As part of Blue Shield’s ongoing efforts to reimagine health care, Blue Shield is using a new tool harnessing artificial intelligence (AI) to provide our members with better access to high quality care.
Blue Shield’s primary doctor matching system, for HMO and PPO members alike, is now powered by AI. It will consider many factors such as claims history (when available), provider ratings, and location to ensure a successful match between members and primary doctors.
Blue Shield fully-insured Full PPO plan members in California will be matched with a primary doctor, otherwise known as a primary care physician (PCP). This match will take place when a member enrolls or renews. Having a designated primary doctor has shown improved access to care, enhanced care coordination, and a better member experience, all of which align with our mission.
Currently all Blue Shield HMO and Tandem PPO plan members are automatically matched with a primary doctor. Blue Shield is now extending primary doctor matching to all Blue Shield fully-insured Full PPO plan members in California. Unlike HMO plan members, ID cards for PPO plan members will not display the name of the primary doctor.
Members in a PPO plan are not required to seek care from their primary doctor match and will not be required to seek a referral before seeing another provider. The purpose of providing members with a suggested primary doctor match is to support enhanced care coordination and improve the member experience.
Member communications will begin on January 1, 2021 upon renewal or new enrollment. Members will be able to see their primary doctor match via a banner on their dashboard when logged in to blueshieldca.com. Members will be able to learn about the benefits of having a primary doctor, details about their suggested doctor match, and instructions on how to make a change. Direct communications to members will begin in the spring to all registered members with a registered account on blueshieldca.com and with an email address on file.
Employer communications will be sent out to groups in a phased approach based on enrollment/renewal month. This is to align with the member experience; PPO PCP matching will occur when a member enrolls in a 2021 plan. Example: Members in a group with July renewal date will be matched with a PCP on 7/1/21, and not 1/1/21.
Employers will receive this information generally 6 weeks prior to the group’s effective date, beginning on November 19 for groups with January 2021 effective dates. For answers to commonly asked questions, please see the Primary Doctor Matching FAQs.