PPO tiered networkCommercial PPO tiered network plans

PPO tiered network plans are available for large group (51+) customers. The plans give customers another way to lower costs while providing their employees with access to high-quality, affordable care.

The PPO tiered network is a broad access PPO network with no participating PPO providers excluded. All network PPO hospitals and ambulatory surgical centers (ASCs) were evaluated and assigned to one of two in-network benefit tiers based on cost and minimum quality standards:

• Tier 1 — members pay the lowest cost-sharing for hospital and outpatient surgery services.
• Tier 2 — members pay a higher cost-sharing for hospital and outpatient surgery services when compared to Tier 1.

The following provider types and services are subject to tiering:

• Outpatient surgery at ASCs
• Inpatient hospital admissions for medical and maternity care
• Hospital-based outpatient radiology centers¹
• Hospital-based outpatient labs¹

Frequently asked questions

What are the criteria used for determining benefit tier placement?

All in-network PPO hospitals and ASCs were evaluated and assigned to one of two in-network benefit tiers based on cost and minimum quality standards. Please also note the following:

• Only hospitals within the Independence Blue Cross (Independence) five-county service area (i.e., Philadelphia, Delaware, Montgomery, Bucks, and Chester counties) were assigned benefit tier placements.
• Hospitals within a health system were assigned the same benefit tier to keep member costs the same and reduce confusion.
• Hospital-based outpatient radiology centers and labs are assigned the benefit tier of their affiliated hospital.

Are all providers in the PPO tiered network assigned a benefit tier?

While all Personal Choice^® PPO providers are included in the tiered network, only facility providers (hospitals, ASCs, hospital-based labs/radiology) are included in tiering.

How do I know what cost-sharing amount to collect from a member enrolled in a PPO tiered network plan?

As you do today, continue to use the Eligibility and Benefits Inquiry transaction on the NaviNet^® web portal to verify your patients’ cost-sharing amount for eligible services. The transaction will display the appropriate cost-sharing amounts for each in-network tier. Therefore, to determine the appropriate amount of cost-sharing, you will need to know the benefit tier placement for the hospitals and ASCs to which you direct your patients for care.

How do I know which benefit tier applies to the hospitals and ASCs to which I direct my patients?

Review a listing of our Tier 1 and Tier 2 hospitals arranged by county.

How will I know if a member is covered through a PPO tiered network plan?

In addition to using NaviNet Open to verify coverage, a unique ID card is issued to members enrolled in PPO tiered network plans to assist providers and members in recognizing the cost-sharing differences between in-network tiered services. ID cards display “PPO tiered network” (in the lower left corner) and member cost-sharing for primary care physician (PCP) office visit, specialist office visit (SPEC), emergency room (ER) visit, deductible (DED), and hospitalization (HOSP).

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How can members enrolled in a PPO tiered network plan identify Tier 1 providers?

Members can use the Find a Doctor tool or log in to the member portal on ibx.com to look for Tier 1 providers. “Personal Choice Tiered” has been added to the Select a Plan drop-down menu. Hospitals and ASCs display with a Tier 1 or Tier 2 indicator, and additional information is provided for members regarding the lower out-of-pocket cost when using a Tier 1 provider.

Which provider types and services are not subject to tiering?

The following provider types and services are not subject to tiering; therefore, member cost-sharing is the same across all in-network providers:

• Primary care and specialist office visits
• Emergency room
• Urgent care centers
• Non-hospital-based outpatient labs (LabCorp, independent labs)
• Ambulance providers for emergency and non-emergency ambulance services
• Physical, occupational, and speech therapists
• Injectable medications (included allergy injections)
• Chemotherapy/dialysis
• Skilled nursing facilities for skilled nursing care
• Hospice
• Home health care
• Durable medical equipment
• Mental health and substance abuse services

How often will Independence update provider benefit tiers?

Independence will re-evaluate the benefit tier placements annually and will provide network providers with advance written notice of any changes to their benefit tier placement that will become effective on January 1 of the following year.

How do tiered network products impact my reimbursement rates?

You will be reimbursed in accordance with your applicable payment rates for commercial products.

Where can I find more information about the PPO tiered network?

Learn more about the Personal Choice PPO tiered network and the full large group product portfolio.