Provider eligibility

Part of Alberta Blue Cross’s role in managing and administering your benefit plan is interacting with service providers. The majority of health care providers who are involved in the delivery of products and services to our plan members conduct themselves professionally and ethically.

As part of our provider management practice, we ensure your plan is protected from abuse or misuse by taking disciplinary action toward those providers whose behaviour may range from suspicious claiming practices to actual illegal activity. We actively investigate and pursue all questionable activities and have extensive measures in place to detect and combat plan abuse.

From time to time we must take a firm stance if a provider’s conduct negatively affects your benefit plan. In these cases, we have several courses of action we may pursue from filing a complaint with the provider’s governing body to removing the provider from our provider eligibility list. In some cases, we may even take legal action. If we remove a provider from our provider eligibility list, this means all claims for products or services from that provider will not be eligible for coverage, payment or reimbursement.

As stewards of your benefit plan dollars, we take our responsibility seriously and take action as warranted to protect the financial well-being and sustainability of your benefit plan.

Frequently asked questions

  1. I’ve been informed that a health provider I’ve seen for years is now listed as an ineligible provider. What did he do?

    From time to time, Alberta Blue Cross reviews and assesses which providers are eligible for coverage of products and services, which are reimbursed or paid for on your behalf through your health benefit plan. This is a process consistent with those conducted by many other health benefit plan carriers. We are aware the decision has serious consequences and therefore we conduct extensive reviews and discussions. As you can appreciate, details regarding each provider must be kept private and confidential.

  2. I’ve never heard of a benefit company deciding which providers are eligible for plan coverage. Is this unique to Alberta Blue Cross?
    No. From time to time, Alberta Blue Cross reviews and assesses which providers are eligible for coverage of products and services, which are reimbursed or paid for on your behalf through your health benefit plan. This process is consistent with those conducted by many other health benefit plan carriers.

  3. I just saw a health provider for an appointment. Now I’m worried that she might be ineligible. Does this mean I’ll have to pay the full amount of the visit?

    No. As we realize that not all plan members are aware if a provider is eligible for coverage or not, we have a first-claim exception rule in place. This means we will pay for the first visit but then notify you that all future claims from that particular provider will not be eligible for coverage, payment or reimbursement. You have the choice to continue to obtain products or services from the ineligible provider but you will be responsible for the total cost of the product or service.

  4. Can the decision be appealed? Is there a way my health provider can become eligible under my Alberta Blue Cross plan again?

    No. After extensive review and discussion, Alberta Blue Cross has determined this provider is no longer eligible for coverage, payment or reimbursement. This decision is now in effect and cannot be appealed.

  5. I love my health provider and don’t want to change providers. Can I remain with her?

    Yes. You are free to continue to request products and services from this provider in the future, but please be advised that if you do so, you will be responsible for the full cost of the product or service. The cost will not be paid for or reimbursed through your health benefit plan.

  6. If I choose to keep seeing this particular provider who is listed as ineligible for coverage and the claims are denied, can I get them paid through my Health Spending Account?

    Yes. Any Health Spending Account that you have is not affected by Alberta Blue Cross’s decision regarding this provider’s eligibility.

  7. How will I know who is eligible for coverage under my Alberta Blue Cross plan when I make appointments?

    We encourage plan members to ask a provider before obtaining a service. You can also call our Customer Services department at 1-800-661-6995 to ask if that particular provider is eligible for Alberta Blue Cross coverage, payment or reimbursement. Please keep in mind that you always have the choice to continue to obtain products or services from a provider we have listed as ineligible, but you will be responsible for the total cost of the product or service.

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