Visiting a Participating Provider
The following FAQs address some common issues concerning doctor visits.
Is there a list of participating doctors for my area?
Yes. The State Health Plan's local provider network is managed by Blue Cross and Blue Shield of North Carolina. To locate a doctor near you, use the BCBSNC online Provider Search.
Simply enter your ZIP Code, select a Specialty, then click Find Doctor Now to view a list of participating providers near you.
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How does my deductible work?
Your deductible is $450 per Plan year, which runs from July 1 through June 30. Until your deductible is met, you are responsible for the entire amount of the allowable charges. After your deductible has been met, you pay 20% of the eligible expenses, up to the maximum out-of-pocket amount of $2,000 ($6,000 per Employee/Child(ren) or Employee/Family contract). For example:
Is there a time limit for submitting a request for prior approval?
Yes. Since January 2, 2004, when prior approval is required, in order to be considered for retrospective review, requests must be received within six months (180 days) of the end date of service. Requests received after 180 days of the end date of service will be denied even if the services were provided in the appropriate setting and met medical necessity criteria as defined by the State Health Plan.
Note: The information contained in these Frequently Asked Questions does not include all the benefits or everything you need to know about the State Health Plan. Please check your Benefit Booklet for further details. For more information click on the appropriate Benefits Book for your health plan: NC SmartChoice Basic PPO, NC SmartChoice Standard PPO, NC SmartChoice Plus PPO and the Indemnity Plan. We encourage you to call if you have questions about any of your health plan benefits. For the contact information, consult our Contact Us page.
- Is there a list of participating doctors for my area?
- How does my deductible work?
- Is there a time limit for submitting a request for prior approval?
Is there a list of participating doctors for my area?
Yes. The State Health Plan's local provider network is managed by Blue Cross and Blue Shield of North Carolina. To locate a doctor near you, use the BCBSNC online Provider Search.
Simply enter your ZIP Code, select a Specialty, then click Find Doctor Now to view a list of participating providers near you.
Back To Top
How does my deductible work?
Your deductible is $450 per Plan year, which runs from July 1 through June 30. Until your deductible is met, you are responsible for the entire amount of the allowable charges. After your deductible has been met, you pay 20% of the eligible expenses, up to the maximum out-of-pocket amount of $2,000 ($6,000 per Employee/Child(ren) or Employee/Family contract). For example:
| BEFORE DEDUCTIBLE HAS BEEN MET | |
|---|---|
| Office Visit | $52.00 |
| Allowable Charge under CostWise | $36.50 |
| Professional Services Copay | $25.00 |
| Applied to Deductible ($36.50-$25.00) | $11.50 |
| You Pay ($11.50+$25.00) | $36.50 |
| AFTER DEDUCTIBLE HAS BEEN MET | |
|---|---|
| Office Visit | $52.00 |
| Allowable Charge under CostWise | $36.50 |
| Professional Services Co-pay | $25.00 |
| Applied to Deductible ($36.50-$25.00) | $11.50 |
| Coinsurance (20% of $11.50) | $ 2.30 |
| You Pay ($25.00 + $2.30) | $27.30 |
- There is no $25.00 Professional Services copayment for X-Rays, lab, radiation therapy, or allergy injections.
- Only one Professional Services Copayment is charged per person, per provider, per day.
Is there a time limit for submitting a request for prior approval?
Yes. Since January 2, 2004, when prior approval is required, in order to be considered for retrospective review, requests must be received within six months (180 days) of the end date of service. Requests received after 180 days of the end date of service will be denied even if the services were provided in the appropriate setting and met medical necessity criteria as defined by the State Health Plan.
Note: The information contained in these Frequently Asked Questions does not include all the benefits or everything you need to know about the State Health Plan. Please check your Benefit Booklet for further details. For more information click on the appropriate Benefits Book for your health plan: NC SmartChoice Basic PPO, NC SmartChoice Standard PPO, NC SmartChoice Plus PPO and the Indemnity Plan. We encourage you to call if you have questions about any of your health plan benefits. For the contact information, consult our Contact Us page.
