Medical FAQs

The Blue Cross Blue Shield (BCBS) PPO Network provides nationwide access to healthcare services for all MCTWF medical plan participants (both active and retiree). Virtually all BCBS plans maintain a “Traditional” network, as well as a PPO network in which most Traditional providers also participate. To receive in-network level medical benefits you must use a BCBS PPO Network provider unless you qualify for a non-access exemption. If you use a BCBS Traditional Network provider your benefits will be subject to out-of-network limitations, but because those providers’ allowable charges are fixed by contract, you will have no balance billing exposure. If you receive services from a provider outside of the networks, you will be responsible for balance billed amounts over and above the applicable deductible, coinsurance, and copayment. Out-of-network provider is addressed in section ‘If my current physician in not a BCBS PPO Network Physician, what are my out-of-pocket expenses? MCTWF’s pharmacy network is administered by CVS Caremark. Mental Health and Substance Use Disorder services are available to all participants through the Blue Cross Blue Shield Network. For 24-hour emergency assistance and BCBS network referrals, call (800) 762-2382.

Yes. The BCBS PPO Network is available most anywhere you travel. You may locate a BCBS PPO Provider by linking to the BCBS website through the “Provider Networks” page on this site.

Also available to you is Blue Cross Blue Shield Global Core which gives you access to medical care when you are outside of the United States. For non-emergency inpatient medical care, you must call Blue Cross Blue Shield Global Core at (800) 810-BLUE (2583) or call collect at (804) 673-1177. In most cases, you should not need to pay upfront for inpatient care except for the out-of-pocket expenses (non-covered services, deductible, copayment, and coinsurance) you normally pay. The hospital should submit the claim on your behalf.

Contact MCTWF’s Member Services Call Center at (313) 964-2400 or (800) 572-7687 and you will be referred to the nearest BCBS PPO Network provider. For BCBS PPO Network provider referrals after business hours call (800) 810-BLUE (2583).

To ensure your full coverage, present both your MCTWF Networks Card and your Blue Cross ID card when receiving any medical services. The cards will evidence your coverage, including restrictions and provide billing instructions.

There are several easy ways to determine your physician’s Network affiliation, including:

• You can ask your current physician if he or she is in the BCBS PPO network; or
• You can link to the BCBS website through the “Provider Networks” page on this website; or
• For BCBS PPO Network provider referrals after business hours call 800-810-BLUE (2583). -OR- You can contact our Member Services Call Center Monday through Friday, 8:30 a.m. to 5:45 p.m. Eastern Standard Time at (313) 964-2400 or toll-free at (800) 572-7687.

In general, and according to your plan of benefits, if you use a physician outside of the BCBS PPO Network you will incur more out-of-pocket expenses. Covered services provided outside of the BCBS PPO Network are subject to out-of-network benefit deductibles and coinsurance charges. MCTWF provides benefits based on its maximum allowable benefit (MAB) schedule; you are responsible for paying any difference between the cost of the service and the amount paid by MCTWF. If services are provided by BCBS Traditional Network provider benefits are subject to out-of-network deductibles and coinsurance charges, but there is no balance billing exposure.

In the event that a particular service or specialty is not available in the BCBS PPO Network, your BCBS PPO Network provider may refer you outside the BCBS PPO Network. Your provider must complete a referral form and the non-BCBS PPO Network provider must submit the referral with the claim to ensure coverage at in-network benefits levels. If the provider does not participate in the BCBS Traditional Network you will be subject to balance billing for charges in excess of MCTWF’s maximum allowable benefit (MAB) schedule.

No. Any questions related to claims should be directed to MCTWF by contacting our Member Services Call Center at (313) 964-2400 or (800) 572-7687, between 8:30 a.m. and 5:45 p.m. Eastern Standard Time Monday through Friday.

Yes. Prior authorization of services is an acknowledgement to the provider that a specific medical service is payable by the plan. Below is a list of frequently used services that require prior authorization. Prior to obtaining any services that requires prior authorization, the patient should verify that their provider has received prior authorization from MCTWF. If no prior authorization has been received, the claim will be denied and the patient will be responsible for full payment of the charges:

• Blepharoplasty & Ptosis Repair; Upper Lid
• Breast Reduction
• Breast Reconstruction
• Durable Medical Equipment – Purchase
• Growth Hormone Stimulation
• Home Health Care
• Hospice
• PET Scans

Since pre-authorization is required for many of these services, please reference the Summary Plan Description booklet available here.

Certain inpatient and outpatient hospital services are covered at in-network benefit levels, despite the provider’s non-participation in the BCBS PPO Network. The below services are characterized by the fact that the patient has little or no control over which provider performs the service:

• Ambulance
• Anesthesiology
• Radiation Therapy
• Radiology
• Laboratory
• Pathology
• Emergency Room Physician
• Nuclear Medicine

We remind you, however, that if the provider does not participate in the BCBS PPO or BCBS Traditional networks, the patient will be subject to balance billing for charges in excess of MCTWF’s maximum allowable benefit (MAB) schedule.

No. The below listed provider categories do not participate in the BCBS PPO Network but do participate in the BCBS Traditional Network. Services obtained from BCBS Traditional Network providers in these categories will be covered at in-network benefit levels:

• Ambulance providers
• Ambulatory surgical centers
• Certified nurse anesthetists
• Certified nurse midwives
• Certified nurse practitioners
• Durable medical equipment suppliers
• Hearing aids suppliers
• Home health care providers
• Hospice providers
• Private duty nursing providers
• Prosthetic and orthotic supplier