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The Alabama Personal Choice benefit plan is a Point-of-Service insurance product. Under this plan, the patient has a choice to receive services in-network or out-of-network. This decision determines the payment level.
In order for a claim to pay in-network, at the highest benefit level, the following things must occur. It is the member’s responsibility to contact his Primary Care Physician (PCP) prior to all specialists visits and within 48 hours after an emergency room visit. This requirement is the subscriber's responsibility as set forth in the contract guidelines for this program. Members cannot enjoy maximum benefits if the PCP is not contacted. The PCP determines the medical necessity for the emergency room visit or specialist visit. If both contract guidelines and medical necessity criteria are met, the PCP should issue a referral.
Without PCP management and intervention, evidenced by a referral, Blue Cross and Blue Shield of Alabama processes claims at the patient's reduced benefit level, which is the out-of-network payment.
As a participating PCP in our network, you are the total manager of healthcare, which includes emergency room visits for patients covered by this plan. If the patient notifies his or her PCP in advance of emergency treatment, regardless of the time of that notification (which may include after hours), and the patient is directed to the emergency room by the PCP because of medical necessity, it is the PCP's responsibility to submit a referral. This does not mean that precertification of emergency room visits is required.