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Healthcare Providers Reference Guide
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5.0 PROVIDERnet Registration
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5.3 Practitioners

5.3 Practitioners

The Provider must verify that each Practitioner is duly registered under the Applicable Laws; or they are qualified to provide the Practitioner Services under Applicable Laws.

Provider Responsibilities

It is your responsibility to advise Pacific Blue Cross within 30 days if:

  • a Practitioner is no longer in their employment or providing services to the Provider as an independent contractor, or
  • if a Practitioner is no longer qualified or registered to provide Practitioner Services in accordance with Applicable Laws, or 
  • a Practitioner has had limits or conditions placed on their ability to provide Practitioner Services pursuant to Applicable Laws.

Eligibility for Reimbursement

Pacific Blue Cross will not pay (or will recover amounts paid to a Provider) for any part of a Claim that is not an Eligible Expense.  Examples include but are not limited to:

  • Claims for Equipment or Services that are not covered under a Member’s Policy as a benefit;
  • Claims for Practitioner Services that are not provided directly by a Practitioner to a Member;
  • Claims for Services that a Practitioner is not licensed or authorized to provide under Applicable Laws; or
  • Claims for Equipment or Services that are not provided in accordance with Applicable Laws.