Private insurance companies can provide either primary or secondary coverage, or they may offer a managed-care plan. To receive covered benefits, private insurance companies may require their customers to obtain medical care from specific networks of doctors and medical facilities. If a private insurance company has no contract with Mayo Clinic, it may not cover any Mayo Clinic services.
If you're insured by a private insurance company that doesn't have a contract with Mayo Clinic, you can still receive treatment at Mayo Clinic. However, you'll be financially responsible for the total charges, and you may be asked to make a deposit before receiving services. It's your responsibility to know what your insurance will cover.
Mayo Clinic may contact your insurance plans for pre-certification or authorization of certain services, or at your request.
Private insurance companies cover charges under their own fee schedule. These covered charges are called allowable charges, and they are often referred to as "usual, customary and reasonable" (UCR) charges. Mayo Clinic charges are determined by a committee consisting of administrators and doctors to support quality care, research and education initiatives.
If there are major differences between your insurance coverage and what Mayo Clinic charges, you can file an appeal with your insurance company. Although Mayo Clinic normally isn't permitted to initiate appeals when it doesn't have a contract, it will provide any information requested by your insurance company to resolve your appeal. Under any plan, some services may not be covered because the insurance company considers them preventive, routine or unnecessary, or because the services aren't part of your benefit plan.
Mayo Clinic and Blue Cross Blue Shield (BCBS) have an agreement to grant out-of-state BlueCard members in-network access to Mayo Clinic providers and facilities in Arizona. This agreement has been expanded to grant select Arizona-based self-insured employer groups in-network access to Mayo Clinic providers and facilities in Arizona. People who have in-network access to Mayo Clinic will use a new PPO network developed by BCBS. In addition, people who have in-network access to Mayo Clinic will be financially responsible for their coinsurance, deductibles and copayments, as well as any noncovered services as determined by their benefit plan.
The following groups aren't included in the agreement and will continue to be out-of-network for services at Mayo Clinic:
Out-of-network BCBS members are responsible for 100 percent of Mayo Clinic's billed charges.
Mayo Clinic is required to electronically file all primary claims with the BCBS-AZ clearinghouse, which then forwards the claims to out-of-state offices in five to seven days.
Blue Cross Blue Shield (BCBS) members receiving their care at Mayo Clinic on an out-of-network basis will receive Mayo Clinic's payment directly from BCBS. You must send these payments to Mayo Clinic when you receive them. Mayo Clinic asks that BCBS members pay their entire balance within 60 days of the date claims are filed. If you feel you may be unable to meet this requirement, you must make alternative payment arrangements with a Patient Account Services representative at 480-301-7033 or 800-603-0558 (toll-free).