Information as of February 2022
Pathway Essentials – Quick Reference Guide
Anthem’s New Network
HMO
POS
Health Maintenance Organization
(HMO) offers care and services from
doctors, other health care providers or
hospitals only in the plan network
Point of Service (POS) offers lower
costs if doctors, health care
providers and hospitals in the plan’s
network are used. Think of it as an
HMO and PPO “hybrid”
Care is generally limited to doctors in
the HMO’s network
Out of network care is allowed, but
staying in the plan’s network is far
less expensive
Typically offers lower monthly
payments and out of pocket costs
Offers the freedom to use out of
network doctors and providers, but
the out of pocket cost is higher than
an in network doctor or provider
No out of network coverage. Includes
coverage of non-network benefits only
for Urgent and Emergent authorized
services. Members are responsible for
100% of non-Urgent & ER related costs
Includes non-network benefits with
higher costs shares including
deductible, coinsurance and copays
No PCP required
No PCP required
Referrals are not required but please
refer as a courtesy to participating
Pathway Essentials
Ancillary/Facility/Physician/Providers to
minimize member’s out of pocket
expense
Referrals are not required but please
refer as a courtesy to participating
Pathway Essentials
Ancillary/Facility/Physician/Providers
to minimize member’s out of pocket
expense
Pathway Essentials is an Affordable Care Act (ACA) plan sold via the Individual marketplace in 45 of 92
Indiana counties, with an exclusive arrangement with five in/out-patient facilities.
Please verify eligibility and benefits via Availity as individuals can choose to be a part of an HMO or POS* plan
within the Pathway Essentials network and prefixes share multiple product options. Please see grid on Page 2
for more details. *POS only sold in Lake, La Porte and Porter counties
Customer Service contact information:
Please refer to the back of the member’s ID card for
the Provider Services phone number.
Claim Mailing Address:
Anthem Blue Cross Blue Shield
PO Box 105187
Atlanta, GA 30348-5187
INBCBS-CM-003952-22-B August 2022
Information as of February 2022
Prod Type
Prefix
HMO
E7E
HMO
K5N
HMO
E7E
HMO
E7E
HMO
K5N
HMO
E7E
HMO
E7E
HMO
K5N
HMO
E7E
POS
S8P
POS
X6K
POS
S8P
HMO
E7E
HMO
K5N
HMO
E7E
HMO
E7E
HMO
K5N
HMO
E7E
HMO
E7E
HMO
K5N
HMO
E7E
HMO
E7E
HMO
E7E
HMO
E7E
HMO
E7E
HMO
K5N
HMO
E7E
HMO
E7E
HMO
E7E
HMO
E7E
HMO
E7E
HMO
K5N
HMO
E7E
HMO
E7E
HMO
E7E
HMO
E7E
HMO
E7E
HMO
K5N
HMO
E7E
HMO
E7E
HMO
E7E
HMO
E7E
Information as of February 2022
Sample Member ID Card
In Network Pathway Essentials Facility Providers
Methodist Hospitals (Gary & Merrillville)
Franciscan-Beacon La Porte
Memorial Hospital (South Bend)
Indiana University Health
Union Hospital
All member ID cards will say Pathway Essentials on the
front
Availity will always be your source of truth for plan,
eligibility and benefit information
Referrals: Pathway Essentials plans are open
access
Referrals are not required but please refer as a
courtesy to participating Pathway Essentials
Ancillary/Facility/Physician/Providers to minimize
members out of pocket expense
Information as of February 2022
Please refer to our online directory for participating Ancillary and Professional
physician/providers: https://www.anthem.com/find-care/
Pre-certification/UM
HMO
POS
In Network Provider - Provider must
get precertification when required.
Out of Network Provider - Member has
no benefit coverage unless: The
member gets approval to use a non-
network provider before the service is
given or the member requires an
emergency care admission*.
Blue Card Provider - Member has no
benefit coverage unless: The member
gets approval to use the provider
before the service is given or the
member requires an emergency care
admission*. Blue Card Providers must
obtain precertification for all Inpatient
admissions.
*ER admissions require the provider or
member to call us within 48 hours.
Please utilize Interactive Care Reviewer
(ICR) on Availity for full Pre-
certification/UM requirements.
In Network Provider - Provider must
get precertification when required.
Out of Network Provider - Member
must get pre-certification when
required. Member may be financially
responsible for charges/costs related
to the service and/or setting in
whole or in part if the service and/or
setting is found not to be medically
necessary.
Blue Card Provider -Member must
get pre-certification when required.
Member may be financially
responsible for charges/costs related
to the service and/or setting in
whole or in part if the service and/or
setting is found not to be medically
necessary. Blue Card Providers must
obtain precertification for all
Inpatient admissions.
Pre-certification is not required to
receive emergency care. ER
admissions do require the provider
or member to call us within 48
hours.
Please utilize Interactive Care
Reviewer (ICR) on Availity for full
Pre-certification/UM requirements.
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc.
In Indiana: Anthem Insurance Companies, Inc. In Kentucky : Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area):
RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits
underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc.
HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc.
and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its
service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the
PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectiv ely, which underwrite or administer
the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols
are registered marks of the Blue Cross and Blue Shield Association.