the most up-to-date information refer back to this site at anthem.com/NGHS or call us at the Member Services number on your Anthem ID card.
 
Q:  Which facilities/medical groups are affected by these negotiations?
 
A: The Northeast Georgia Health System facilities include:
 
  • Healthlink Laboratory – Braselton Medical Plaza I
  • Healthlink Laboratory – Dawsonville Medical Plaza 400
  • Healthlink Laboratory – Gainesville
  • Hospice of Northeast Georgia Medical Center
  • Laurelwood (Psych)
  • New Horizons Lanier Park
  • New Horizons Limestone
  • Northeast Georgia Medical Center Barrow
  • Northeast Georgia Medical Center Braselton
  • Northeast Georgia Medical Center Gainesville
  • Sleep Disorder Center of NGMC – Braselton
  • Sleep Disorder Center of NGMC – Gainesville
  • The Imaging Center – Barrow
  • The Imaging Center – Braselton Medical Plaza I
  • The Imaging Center – Buford
  • The Imagine Center – Dawsonville Medical Plaza 400
  • The Imaging Center – Gainesville Medical Park I
  • The Rehabilitation Institute
  • The Rehabilitation Institute – Braselton Medical Plaza I
  • The Rehabilitation Institute – Buford
  • The Rehabilitation Institute – Cleveland
  • The Rehabilitation Institute – Dahlonega
  • The Rehabilitation Institute – Dawsonville
  • The Rehabilitation Institute at Sherwood Park - Gainesville
  • The Ronnie Green Heart Center
  • The Toccoa Cancer Center
The Northeast Georgia Health System medical groups include:
 
  • Northeast Georgia Physicians Group
  • The Heart Center, LLC
  • Urgent Care
 
Q:  What products/plans are affected by these contract talks? What happens if I go to NGHS or a NGHS affiliated doctor on or after October 1, 2019?

A: All of the Anthem networks that are currently contracted with NGHS are affected. This includes the network for the State Health Benefit Plan.
 
  • POS and PPO: NGHS is no longer in our network as of October 1, 2019, so consumers will need to use an in-network care provider for non-emergencies to receive in-network benefits under your plan. Those who choose to see an out-of-network care provider will be subject to higher costs. Additionally, the care provider can bill consumers if there is a difference between what Anthem allows or pays for the claim and the amount the provider charges the consumer.
  • HMO: NGHS is no longer in our network as of October 1, 2019, so consumers will need to use an in-network care provider for non-emergencies to receive in-network benefits or coverage under your plan. Those who choose to see an out-of-network care provider will be subject to higher costs, including the full cost of care.
 
Q: What other participating Anthem network hospitals are available in the vicinity of the Northeast Georgia facilities?
 
A: The Find a Doctor feature available on www.anthem.com can be used to locate a participating hospital in a specific area. Anthem members are advised to verify with both their provider and the Anthem Blue Cross and Blue Shield website that the alternate facility is participating in their benefit plan’s network. 
 
For a complete list of contracted hospitals, as well as ambulatory surgical centers and other ancillary facilities, please visit www.anthem.com. Customer Service representatives can check the provider database for a physician’s admitting privileges at another nearby in-network facility. Members should confirm the information they receive with their treating physician. Every effort will be made to assist members in determining their choices and understanding the potential financial consequences of seeking care with a provider that is not in the Anthem Blue Cross and Blue Shield provider network.
 
Q: I am in a gatekeeper plan and have a Northeast Georgia physician as my Primary Care Physician.  Can I continue to see him/her after the term?
 
A: Only members participating in a Gatekeeper HMO plan with an NGHS Primary Care Physician will be reassigned to a new in-network PCP and receive a new member ID card reflecting this change. If you believe you should have received a new ID card and have not, please visit the online member portal at Anthem.com to print your ID card, or contact the Member Services number on your existing Anthem ID card. Updated ID cards are also available on our mobile app.
 
You may select a different in-network provider at any time by using the Find a Doctor feature on anthem.com. Please note that if you choose to see an out-of-network NGHS Primary Care Physician you will be subject to higher costs up to the entire cost of care reflected in the NGHS provider’s billed charges. 
 
Q:  Why did the contract end between Anthem and NGHS?
 
A:  Anthem had a multi-year agreement with NGHS that expired on September 30, 2019. Unfortunately, we are unable to reach mutually agreeable terms to extend the contract or retain the provider in our network. Contract discussion is a standard, normal and routine part of what we do. Our goal is to reach an agreement that gives consumers access to affordable care, while also ensuring that we’re paying healthcare providers and hospitals fairly.
 
Q: What are the core issues that Anthem and NGHS disagree upon?
 
A: Our top priority during these negotiations continues to be protecting consumers’ access to affordable health care. Any increases in costs are often paid for by our consumers, and public and private employers, the majority of which are self-insured and pay for their employees’ medical care directly.
 
As with any provider negotiation, Anthem works to address both financial and nonfinancial related provisions to protect consumers. Both types of provisions can affect cost and our ability to offer flexible networks and innovative, more cost-effective benefit designs. We are actively negotiating in good faith and we believe common ground can and should be found.
 
Q: What is Anthem doing to provide Continuity of Care/Transition Assistance to members?

A: Members wishing to request continuity of care should contact their new participating medical group or PCP.  If an Anthem member began a course of treatment with NGHS before the Sept. 30, 2019 termination for one of the following conditions, he or she may be eligible to receive continuity of care:
 
  • The member is in an active course of treatment for an acute medical condition, behavioral health condition, or serious chronic condition.
  • The member is pregnant, regardless of trimester.
  • The member has a terminal illness.
If you think you might be eligible, call us right away
We’ll confirm whether you’re eligible. And then you can work with your doctor to fill out the Continuity of Care form. You can download the Continuity of Care form or you can call the Member Services number on your Anthem ID card to get a copy mailed or emailed to you.
 
When you fill out the form:
  1. Please answer all questions completely. To help us review your form quickly, return it as soon as possible.
  2. Section 1 and 2 need to be completed by the patient. If the patient is a minor, a guardian’s signature is required.
  3. Section 3 is completed by the treating health care provider or doctor.
  4. The treating health care provider should fax the completed form to Medical Management at 1-877-254-4971.
If you need ongoing care for a worsening condition and do not require a special course of treatment, you’ll need to choose an in-network health care provider to meet your ongoing health care needs. And you do not need to complete this form.
 
What will happen once we receive your completed form?
We’ll review it and let you know if you can continue your health care with the hospital, facility or care provider and still receive in-network benefits, or if you have to change to an in-network care provider. If you have to change health care providers to get in-network benefits, we’ll help you find a hospital or facility that fits your needs.
 
When a case is approved for continuity of care through Anthem’s Transition Assistance Unit, the claim is processed at in-network benefit levels. Once a member is determined to be eligible for transition assistance, the member is only financially responsible for applicable deductibles, coinsurance and/or co-payments. If an Anthem member has one of the conditions that qualify for transition assistance listed above, but transition assistance does not approve the request (i.e. the member was not in a course of treatment with NGHS before the termination date), continuity of care will not be provided. In this situation, the provider will be considered out-of-network and the member, if he or she chooses to receive care from the provider, may incur significant out-of-pocket expense, depending on their benefit structure. 
 
Q: What about members who need emergency medical care from a NGHS hospital on or after October 1, 2019?

A: A hospital’s emergency medical services are considered a covered benefit and therefore do not require pre-authorization, regardless of where they are delivered. The NGHS hospitals must provide services for members requiring emergency care. Coverage will be provided according to the member’s policy benefits. Anthem encourages members to make informed decisions about when to use urgent care as opposed to emergency room care. Urgent care is appropriate when a member needs a physician’s attention for a condition that is non-life threatening. A member who needs urgent care should go to the nearest immediate or urgent care facility when his or her physician or network provider is unavailable.
 
Q: Will I be receiving a new member ID card?

A: Only members participating in a Gatekeeper HMO plan with an NGHS Primary Care Physician will be reassigned to a new in-network PCP and receive a new member ID card reflecting this change. If you believe you should have received a new ID card and have not, please visit the online member portal at Anthem.com to print your ID card, or contact the Member Services number on your existing Anthem ID card. Updated ID cards are also available on our mobile app.