Does the Code of Federal Regulations (CFR) bar some out-of-network FEDVIP providers?

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I have been enrolled in the FEDVIP programs for many years with the understanding that I am free to select a provider that I believe to be best for me. However, I’m now told that out-of-network providers for the BlueVision program are not covered if a network provider is said to be “available”. Is there a citation for this exclusion in the CFR or perhaps some other publication?

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Posted by (Questions: 1, Answers: 1)
Asked on May 24, 2018 6:42 pm
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For all FEDVIP plans, benefits are offered through carriers chosen by the Office of Personnel Management. Each plan offers a brochure with an explanation of what is and is not covered. They offer both High Option and Standard Option benefits. It appears, based on the question you posed, you have the Standard Option and the Standard Option does not cover services from non-participating providers. Page 4 of the BlueVision program brochure states: Out-of-network providers are referred to as non-participating providers. High Option: We will provide fee schedule allowances as described in Section 4, Your Cost For Covered Services, for covered services performed by non-participating providers. However, since these providers do not participate with FEP BlueVision, you may be responsible for any amounts over the fee schedule allowances. Please see Section 8, Claims Filing and Disputed Claims Processes, for information.
Under Standard Option, you must stay in-network for covered services. If you receive care from a non-participating provider, we will not pay for any services unless you reside in a limited access area. Please see Section 4, Your Cost For Covered Services. The brochure can be found at the following link: https://dvtv.davisvision.com/pdf/2018_FEP_BlueVisionBrochure.pdf

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Answered on May 25, 2018 12:13 am
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Davis Vision provided clarification where FEP BlueVision, for lack of attention to detail, did not. BlueVision (via unsigned letterhead) wrote, “reimbursement has been denied for reasons shown below”. The reason shown was, “there are participating providers within your area”. BlueVision made no reference to “High Option” or “Standard Option” which, as it turns out is the crux of this issue but viewed to be irrelevant by BlueVision. It’s not entirely clear who flunked, “attention to detail” but the letterhead shows, “FEPBlueVision” which I view to be highly relevant to the next “open season”.
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Posted by (Questions: 1, Answers: 1)
Answered on May 26, 2018 1:42 am