My Medical  Benefits

Blue Cross and Blue Shield of North Carolina (BCBSNC) Provider Network Questions

What network of providers do I have access to if I am enrolled in the Consumer-Directed Health Plan, Enhanced 80/20 Plan and the Traditional 70/30 Plan?
Yes. If you are enrolled in the Consumer-Directed Health Plan, Enhanced 80/20 Plan and the Traditional 70/30 Plan, you will use the Blue Cross and Blue Shield of North Carolina Blue OptionsSM network of providers. The Blue OptionsSM network includes about 90% of the primary care physicians in the state, 97% of the hospitals in the state, and participating providers in all 100 counties of North Carolina. Members who reside or travel outside of North Carolina will be able to receive in-network coverage through the extensive BlueCard® network of providers.
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Are network providers available in all 100 counties?
Yes. If you are enrolled in the Consumer-Directed Health Plan, Enhanced 80/20 Plan and the Traditional 70/30 Plan, you will use the Blue Cross and Blue Shield of North Carolina Blue OptionsSM network of providers. The Blue OptionsSM network includes about 90% of the primary care physicians in the state, 97% of the hospitals in the state, and participating providers in all 100 counties of North Carolina. Members who reside or travel outside of North Carolina will be able to receive in-network coverage through the extensive BlueCard® network of providers.
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What is the greatest distance I may have to travel to receive care from a primary care provider or a specialist if I am enrolled in the Consumer-Directed Health Plan, Enhanced 80/20 Plan and the Traditional 70/30 Plan?
BBlue Cross and Blue Shield of North Carolina (BCBSNC), through its Physician Advisory Group and Quality Improvement Committee, has established standards that limit the driving distance a member must travel to receive the services of an in-network provider. The standards are different for counties that are highly populated or highly urbanized. The driving distance for more populated counties is less than for counties that are not as populated. The following counties are considered highly urbanized counties: Cumberland, Durham, Forsyth, Gaston, Guilford, Mecklenburg, New Hanover and Wake counties. All other counties in North Carolina are considered low-urbanized counties.

The driving distance standards are listed below and are based on the type of provider.
Adult and Pediatric Primary Care Providers:
High-Urbanized Counties One provider within 15 miles
Low-Urbanized Counties One provider within 30 miles

Ob/Gyn Providers:
High-Urbanized Counties One provider within 15 miles
Low-Urbanized Counties One provider within 30 miles

Specialist MD – High Volume and non-MD Specialist Providers: MDs who contract with BCBSNC in the specialties of allergy, cardiovascular disease, dermatology, gastroenterology, general surgery, hematology/oncology, neurology, ophthalmology, orthopedic surgery, otolaryngology (ear, nose and throat) and urology.
High-Urbanized Counties One provider within 30 miles
Low-Urbanized Counties One provider within 60 miles

Specialist MD – Low Volume Providers: MDs who contract with BCBSNC in specialties not designated as high volume.
High- Urbanized Counties One provider within 45 miles
Low- Urbanized Counties One provider within 85 miles
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Is my provider a Blue OptionsSM provider?
In order to find out which providers participate in the Blue OptionsSM Network, please visit Find a Doctor, or simply ask your physician if he or she is a participating provider in the Blue OptionsSM network.
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What is a Blue Options Designated Provider?
Under the Enhanced 80/20 Plan and the Consumer-Directed Health Plan, you can save money when you use Blue Options Designated providers for certain services. These providers have been “designated” because they provide both quality and cost-effective care. To find a Designated Blue Options provider, visit the Plan's website at www.shpnc.org and click on Member Services or call BCBSNC at 888-234-2416. In the Find a Doctor search, these providers are listed as: State Health Plan/Designated for Cost and Quality.
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I noticed on the Blue Cross and Blue Shield of North Carolina online provider directory that some providers have a yellow circle or a red square. What do the symbols mean?
If a provider has a yellow circle on the directory, it means the doctor MAY bill for services as outpatient services; subject to the deductible and coinsurance. If the provider has a red square, services WILL be billed as outpatient services; subject to the deductible and coinsurance.

If the services are provided by a facility that is hospital owned, the covered member should inquire as to whether or not the deductible and coinsurance will apply to the visit. For example, although Duke University Health Care has primary care providers, services may actually be billed as outpatient visits; subject to the deductible and coinsurance. On the other hand, the majority of UNC Health Care System physicians are also primary care providers, but services billed are only subject to the copay. There are exceptions to how services are billed. This is just one example. When making provider selections, be sure to visit the online directory. Click on the yellow circle or red square for details on how services are billed based on the specific provider.
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If my participating provider terminates from the Blue Cross and Blue Shield of North Carolina network, what should I do if I still want to use him or her?
You may continue to use your physician if he or she terminates from the network, but out-of-network deductibles and coinsurances will apply.
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What happens if my provider drops out of the Blue Cross and Blue Shield of North Carolina network during the middle of a treatment plan?
If a provider drops out of the network during treatment for a special ongoing condition such as pregnancy, services are still covered for possibly up to a 90-day period or more depending on plan rules and utilization management. The covered member should contact 888-234-2416 to discuss continuation of care.
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How will I know if my provider terminates from the Blue OptionsSM network?
Participating providers are required to give a 30-60 day notice of termination from the network. Once the termination is received and processed, members will receive a notice advising them that their physician will no longer be participating as of the date they requested, and indicating that the member should begin seeking alternative physicians.
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