How Benefits Are Determined
Customary and Reasonable (C&R) Charges
Customary and Reasonable Charges are those covered charges for services rendered by or on behalf of a non-network physician, for an amount not to exceed the amount determined by Anthem Blue Cross in accordance with the applicable fee schedule.
A Customary and Reasonable Charge is a charge which falls within the common range of fees billed by a majority of physicians for a procedure in a given geographic region. If it exceeds that range, the expense must be justified based on the complexity or severity of treatment for a specific case.
Covered Health Services
Covered Health Services are those health services, supplies or equipment provided for the purpose of preventing, diagnosing or treating a sickness, injury, covered medical condition, or its symptoms.
A Covered Health Service is a Medically Necessary health care service or supply described under NAP Covered Services as a Covered Health Service and which is not excluded under "What the NAP Does Not Cover", including experimental or investigational services or unproven services.
Covered Health Services must be provided:
  • When the Plan is in effect;
  • Prior to the effective date of any of the individual termination conditions set forth in this Summary Plan Description; and
  • Only when the person who receives services is a covered person and meets all eligibility requirements specified in the Plan.
Decisions about whether to cover new technologies, procedures and treatments will be determined by Anthem Blue Cross.
Medically Necessary Services
Medically Necessary Services are those procedures, supplies, equipment or services which the Claims Administrator, Anthem Blue Cross on behalf of Anthem Blue Cross Life & Health, determines to be:
  • Appropriate and necessary for the diagnosis or treatment of the medical condition;
  • Provided for the diagnosis or direct care and treatment of the medical condition;
  • Within standards of good medical practice within the organized medical community;
  • Not primarily for your convenience, or for the convenience of your physician or another provider; and
  • The most appropriate procedure, supply, equipment or service which can safely be provided. The most appropriate procedure, supply, equipment or service must satisfy the following requirements:
    • There must be valid scientific evidence demonstrating that the expected health benefits from the procedure, supply, equipment or service are clinically significant and produce a greater likelihood of benefit, without a disproportionately greater risk of harm or complications, for you with the particular medical condition being treated than other possible alternatives; and
    • Generally accepted forms of treatment that are less invasive have been tried and found to be ineffective or are otherwise unsuitable; and
    • For hospital stays, acute care as an inpatient is necessary due to the kind of services you are receiving or the severity of your condition, and safe and adequate care cannot be received by you as an outpatient or in a less intensified medical setting.
The fact that a physician, licensed professional or other provider may prescribe, order, recommend, or approve a service or supply does not, in itself, make it Medically Necessary, even though it is not specifically listed as an exclusion or limitation. The services or supplies must be ordered by the attending physician or licensed professional for the direct care and treatment of a covered illness, injury or condition. Services must be standard medical practice where received for the illness, injury or condition being treated and must be legal in the United States.
Special Situations — Emergency Care and Treatment Away From Home
Emergency Care
If you or a covered family member experiences a medical emergency, seeking prompt care should be the first priority. Under the Plan, emergency care is provided 24 hours a day, seven days a week, anywhere in the world.
A medical emergency is defined as a sudden and unforeseeable illness or injury of such a nature that failure to get immediate medical care could be life-threatening or cause serious harm to bodily function.
Examples of medical emergencies include:
  • Apparent heart attack
  • Severe shortness of breath
  • Severe bleeding
  • Apparent poisoning
  • Obvious fractures
  • Sudden vision loss
  • Severe or multiple injuries
  • Allergic reactions accompanied by swelling of the face and lips or wheezing in the chest
  • Sudden loss of consciousness
  • Convulsions
What to Do in Case of Emergency
In case of a medical emergency, go immediately to the nearest hospital emergency room. Call BlueCard at 800-810-BLUE (2583) or call collect at 804-673-1177 if you are admitted to the hospital. For emergency room visits, you pay a $35 copayment for each visit and then the deductible applies, if applicable. If hospitalization is required, your emergency room copayment will be waived; however, a hospital copayment of $100 will apply, then the deductible, if applicable.
It is important to understand that symptoms such as colds, earaches, sprains and rashes, although potentially serious, are not immediately life-threatening and, thus, may not require a visit to the emergency room. In these cases, you should always call your regular physician first.
Emergency room visits for non-emergencies (as determined by Anthem Blue Cross) at non-network hospitals will be covered at the non-network benefit level.
Treatment Away From Home
While Working Away From Home
If you have a work assignment outside of your home area — where there are no PPO network providers — you will be covered at the higher level of benefits for non-routine medical care provided by any licensed physician, surgeon or general hospital. To receive network benefits, you should submit a letter with your first claim explaining the location and length of your assignment. Anthem Blue Cross will verify the assignment with the PG&E Benefits Service Center. You will then be eligible to receive the higher level of network benefits for Covered Health Services.
While Traveling Away From Home
If you are traveling away from home within the United States, but where there are no PPO network providers, and you need non-emergency medical services, you may be eligible to receive the higher level of network benefits by sending a written appeal to Anthem Blue Cross. See the Claims and Appeals Process section for information on the appeals process.
If you are traveling out of the country, you may seek urgent or emergency care from any licensed provider. Non-emergency/non-urgent care is not covered outside of the United States. Before leaving the U.S., you can call 800-810-BLUE (2583) and a BlueCard coordinator can provide you with a list of Blue Cross Association participating hospitals in several international cities. You may also find this information at www.anthem.com/ca/pge. For inpatient care at a network BlueCard hospital, you pay only the applicable deductibles and copays. The provider files the claim for you.
For inpatient care at a non-network hospital, you will need to pay the hospital at the time you receive services and then submit a claim for reimbursement. To locate a claim form, go to www.anthem.com/ca/pge, then under "Tools & Information," select "Forms." To receive higher level network benefits, submit your claim form to Anthem Blue Cross with a letter explaining that the claim was incurred while traveling outside the country, along with a receipt for services, translated in English, if possible, which includes the following:
  • dates of service;
  • procedure codes or description of services; and
  • provider's name.
If you need treatment for a life-threatening emergency while traveling away from home, you should follow the steps under Emergency Care listed under Special Situations in this section.
Dependent Children Living Away From Home
Dependent children covered under the NAP who are residing away from home (for example, while attending school) will receive benefits in accordance with the provisions of the NAP. If your dependent children reside in an area where there are no PPO network providers or BlueCard providers — and they need non-emergency medical services — they may be eligible to receive the higher level of network benefits by sending a written appeal to Anthem Blue Cross. See the Claims and Appeals Process section for information on the appeals process.
If out-of-state, your Enrolled Dependents may access benefits with the BlueCard program, which enables members traveling or living outside their home state to access a broader network of doctors and hospitals at discounted rates through other Blue Cross/Blue Shield plans. To locate BlueCard providers, call toll-free 800-810-BLUE (2583). This number is also printed on the back of your ID card for handy reference.