Locum Tenens
A locum tenens is a physician who is hired to temporarily replace another physician. The usual physician may be absent for reasons such as illness, pregnancy, vacation or continuing medical education. The usual physician identifies the reported services as locum tenens physician services by entering code Modifier Q6 (service furnished by a locum tenens physician) after the procedure code on the CMS-1500 claim form. Blue Cross follows the CMS locum tenens billing requirements, which can be found at www.cms.gov.
Non-participating Providers
Non-participating providers do not have a contract with Blue Cross and Blue Shield of Louisiana, HMO Louisiana, Inc. network, or any other Blue Cross and Blue Shield plan. These providers are not in our networks. We have no fee arrangements with them. We establish an allowable charge for covered services rendered by non-participating providers. We use this allowable charge to determine what to pay
for a member’s covered services when a member receives care from a non-participating provider. The member will receive a lower level of benefit because he did not receive care from a network provider.
Additionally, a 30 percent penalty may apply when the non-participating provider is a hospital.
Members usually pay significant costs when using non-participating providers. This is because the amounts that providers charge for covered services are usually higher than the fees that are accepted by participating and HMO Louisiana providers. In addition, participating and HMO Louisiana providers waive the difference between the actual billed charge for covered services and the allowable charge, while non-participating providers do not. The member will pay the amounts shown in the “Non-Network” column on their schedule of benefits, and the provider may balance bill the member for all amounts not paid by Blue Cross or HMO Louisiana.
Please note: The member’s policy is an agreement between the member and Blue Cross or HMO Louisiana only. Providers cannot waive the member’s cost sharing obligations, such as deductibles, coinsurance (including out-of-network coinsurance differentials), penalties or the balance of the bill.
A claim that is filed that includes any amounts the provider waives may be a fraudulent claim because it includes amounts that the member is not being charged, and will be reduced by the total amount waived.
PPO and HMO Point of Service Members
When a member receives covered services from a non-participating hospital, the benefits that Blue Cross will pay under the member’s benefit plan will be reduced by 30 percent. This penalty is the member’s responsibility.
The member may also be responsible for higher copayments, coinsurances and deductibles when receiving services from non-participating providers.
A locum tenens is a physician who is hired to temporarily replace another physician. The usual physician may be absent for reasons such as illness, pregnancy, vacation or continuing medical education. The usual physician identifies the reported services as locum tenens physician services by entering code Modifier Q6 (service furnished by a locum tenens physician) after the procedure code on the CMS-1500 claim form. Blue Cross follows the CMS locum tenens billing requirements, which can be found at www.cms.gov.
Non-participating Providers
Non-participating providers do not have a contract with Blue Cross and Blue Shield of Louisiana, HMO Louisiana, Inc. network, or any other Blue Cross and Blue Shield plan. These providers are not in our networks. We have no fee arrangements with them. We establish an allowable charge for covered services rendered by non-participating providers. We use this allowable charge to determine what to pay
for a member’s covered services when a member receives care from a non-participating provider. The member will receive a lower level of benefit because he did not receive care from a network provider.
Additionally, a 30 percent penalty may apply when the non-participating provider is a hospital.
Members usually pay significant costs when using non-participating providers. This is because the amounts that providers charge for covered services are usually higher than the fees that are accepted by participating and HMO Louisiana providers. In addition, participating and HMO Louisiana providers waive the difference between the actual billed charge for covered services and the allowable charge, while non-participating providers do not. The member will pay the amounts shown in the “Non-Network” column on their schedule of benefits, and the provider may balance bill the member for all amounts not paid by Blue Cross or HMO Louisiana.
Please note: The member’s policy is an agreement between the member and Blue Cross or HMO Louisiana only. Providers cannot waive the member’s cost sharing obligations, such as deductibles, coinsurance (including out-of-network coinsurance differentials), penalties or the balance of the bill.
A claim that is filed that includes any amounts the provider waives may be a fraudulent claim because it includes amounts that the member is not being charged, and will be reduced by the total amount waived.
PPO and HMO Point of Service Members
When a member receives covered services from a non-participating hospital, the benefits that Blue Cross will pay under the member’s benefit plan will be reduced by 30 percent. This penalty is the member’s responsibility.
The member may also be responsible for higher copayments, coinsurances and deductibles when receiving services from non-participating providers.
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