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Important PPO Plan Information - Outpatient Fees & Surgery Requirements

To help control rising health care costs while maintaining access to safe, high-quality care, PPO plans include specific rules and cost limitations for certain outpatient procedures.

Members must use in-network providers and facilities to be eligible for full benefits. Carefully review your plan documents to understand coverage details.

Colonoscopy and Other Outpatient Procedures

For procedures such as colonoscopies, PPO plans limit how much they will pay for services performed at an in-network outpatient hospital. For example, the maximum benefit for a colonoscopy at an outpatient hospital is $1,500. However, there is no benefit limit when the procedure is performed at an in-network Ambulatory Surgery Center (ASC).

To avoid unexpected out-of-pocket costs:

• Choose an in-network ASC for covered procedures. 

•  If a hospital is medically necessary, your provider must submit clinical justification to request an exception.

• Advance certification (pre-authorization) may be required—especially for services like anesthesia. Be sure your provider secures this before your procedure.

• The procedure must occur at a certified site unless an exception is granted by Anthem.

  
  
  If you live more than 30 miles from an ASC or face scheduling barriers, your provider can also request an exception.
  
  Questions?
  If you have any questions about your benefits or provider options, please call Anthem before scheduling any procedures to ensure coverage and minimize your costs.
  
  Hospital Limit for Outpatient Procedures