Medical Benefits & Claims - Non-Network

The DGA–Producer Health Plan has partnered with Green Light Cost Management to help negotiate lower rates for non-network claims and eliminate balance billing whenever possible. Green Light will attempt to reduce out-of-pocket costs when you use non-network providers, as well as reduce overall costs to the Health Plan.

For more information about non-network claims, click the button below.

Go to Non-Network Claims Information

SCHEDULE OF NON-NETWORK MEDICAL BENEFITS

Below is a summarized schedule of medical benefits under the Health Plan.

Non-Network Provider Network Provider
Calendar Year Deductible $325/person; $975/family
Percentage Paid by the Health Plan

DGA Premier Choice Plan
70% of covered expenses

DGA Choice Plan
60% of covered expenses

 		90% of covered expenses
Calendar Year Out-of-Pocket Limit (in excess of deductible)

DGA Premier Choice Plan
$12,500 per person

DGA Choice Plan
$20,000 per person

 		$1,000 per person
All Inclusive Network Out-of-Pocket Limit (includes deductibles, co-insurance and co-payments [including prescription drug co-payments])

Not applicable $10,600 per person
$21,200 family

REASONABLE AND CUSTOMARY CHARGES (R&C)

For doctors outside of the United States, the Reasonable and Customary Charge as described below–whether based on 80% of the FAIR Health standard or 150% of the applicable Medicare reimbursement rate–are based on the applicable rate for the specified procedure in the New York metropolitan area.

When determining the Reasonable and Customary Charge—which is the amount the Health Plan will reimburse you for a covered medical service rendered by a non-network provider—the Health Plan generally uses two pricing standards: (1) 80% of the FAIR Health* rate, or (2) 150% of the Medicare reimbursement rate for that service, though there are exceptions. Beginning January 16, 2024, the Reasonable and Customary Charge will be determined as follows:

  • The Health Plan will reimburse non-network claims at 80% of the FAIR Health standard under the circumstances below:
    1. When you pay upfront and FAIR Health pricing exists; or
    2. When Green Light negotiations with the provider are unsuccessful.
  • The Health Plan will use the 150% of Medicare reimbursement rate when a FAIR Health rate does not exist for the service provided.
  • When you have not paid your non-network provider upfront, Green Light will attempt to negotiate with your provider regarding your billed charges. If Green Light is successful in negotiating a better rate, you will be protected from balance billing, and you and the Health Plan will benefit from lower pricing.

    Non-network providers will be prevented from balance billing you only when the claim has been successfully negotiated by Green Light. In all other cases, you may be subject to balance billing by the non-network provider. Whenever possible, you should negotiate pricing before making an upfront payment.

  • When the Health Plan is not your primary plan, the Health Plan will begin by determining how much it would have paid had there been no other group coverage. Next it will find out what the primary plan paid. Then it will make a payment for the difference, if any, between the greater of the allowable amount and the amount paid by the primary plan, but not to exceed the amount the Health Plan would have paid if it was primary.
  • When there are Plan limits for a covered service (e.g., chiropractic and ambulatory services), the Health Plan will reimburse up to the plan limit amount. See Article 1, Section 1 Visit and Benefit Amount Limitations of the Health Plan’s March 2025 Summary Plan Description for more information.

The Health Plan’s allowable charge for any medical procedure or service from a non-network provider is based on the applicable Reasonable and Customary amount. You are responsible for any charges from non-network providers in excess of the maximum allowable charge, unless otherwise negotiated by Green Light, and all non-covered expenses, except with respect to emergency services, non-emergency services received from a non-network provider at certain network facilities, and air ambulance services furnished by non-network providers.

NON-NETWORK CLAIMS NEGOTIATION

When you use non-network providers, they often charge you for billed amounts that exceed the Reasonable and Customary Charge. The DGA–Producer Health Plan will work to help negotiate lower rates for non-network claims and eliminate balance billing whenever possible, reducing out-of-pocket costs for you and overall costs to the Health Plan. In order to try to negotiate better pricing for you, it is important that you do not pay the non-network provider up front when you can. (See Tips to Avoid Paying the Entirety of Your Non-Network Medical Bill Up Front.) Instead, ask your provider to submit your claim electronically through the Health Plan’s normal claims filing process. If you pay up front, you may lose out on potential savings that could have been achieved through the negotiation process and be subject to a lower reimbursement amount from the Health Plan for your claim. If you disagree with the reimbursement amount, you may file an appeal with the Health Plan to have the reimbursement amount reviewed.

HOW NON-NETWORK CLAIMS ARE PROCESSED

For more information on how to submit your non-network claims and how you may be reimbursed, click the button below.

Go to Non-Network Claims Information

NON-COVERED SERVICES

Most medically necessary services are covered by the Health Plan. However, not all services provided by a doctor are covered (cosmetic surgery, for example). You are responsible for 100% of the cost of non-covered services.

Do not assume that all services performed by a doctor are covered. Some doctors offer non-covered, medical services.

The best way to determine if a treatment is covered is to refer to the March 2025 Health Plan Summary Plan Description or contact the Plan office at (877) 866-2200 ext. 402.

FILING A NON-NETWORK MEDICAL CLAIM

A NEW COORDINATION OF BENEFITS FORM IS REQUIRED EACH YEAR

If you have not completed a Coordination of Benefits form within the past year, you will need to do so before your claims can be processed. Each year, a Coordination of Benefits form is mailed to you during your open enrollment period. If the Health Plan has not received a current Coordination of Benefits form, even if your information has not changed, your claim may be denied.

STEP-BY-STEP INSTRUCTIONS

Click the tab below that corresponds to the type of claim you will be filing.

Step 1: Download the Claim Form – Medical – Services Received in the U.S.

NOTE: For fastest processing, you must include both a completed claim form AND your itemized bill.

Step 2: Complete your claim form in its entirety and attach your itemized bill.

Your itemized bill must include the following:

    • Name and address of provider
    • Place of service (i.e., doctor, hospital, laboratory, ambulance service, etc.) 
    • Name of patient
    • Description of service
    • Date of service
    • Amount charged for each service
    • Diagnosis code
    • Procedure code
    • Tax ID
    • National Provider ID (NPI)

For Ancillary charges on Durable Medical Equipment or Lab work performed by an independent laboratory, Anthem will require both the rendering provider’s NPI and the ordering/referring provider’s NPI numbers. For other medical claim submissions where health information is submitted to insurance, the medical provider should include their NPI number.

Step 3: Submit your claim.

Only a single login is required to use on both Anthem.com and the Sydney Mobile App. The same login credentials must be used for both platforms, and you must first be registered before you can submit your claims from either platform.

📱Sydney Mobile App (Recommended)

To submit your claims via the Sydney Mobile App:
  1. Log into the Sydney Mobile App (Download the app here: Android or iOS).
  2. Scroll down to Claims & EOBs or tap the Claims icon in the bottom navigation menu.
  3. Scroll down to the Claim Submission Center section and tap Go to Claims Submission Center.
  4. On the Claim Submission Center page, tap Medical.
  5. Proceed through the onscreen prompts to complete your claim submission.

For technical assistance with the Sydney claims submission process, tap the Chat With Us button at the bottom of your phone screen or contact Anthem Blue Cross at (866) 755-2680.

TIP: When submitting your claims via the Syndey Mobile App, you can receive phone notifications updating you on the status of your claim.
To submit your claims online at Anthem.com:.
  1. Log onto Anthem.com.
  2. Under Claims & Payments choose Claims Submission Center.
  3. On the Claims Submission page, under Medical, click Get Started.
  4.  Proceed through the onscreen prompts to submit your claim.

For technical assistance with the online claims submission process, contact Anthem Blue Cross at (866) 755-2680.

DO NOT submit claims to the Health Plan office.

Mail your claim directly to Anthem Blue Cross at the address below:

Anthem Blue Cross
P.O. Box 60007
Los Angeles, CA 90060-0007

Step 4: The Health Plan will determine the portion of the claim’s billed amount the Health Plan will pay under its terms.

For doctors outside of the United States, the Reasonable and Customary Charge as described below–whether based on 80% of the FAIR Health standard or 150% of the applicable Medicare reimbursement rate–are based on the applicable rate for the specified procedure in the New York metropolitan area.

When determining the Reasonable and Customary Charge—which is the amount the Health Plan will reimburse you for a covered medical service rendered by a non-network provider—the Health Plan generally uses two pricing standards: (1) 80% of the FAIR Health* rate, or (2) 150% of the Medicare reimbursement rate for that service, though there are exceptions. Beginning January 16, 2024, the Reasonable and Customary Charge will be determined as follows:

  • The Health Plan will reimburse non-network claims at 80% of the FAIR Health standard under the circumstances below:
    1. When you pay upfront and FAIR Health pricing exists; or
    2. When Green Light negotiations with the provider are unsuccessful.
  • The Health Plan will use the 150% of Medicare reimbursement rate when a FAIR Health rate does not exist for the service provided.
  • When you have not paid your non-network provider upfront, Green Light will attempt to negotiate with your provider regarding your billed charges. If Green Light is successful in negotiating a better rate, you will be protected from balance billing, and you and the Health Plan will benefit from lower pricing.

    Non-network providers will be prevented from balance billing you only when the claim has been successfully negotiated by Green Light. In all other cases, you may be subject to balance billing by the non-network provider. Whenever possible, you should negotiate pricing before making an upfront payment.

  • When the Health Plan is not your primary plan, the Health Plan will begin by determining how much it would have paid had there been no other group coverage. Next it will find out what the primary plan paid. Then it will make a payment for the difference, if any, between the greater of the allowable amount and the amount paid by the primary plan, but not to exceed the amount the Health Plan would have paid if it was primary.
  • When there are Plan limits for a covered service (e.g., chiropractic and ambulatory services), the Health Plan will reimburse up to the plan limit amount. See Article 1, Section 1 Visit and Benefit Amount Limitations of the Health Plan’s March 2025 Summary Plan Description for more information.

The Health Plan’s allowable charge for any medical procedure or service from a non-network provider is based on the applicable Reasonable and Customary amount. You are responsible for any charges from non-network providers in excess of the maximum allowable charge, unless otherwise negotiated by Green Light, and all non-covered expenses, except with respect to emergency services, non-emergency services received from a non-network provider at certain network facilities, and air ambulance services furnished by non-network providers.

To submit a medical claim for services received outside the U.S., follow the three steps below.

Step 1: Download the Claim Form – Medical – Services Received Outside the U.S.

This is the Blue Cross Blue Shield Global Core International Claim Form. You should submit the completed form along with any itemized bill you might have.

Step 2: Be sure your claim submission includes both a completed Blue Cross Blue Shield Global Core International Claim Form and an itemized bill with all information listed below.

If you do not provide all of the required information, your claim could be delayed.

  • Health Plan Participant’s Information
    • Name
    • Health Plan ID Number (as it appears on your Health Plan ID Card)
    • Health Plan Group Number
  • Patient’s Information
    • Name
    • Date of Birth
  • Provider’s Information
    • Name
    • Address
    • Federal Tax ID Number
  • Service Information
    • A Description of Services and Diagnosis (provided by the doctor).
    • Amount Paid/Proof of Payment

Step 3: Submit your claim to Blue Cross Blue Shield Global Core using the information below.

It is recommended that you submit your claim by email, mobile app or online in order to have proof of your claim submission.
  • By email: claims@bcbsglobalcore.com
  • By mobile phone: Download the Blue Cross Blue Shield Global Core mobile app     For Android     For iOS
  • Online:  www.bcbsglobalcore.com
  • By mail: DO NOT submit claims to the Health Plan Office. Mail your claim directly to Blue Cross at the address below:
    • Service Center
    P.O. Box 2048
    Southeastern, PA  19399

If you have any questions regarding your medical claim submission, you can reach Blue Cross Blue Shield Global Core at (800) 810-BLUE or collect at (804) 673-1177.

Step 4: The Health Plan will determine the portion of the claim’s billed amount the Health Plan will pay under its terms.

You will be reimbursed the Reasonable and Customary rate according to the New York City metropolitan area. If you disagree with the reimbursement amount, you may file an appeal with the Health Plan to have the reimbursement amount reviewed.

Step 1: Download the Claim Form – Medical – Services Received in the U.S.

NOTE: For fastest processing, you must include both a completed claim form AND your itemized receipt. In lieu of the claim form, an itemized receipt may be accepted alone as long as it includes BOTH (1) the information normally supplied on the claim form and (2) the required information for the itemized receipt (detailed in Step 2).

Step 2: Complete your claim form in its entirety and attach your itemized receipt.

Required Information for Medical Claims

The following information must appear on your document. Having all this information on your receipt will make your claim submission process go faster. All information must be legible, or the claim could be incorrectly processed and rejected. Contact your provider to supply any missing required information in a new document.

  • Provider name
  • Provider address
  • Tax ID
  • Procedure codes/CPT or HCPC
  • Units for each procedure
  • Diagnosis codes
  • Patient name
  • Service location
  • Date of service
  • Billed amount for each procedure code
  • Amount paid ion USD
  • National Provider ID (NPI) For claims using durable medical equipment, lab work performed by an independent laboratory, or prescriptions purchased from a specialty pharmacy, please obtain the referring or ordering provider’s NPI from the provider.

Step 3: Submit your claim.

🖥️ Online (Recommended)

You must first be a registered user of Anthem.com to submit your claims online.
  1. Log onto Anthem.com
  2. Under the Claims & Payments tab, click Member Submitted Claims Center.
  3. On the Member Submitted Claims Center page, select Submit a Claim.
  4. Select the type of claim you are submitting.
  5. Select Patient name.
  6. Review the claim submission requirements and upload the necessary files.

For technical assistance with the online claims submission process, contact Anthem Blue Cross at (866) 755-2680.

Choose one:
(866) 896-1393
(866) 896-6531
(866) 896-6626
(866) 896-6532
When faxing your claim, be sure to keep your fax confirmation sheet for your records.

NOTE: If you have Caller ID Block installed on your phone line, you will need to temporarily disable the feature by dialing *82 before faxing your claim to Blue Cross.

DO NOT submit claims to the Health Plan Office.

Mail your claim directly to Blue Cross at the address below:

Anthem Blue Cross
P.O. Box 60007
Los Angeles, CA 90060-0007

Step 4: The Health Plan will determine the portion of the claim’s billed amount the Health Plan will pay under its terms.

  • If the claim is less than $500, the Health Plan will pay the Reasonable and Customary amount for any covered expenses, as defined in the Benefits Summary tab (usually 150% of Medicare’s reimbursement rate). You will be responsible for any amounts in excess of the Reasonable and Customary amount, plus any expenses not covered under Health Plan rules.  NOTE: When possible, similar or related claims will be bundled to meet the $500 threshold.
  • If the claim is more than $500 and you have not yet paid the provider:
    1. We will attempt to negotiate with the provider on your behalf to determine a mutually agreeable allowance.
    2. If able to negotiate a more favorable rate with your non-network provider, you will be responsible for any applicable deductible and co-insurance based upon the negotiated rate on covered expenses. The non-network provider will agree not to balance bill you for any remaining charges.
    If unable to reach a negotiated rate agreement, the Health Plan will pay the standard Reasonable and Customary rate, as defined above (usually 150% of Medicare’s reimbursement rate) on any covered expenses. You may be balance billed by the non-network provider for any amounts in excess of the Reasonable and Customary rate, plus any expenses not covered under Health Plan rules.
  • If the claim is more than $500 and you have already paid the provider, the Health Plan will reimburse you at the Reasonable and Customary amount, as defined above (usually 150% of Medicare’s reimbursement rate) for any covered expenses. If you would like us to try to negotiate with your provider after you have already paid, please contact the Health Plan at (877) 866-2200, Ext. 401.
To submit a medical claim for services received outside the U.S., follow the three steps below.

Step 1: Download the Claim Form – Medical – Services Received Outside the U.S.

This is the Blue Cross Blue Shield Global Core International Claim Form. You should submit the completed form along with any itemized bill you might have.

Step 2: Be sure your claim submission includes both a completed Blue Cross Blue Shield Global Core International Claim Form and an itemized bill with all information listed below.

If you do not provide all of the required information, your claim could be delayed.

  • Health Plan Participant’s Information
    • Name
    • Health Plan ID Number (as it appears on your Health Plan ID Card)
    • Health Plan Group Number
  • Patient’s Information
    • Name
    • Date of Birth
  • Provider’s Information
    • Name
    • Address
    • Federal Tax ID Number
  • Service Information
    • A Description of Services and Diagnosis (provided by the doctor).
    • Amount Paid/Proof of Payment

Step 3: Submit your claim to Blue Cross Blue Shield Global Core using the information below.

It is recommended that you submit your claim by email, mobile app or online in order to have proof of your claim submission.
  • By email: claims@bcbsglobalcore.com
  • By mobile phone: Download the Blue Cross Blue Shield Global Core mobile app     For Android     For iOS
  • Online:  www.bcbsglobalcore.com
  • By mail: DO NOT submit claims to the Health Plan Office. Mail your claim directly to Blue Cross at the address below:
    • Service Center
    P.O. Box 2048
    Southeastern, PA  19399

If you have any questions regarding your medical claim submission, you can reach Blue Cross Blue Shield Global Core at (800) 810-BLUE or collect at (804) 673-1177.

Step 4: The Health Plan will determine the portion of the claim’s billed amount the Health Plan will pay under its terms.

You will be reimbursed the Reasonable and Customary rate according to the New York City metropolitan area. If you disagree with the reimbursement amount, you may file an appeal with the Health Plan to have the reimbursement amount reviewed.
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