This appeal arises out of a dispute over the denial of in-network medical benefits to Kimberly Mitchell for two surgeries she elected to undergo at the University of Alabama, Birmingham Hospital “UAB” in 2002 and 2003. As a state employee, Mitchell is eligible to participate in the state health benefit plan “SHBP”, operated by the Georgia Department of Community Health “DCH”. SHBP members’ health benefits vary based on the coverage plan chosen by the member and whether the member receives treatment from an in-network versus an out-of-network provider and/or facility. DCH contracts with Blue Cross and Blue Shield of Georgia, Inc. “BCBS” to administer all claims for the Indemnity and PPO plans of the SHBP. BCBS is responsible for handling customer service requests from SHBP members and is responsible for determining the usual, customary and reasonable “UCR” fees for physician providers. DCH also contracts with Beech Street Corporation “Beech Street”, a national managed health care company that is responsible for the development, administration and maintenance of a national PPO network of providers for the benefit of the SHBP members. Beech Street allows clients to customize their individual contracts, making certain providers within the national PPO network ineligible under the client’s offered health care plan, thereby reducing costs for plan members. Therefore, the Beech Street website contains the names of providers who are part of the Beech Street PPO network, but are not part of the SHBP/Beech Street PPO network.
The DCH website directs SHBP members to consult its website to determine whether a particular facility is a participating provider in the SHBP/Beech Street PPO network. The DCH website also incorporates multiple disclaimers stating that certain Beech Street hospitals and providers are not participating providers for purposes of the SHBP PPO plan. These disclaimers prominently appear in red ink alongside the link to Beech Street’s website. In addition, once a member links to the Beech Street website, there are also disclaimers warning members to confirm the network status of providers with their individual health benefit plan. Disclaimers are both imbedded in the web page and appear as pop-ups when an individual attempts to search for a provider or facility.1 In the present case, although UAB was a part of Beech Street’s national PPO network, UAB was excluded as an “in-network” provider available to SHBP PPO members. Beech Street has no involvement with the administration of benefits under the SHBP or in the determination of UCR charges.
