Preferred Medical Doctor

Blue Cross and Blue Shield of Alabama’s Preferred Medical Doctor (PMD) Program is a statewide Preferred Provider Organization (PPO). PMD physicians sign an agreement with Blue Cross to provide quality healthcare in the least costly manner. Members with PMD benefits receive the highest level of coverage when services are provided by a physician participating in the PMD Program. Members who receive services from a non-PMD physician are subject to out-of-network contract benefits.

PMD physicians receive payment based on the PMD fee schedule for covered services. The PMD fee schedule indicates a maximum allowance for each procedure code. PMD physicians agree to accept, as payment in full, the lower of the submitted charge or the PMD allowance on covered services. Members are responsible for any copayment and deductible amounts.

Following are some of the contractual guidelines PMD physicians have agreed to when providing services to a member with PMD benefits:

• PMD physicians agree to file claims to Blue Cross on the PMD member’s behalf. Payments are made to the physician.
• A Non-Covered Services Statement must be obtained from the member prior to services being rendered for each encounter where services are not covered or considered not medically necessary. Without this document,the services are not billable to the member.
• PMD physicians must refer members to other Preferred Providers (e.g., physicians, laboratories, etc). Laboratory procedures other than those listed in Exhibit I (see laboratory section of this manual or PMD Agreement) must be sent to a Preferred Laboratory.
• Members are not charged for services that are combined with and reimbursed by Blue Cross under other Physicians’ Current Procedural Terminology (CPT) codes due to fragmented coding edits.
• A PMD physician’s National Provider Identifier (NPI) should be used only to file for services personally performed by the physician.
• PMD physicians must report, within 45 days, any license or prescribing restrictions, limits to hospital privileges, malpractice judgments or reports made to the National Practitioner Data Bank.
• With the exception of deductibles or copayments, PMD members are not charged up front for PMD covered services.
• Some services are not included and paid under the PMD fee schedule. PMD physicians agree to accept the allowed amount for these services and not bill PMD members amounts over the allowed amount.
  

Advantages of Participation in the PMD Program

PMD Physicians:

• Manage their own patients
• Enjoy increased communication with Blue Cross
• Increase and maintain their total number of patients
• Receive reliable and consistent direct payment for services
• Benefit from efficient and timely claim processing and payment

PMD Members:

• Receive care from high quality physicians
• Enjoy no restrictions in physician selection
• Benefit from less out-of-pocket expense
• Have no claims to file