Policy update: Use of out-of-network providers may result in penalties or termination
As a reminder, AZ Blue requires network providers to coordinate member care with contracted providers that are in-network for the member’s benefit plan. We see an increasing trend in providers and facilities referring to and routinely using out-of-network providers. For this reason, we are notifying you of new measures to ensure compliance with our requirements.
Policy update for use of out-of-network providers begins soon
Starting Tuesday, May 27, 2025, routine use of out-of-network providers may result in the following actions:
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A penalty of $1,500 per claim
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Disciplinary steps, including possible termination, for breach of contract
We recognize that there will be exceptions for use of an out-of-network provider in certain situations where there is no time to schedule an in-network provider or when a covered service cannot reasonably be provided in network. However, these should be rare exceptions rather than common practice.
In-network facilities, including emergency rooms and surgery centers, should be staffed with in-network providers, including emergency physicians, hospitalists, anesthesiologists, and radiologists.
New! Get Medicare Advantage member attribution info online
We have enhanced our Medicare Advantage eligibility and benefits responses (270/271). They now include HMO member attribution information, based on the member’s PCP selection. Our 2025 plans use one of these three administrators for prior authorization and claim/payment services:
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AZ Blue
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Optum Health Network Arizona (OHNAZ)
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Arizona Priority Care (AZPC)
It’s easy to find this info in the Availity EssentialsTM portal. After you pull up the member’s information, scroll down to the “Plan Maximums and Deductibles” section. Under the benefit descriptions links, you’ll see the administrator’s name, payer ID, and contact information.
In case you hadn’t heard …
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We’ll start using the 29th edition of the MCG care guidelines in June. Learn more.
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You can find three years of remits on the Availity EssentialsTM portal. Here’s how.
Our Medicare Advantage dental benefits use the BlueDentalSM Prime Network. Get the details.
Free CEUs
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Many providers like to help patients make lifestyle changes. The “Essentials” course, offered by the American College of Lifestyle Medicine (ACLM), offers ideas you can use right away to get your patients on the right track for lifestyle changes that stick. When you register, use promo code ESS-BCBSAZ to get 5.5 CME/CE credits free of charge.
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Patients living with diabetes can benefit from the right behavioral health support. Check out these free continuing education courses and resources from the American Diabetes Association® to learn more.
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Please join us for the next Grand Rounds session.Save a seat now for our May 14 discussion at 12 – 1 p.m. Just in time for the summer months, we’ll share perspectives on current efforts to mitigate Arizona’s heat-related health risks. Joining us are key state and local partners working together on the Arizona Extreme Heat Preparedness Plan:
The MCG care guidelines are the proprietary and copyright-protected information of MCG Health, part of the Hearst Health network.
Availity is a separate, independent company contracted with AZ Blue for provider portal services. Availity and Availity Essentials are registered trademarks of Availity, LLC.
American Diabetes Association is a trademark of American Diabetes Association, Inc.
Blue Cross, Blue Shield, and the Cross and Shield Symbols are registered service marks, and BlueDental is a service mark of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
