Eligibility List of BlueChoice Members2 Covering Physician · f. Diagnostic and laboratory...

BlueChoice Policy and Procedure

BCBSIL Provider Manual—Rev 9/09 1

Eligibility List of BlueChoice Members...................................................................................2

Covering Physician ..................................................................................................................5

OB/GYN Provider Scope of Care.............................................................................................6

Obstetric Program Requirements/Referral and Perinatal Services......................................9

Network Waiver Requests......................................................................................................11

Patient Age Guidelines...........................................................................................................12

Physical, Occupational, & Speech Therapy Network ..........................................................14

Practice Closure/ Patient Termination or Refusal/Provider Network Termination ...........15

Provider Rights and Responsibilities ...................................................................................17

Participating Specialist Physician (PSP) Departicipation Member Notification Process.21

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association



Policy Name: Eligibility List of BlueChoice Members Policy Number: Administrative -2 Effective Date: 1/1/94 Revision Date: Review Date: 9/1/09 Approval Signature:

Senior Medical Director Vice President–Network

Management Approved QI: 9/2/09 Approved P&P: 8/12/09

Policy: Blue Cross and Blue Shield of Illinois (BCBSIL) will provide the Primary Care Physician (PCP) with a monthly listing of names for BlueChoice members that have selected the PCP. Purpose: To facilitate the PCP's verification of BlueChoice member eligibility under the Plan. Eligibility List Report Definitions: 1. The Cover Page of each physician’s eligibility list will be used as a mailing insert. The cover page will

include: • Name (PCP, Group or the contracted entity) and designated mailing address.

2. The Detail Page identifies member information, effective dates and group/subscriber numbers for

members that have selected the physician for the coming month. (Attachment I). 3. The Change Page identifies changes applied to the eligibility list from the previous month’s list. The

member changes will be listed in alphabetical order and include: • Member Name • Group Number • Subscriber Number • Effective Date of the Change • Process Date of the Change • Description Codes

4. Transfer In - member transferring into PCP practice. 5. Transfer Out - member transferring from PCP practice. 6. New Addition - member converting to BlueChoice Plan from another BCBSIL insurance plan. 7. Cancellation - member’s coverage has been canceled or their benefit package changed. This may

cause a gap in coverage; therefore, verification of the member's eligibility status with the Plan is highly recommended.

8. Reinstatement - member’s insurance coverage has been reinstated. This does not cause a gap in

coverage.



Eligibility List of BlueChoice Members Page 2 of 3 9. A Summary Information/Totals Page is provided at the end of the Eligibility List that gives each

membership count. 10. Supplemental Eligibility List:

• Use the weekly Supplemental Eligibility List in addition to the monthly BlueChoice Eligibility List when verifying a member’s eligibility status. Members included on the Supplemental Eligibility List will appear on the next monthly BlueChoice Eligibility List.

Procedure: 1. By the first of each month, the PCP will receive a BlueChoice Eligibility List detailing each member

who has selected that physician as their PCP for the coming month. The eligibility list consists of four sections; a cover page, a detail sheet, a change sheet and a summary sheet.

2. Supplemental Eligibility Lists are generated weekly and identify new additions to the PCP’s most recent monthly eligibility list. Only PCPs that have additions to their current monthly eligibility will receive a Supplemental Eligibility List.

3. The PCP should reference the Eligibility List or the Supplemental Eligibility List to verify a patient’s current eligibility as a BlueChoice member.

4. If a patient cannot be verified as a BlueChoice member using the current month’s Eligibility List or Supplemental Eligibility List, the PCP should contact the Provider Telecommunications Center (PTC) at (800) 972-8088.



Eligibility List of BlueChoice Members Page 3 of 3 Attachment 1

Report: 2251 HEALTH CARE SERVICE CORPORATION PAGE: 2 MCN-P MEMBER ELIGIBILITY LIST RUN DATE: MM/DD/YY

PRIMARY CARE PHYSICIAN NO: 999999999999 NPI XXXXXXXXX NAME: XXXXXXXXXXX XXXXXXXXXX BENEFIT PERIOD: MM/DD/YY TO MM/DD/YY

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) MEMBER NAME M

E RELATION O

A BIRTH DATE

EFFECTIVE DATE

MCN-P DATE

SOC SEC NUMBER

P D

S R

GROUP NUMBER

SUBSCRIBER NUMBER

SUBSCRIBER LAST NAME

BENEFIT PLAN

DRUG CODE

Smith, John SON M 08/03/80 08/01/97 08/01/97 658992140 M90026 035526666 SMITH MCNP-H Doe, John SON M * 06/24/56 08/01/97 08/01/97 Y 90008 321461850 DOE ASC-2 Smith, Jane SPOUSE F 10/18/55 08/01/97 08/01/97 123456789 Y 78717 321461853 ATECH Doe, Mary SUBSCR F 09/22/56 08/01/97 08/01/97 987654321 D Y 78717 321461853 ATECH Brown, JAMIE DAUGHTER 03/07/79 08/01/97 08/01/97 789456123 D Y 78717 321461853 ATECH Black, MICHELLE DAUGHTER 11/27/81 08/01/97 08/01/97 D Y 78717 321461853 ATECH Doe, KATHIE SPOUSE F 10/18/55 08/01/97 08/01/97 123654789 D Y M90000 321461852 MCNP-L INC Green, KAREN DAUGHTER 04/15/90 08/01/97 08/01/97 D Y M90000 321461852 MCNP-L INC Smith, KENNETH E. SUBSCR M 11/10/54 08/01/97 08/01/97 963852741 Y M90000 321461852 MCNP-L INC

ELIGIBILITY DEFINITIONS (1) Member Name: Identifies members that are eligible to receive services. Last Name, First Name, Middle

Initial (2) Medicare Eligibility: A “Y” identifies members that are eligible. (3) Relationship: Indicates relationship between member and subscriber. Also identifies member’s sex

(M/F). (4) Over-Age Dependent: An * will identify an over-age dependent, other than spouse who is allowed to

receive services. (5) Birthdate: Date of Birth of member. (6) Effective Date: Date member became effective with Blue Cross and Blue Shield of Illinois (BCBSIL)

coverage (7) MCN-P Date: Identifies member’s effective date of participation in BlueChoice. (8) Social Security Number: Social Security Number of each member. (9) DP (Dual PCP Indicator): A “D” in this field identifies female members that have selected both an

Internist or a Family Practitioner and an OB/GYN. (10) SR (Special Requirements): Identifies members with benefit plans that have Special Requirements. (11) Group Number: Associated subscriber’s employer group number. (12) Subscriber Number: Associated subscriber’s identification number for each member (may be the same

as the social security number). (13) Subscriber Last Name: Subscriber’s last name, if different from member.

(1) Benefit Plan: Identifies the member’s office copay. All charges for PCP provided office visits (identified by the appropriate CPT Codes) are reimbursed at 100% of the allowed amount less the copay.

ASC-1 or ASC-2 ATECH MCNP-H MCNP-B MCNP-L (2) Drug Code: Identifies members who have prescription drug benefits and the type of coverage. (Note: Some

employers have selected an outside vendor so a code will not be applicable.) IC - Drug coverage includes injectibles and contraceptives INC - Drug coverage includes injectibles but not contraceptives NIC - Drug coverage includes contraceptives but not injectibles NINC - Drug coverage includes neither injectibles nor contraceptives



Policy Name: Covering Physician Policy Number: Administrative -6 Effective Date: 1/1/96 Revision Date: Review Date: 9/1/09 Approval Signature:



Policy: The Primary Care Physician (PCP) must arrange for coverage to provide services to BlueChoice members after hours and during PCP absences. Purpose: • To ensure that members have access to appropriate medical services. • To ensure that members receive the maximum benefits available. Procedure: 1. The PCP must arrange for physician coverage to provide services to BlueChoice members when the

PCP is unavailable. 2. The covering Physician must be a Participating BlueChoice PCP. 3. If the covering physician bills under a different Tax ID and National Provider Identifier (NPI) Number,

the PCP must write a BlueChoice Referral Form for any services rendered during his/her absences.

4. If covering physician bills under the same Tax ID and NPI Number as the PCP, no referral form is necessary.

5. The covering physician will be responsible for compliance with BlueChoice Policies and Procedures,

for all services rendered and/or authorized, including notifying Utilization Management at (800) 232-3476 for precertification.

6. The PCP’s performance measures will include services rendered and or authorized by the covering

Physician. Should you have questions or concerns about this policy, please contact the Customer Assistance Unit at (800) 582-3392- or (312) 653-7433.



Policy Name: OB/GYN Provider Scope of Care Policy Number: Administrative -9 Effective Date: 1/1/95 Revision Date: Review Date: 1/1/09 Approval Signature:

Senior Medical Director Vice President–Network Management

Approved QI: 01/07/09 Approved P&P: 12/11/08

Policy: Obstetric and gynecologic (OB/GYN) services must be directed to providers who are specifically contracted with BlueChoice to provide care within these specialties. Purpose: To ensure that members receive maximum benefits for OB/GYN services. Procedure: I. BlueChoice has two in-network options for OB/GYN care. Each employer group selects one of these options. The options are:

A. Primary Care Physician (PCP)/ Participating Certified Nurse Midwife (PCNM) Option:

Female members over the age of 13 may select an OB/GYN PCP/PCNM in addition to a Family Practitioner, Internist, or Pediatrician PCP.

B. Participating Specialist Physician (PSP) Option:

Female members over the age of 13 do not have the option to select an OB/GYN PCP/PCNM. Under this option, the member may have one of the following alternatives, based on the coverage provided by their specific employer group. 1. Self-refer to a BlueChoice contracted OB/GYN PCP or Nurse Midwife (PCNM) for one annual

wellness visit. 2. In addition to self referral for one annual wellness visit, some employer groups have specific

BlueChoice OB/GYN guidelines. Examples are • self-referral to a BlueChoice contracted OB/GYN PCP/PCNM with a positive home

pregnancy test, • self-referral for all obstetrical and gynecological care.

3. For services beyond the self-referred annual exam, the PSP has two options: • The PSP can refer back to the Family Practice, Internist or Pediatrician PCP for

authorization, OR • The PSP can request a waiver through the Medical Management Department (800)

232-3476 to provide care beyond the annual exam.



OB/GYN Provider Scope of Care Page 2 of 3 II. When a BlueChoice member presents their identification card, please check the monthly

eligibility list to determine which option applies. 1. If the member appears on the monthly eligibility list, the PCP/PCNM Option applies. 2. If the member does not appear on the monthly eligibility list, the PSP Option applies. The

purpose of the visit will need to be verified as: a. self-refer to a BlueChoice contracted OB/GYN PCP/PCNM for one annual wellness visit, b. self-refer for obstetrical care to a BlueChoice contracted OB/GYN PCP/PCNM with a

positive home pregnancy test, c. self-refer to a BlueChoice contracted OB/GYN PCP/PCNM for all obstetrical or gynecologic

care. III. Under the PCP/PCNM OPTION -

1. The OB/GYN may provide: a. Gynecologic care, inpatient and outpatient, b. Obstetric care, inpatient and outpatient, c. Infertility care (consistent with group specific benefits), d. Urologic care, inpatient and outpatient, e. Preventive care, f. Diagnostic and laboratory procedures related to obstetric, gynecologic, urologic and preventive care (including OB ultrasound, Pap smear, mammography, etc.).

2. The OB/GYN PCP/PCNM may write a referral to a BlueChoice provider/facility for: a. Gynecologic care, b. Complications of pregnancy, c. Urologic care, d. Diagnostic procedures related to obstetrical, gynecologic, urologic and preventive care

(including OB ultrasound, Pap smear, mammography, etc.).

3. The OB/GYN PCP/PCNM may provide care for or refer patient for other services if a waiver has been received through the Medical Management Department.

IV. Under the PSP OPTION –

1. During the self-referred annual wellness visit, the BlueChoice OB/GYN PCP/PCNM provider may render:

a. Preventive care and related diagnostic and laboratory services.

2. During self-referral for obstetrical care with a positive home pregnancy test, as allowed by some employer groups, the BlueChoice OB/GYN PCP/PCNM provider may render:

a. Obstetric care, inpatient and outpatient, b. Diagnostic and laboratory procedures related to obstetrical and urologic care (including OB

ultrasound).

3. During the self-referral for all obstetrical or gynecologic care under the terms of a specific coverage the BlueChoice OB/GYN PCP/PCNM provider may render:

a. Gynecologic care, inpatient and outpatient, b. Obstetric care, inpatient and outpatient, c. Infertility care (consistent with group specific benefits), d. Urologic care, inpatient and outpatient, e. Preventive care, f. Diagnostic and laboratory procedures related to obstetric, gynecologic, urologic and

preventive care (including OB ultrasound, Pap smear, Mammography, etc.).



OB/GYN Provider Scope of Care Page 3 of 3

4. To refer for services other than those listed above, the OB/GYN PCP/PCNM acting as a Participating Specialist Provider must request a waiver through the Medical Management Department (800) 232-3476)

V. In instances where the member’s Family Practitioner, Internist, or Pediatrician PCP determines

that a referral to an OB/GYN for consultation and/or treatment is warranted, the PCP must select a BlueChoice OB/GYN/PCNM provider from the Provider Finder® located at www.bcbsil.com and complete the BlueChoice Referral Form (see HCM Reference 2- Plan Notification of Medical/Surgical Services policy).

1. BlueChoice OB/GYN PCP/PCNM provider may function during the period specified on the referral

form for: • Gynecologic care, inpatient and outpatient, • Obstetric care, inpatient and outpatient, • Infertility care (consistent with group specific benefits), • Urologic care, inpatient and outpatient, • Preventive care, • Diagnostic and laboratory procedures related to obstetric, gynecologic, urologic and

preventive care (including OB ultrasound, Pap smear, Mammography, etc.). 2. Referrals for obstetrical care will be for global obstetric services. The OB/GYN PCP/PCNM may

provide care for or refer patient for other services other than those listed above if a waiver has been received through the Medical Management Department (800) 232-3476.

Should you have questions or concerns about this policy, please contact the Customer Assistance Unit at (800) 582-3392 or (312) 653-7433.



Policy Name: Obstetric Program Requirements/Referral and Perinatal Services

Policy Number: Administrative -10 Effective Date: 1/1/96 Revision Date: Review Date: 1/1/09 Approval Signature:



Policy: The Attending Primary Care Physician (PCP), Participating Specialist Physician (PSP) or Participating Certified Nurse Midwife (PCNM) will notify the Plan of, and participate in, the Perinatal program for all confirmed pregnancies. Purpose: • To ensure that members receive appropriate obstetrical services at the maximum benefit level. • To ensure that the Medical Management Department communicates available pregnancy services

information and plan expectations regarding Obstetric (OB) care to the PCP, PSP, PCNM and member.

Procedure: 1. The Attending PCP/PSP/PCNM is responsible for notifying Medical Management by calling (800)

232-3476 or by fax at (800) 385-9125 upon pregnancy confirmation. 2. Notification is to be made during the first trimester. If pregnancy is confirmed after the first trimester,

the OB/GYN PCP should notify Medical Management upon the first prenatal visit. 3. The following additional information will be collected at the time of notification:

• Patient Identifiers (Name, Group/ID #, Address and Phone Number) • Admitting/Performing Provider Name • Hospital/Facility Name and City • Expected Date Of Delivery • Information on predisposing conditions will be collected to identify high risk patients • Anticipated Procedure • First prenatal visit date

4. Members, whose employer groups provide Healthy Expectations Program, will receive instructions on how to participate in the Healthy Expectations Program.

5. Pregnancy literature will be mailed to the pregnant member once registration in Healthy

Expectations is complete. 6. Length of Stay (LOS) expectations for non high-risk pregnancies are as follows:

• Normal Vaginal Delivery – 48 hours following vaginal delivery.



Obstetric Program Requirements/Referral and Perinatal Services Page 2 of 2

• Cesarean Section – 96 hours following delivery by Cesarean section. • If medically necessary, additional day(s) may be approved upon review by Medical Management.

7. LOS for high risk pregnancies and complicated deliveries will be determined on an individual basis

and will be dependent on medical necessity criteria used by BlueChoice. 8. During the pregnancy, the Attending PCP/PSP/PCNM is expected to discuss with the member the

expected LOS and arrangements for follow-up care of mother and infant. This includes, but is not limited to, making arrangements for the following to occur between 48-72 hours after birth and/or for discharges occurring within one day of delivery: • Physical exam of mother (as needed) and infant • Collection of lab samples for requisite infant genetic screening

9. These services may be performed in the physician’s office, the hospital or patient’s home by

ordering appropriate home health agency follow-up. To facilitate these arrangements, the Attending PCP/PSP/PCNM should encourage the mother to select a PCP Pediatrician.

10. The Attending PCP/PSP/PCNM is responsible for notifying Medical Management at (800) 232-3476

upon admission. 11. Prior to discharge, the Attending PCP/PSP/PCNM will:

• Provide discharge instructions; • Arrange for two Home Health Care Visits, if appropriate, and; • Notify Medical Management of Home Health Care Visits, if applicable.

12. Post Delivery Checkup Record Submission (this visit should occur between 21-56 days post delivery) documentation should include the following: • Date of delivery • Date of checkup • Pelvic exam or evaluation of weight, blood pressure, breast and abdominal examination

Should you have questions or concerns about this policy, please contact the Medical Management Department at (800) 232-3476.



Policy Name: Network Waiver Requests Policy Number: Administrative -11 Effective Date: 1/1/96 Revision Date: Review Date: 1/1/09 Approval Signature:


Management BlueChoice Approved QI: 1/07/09 Approved P&P: 12/11/08

Policy: In exceptional situations, the Primary Care Physician (PCP) may request a network waiver to use when referring members to non-network providers. Purpose: To establish a mechanism enabling the PCP to refer members to non-network providers, as clinically appropriate, while receiving the highest level of benefit. Procedure: 1. The PCP is required to use Network Providers exclusively. However, when in the PCP’s judgement,

use of a Plan Provider is not appropriate, a Network Waiver may be requested by calling the Medical Management Department at (800) 232-3476 for the following reasons: Continuity of care Coordination of benefits with another insurer Special clinical needs of the patient

2. Waiver requests will be reviewed and determination made by the Medical Director. 3. Waiver decisions will be verbally communicated to the PCP, followed by written confirmation to the

PCP and patient, within one week of receipt of the information necessary to make the determination.

4. Waiver requests that are approved do not require a BlueChoice written referral. 5. Waiver requests that are denied may be appealed. Should you have questions or concerns about this policy, please contact the Medical Management Department at (800) 232-3476.



Policy Name: Patient Age Guidelines Policy Number: Administrative -16 Effective Date: 1/1/97 Revision Date: Review Date: 9/1/09 Approval Signature:



Policy: BlueChoice has established patient age guidelines to assist members with the selection of a Primary Care Physician (PCP) with appropriate age and specialty specific expertise. This policy does not apply to emancipated minors. Emancipated minors are those individuals who understand the risks, benefits and proposed alternatives to certain health care services and give informed consent. This applies to minors who are legally married, a parent, pregnant or have been legally emancipated by a court. Purpose: To ensure that BlueChoice patients are treated by a BlueChoice PCP having expertise in the care and treatment of patients with age specific and specialty specific needs. Procedure: 1. The established BlueChoice patient age guidelines are as follows:

a) Internal Medicine • Internists are trained in all aspects of adult diagnostic and non-surgical treatment of

diseases and disorders. • New patients under the age of 13 cannot select an Internist as a PCP. On an individual

basis, Internists may request that their practice be restricted to patients using a higher threshold than 13 years of age.

b) Pediatricians • Pediatricians are trained in the care and development of infants and children and the

diagnosis and treatment of children’s diseases and disorders. • New patients over the age of 21 cannot select a Pediatrician as a PCP. On an individual

basis, Pediatricians may request that their practice be restricted to patients using a lower ceiling than 21 years of age.

c) Family Practice • Family practitioners are trained in all aspects of primary care for patients of all ages, and

for obstetric/ gynecology care. • BlueChoice Family Practitioners may request that their practice be limited to specific age

groups. d) Obstetrician/Gynecologists (OB/GYN) and Participating Certified Nurse Midwife (PCNMs)

• OB/GYNs are trained in the care of pregnancy and childbirth, as well as health conditions unique to females.

• PCNMs are licensed in the care of pregnancy and childbirth, as well as health conditions unique to females.



Patient Age Guidelines Page 2 of 2

• Female patients under the age of 13 cannot select an OB/GYN or PCNMs as a PCP. On an individual basis, these practitioners may request that their practice be restricted to patients using a higher threshold than 13 years of age.

2. Age thresholds will be maintained in the Blue Cross and Blue Shield of Illinois BlueChoice processing

systems. The PCP must contact the Plan in writing to formally request a change to the age limits for their practice.

Should you have questions or concerns about this policy, please contact the Customer Assistance Unit at (800) 582-3392 or (312) 653-7433.



Policy Name: Physical, Occupational, & Speech Therapy Network

Policy Number: Administrative -17 Effective Date: 1/1/98 Revision Date: Review Date: 9/1/09 Approval Signature:

Senior Medical Director Vice President-Network Management


Policy: BlueChoice Primary Care Physicians (PCPs) must utilize BlueChoice contracted Physical, Occupational, and Speech Therapy providers for all BlueChoice members. Purpose: To ensure that members receive clinically appropriate, cost effective Physical, Occupational, and Speech Therapy services.

Procedure 1. The PCP determines if the therapy is medically necessary.

2. The PCP and Participating Specialist Physician (PSP) are required to direct BlueChoice members to contracted BlueChoice Therapy providers.

3. The BlueChoice written referral form is required for all therapy referrals directed by the PCP.

4. Contracted Therapy Network Providers are listed on the BCBSIL Provider Finder® located at www.bcbsil.com.

Should you have any questions or concerns about this policy, please contact Network Development at (312) 653-5333.



Policy Name: Practice Closure/ Patient Termination or Refusal/Provider Network Termination

Policy Number: Reference 6 Effective Date: 1/1/94 Revision Date: Review Date: 9/1/09 Approval Signature:



Policy: A BlueChoice Primary Care Physician (PCP) may close his/her practice to new members when it is felt that acceptance of additional members may impact the delivery of care to existing patients. The PCP and Participating Specialist Physician (PSP) have the right to refuse to accept a BlueChoice member as a patient or terminate a relationship with a member when the PCP or PSP believes that, because of factors related to the member, there is an inability to achieve a therapeutic relationship. The Plan sends notification to patients when a PCP or PSP terminates their contract and leaves the network. Purpose: • To allow providers to close their practice to new patients • To allow providers to refuse to establish or terminate a patient relationship • To ensure notification to members affected by providers leaving the network.

Procedure: A. Practice Closure to New Members 1. Non-OB/GYN PCPS must have a minimum of 50 patients enrolled in order to close his/her practice to

new members. 2. The PCP must contact the Plan in writing to formally request closure of his/her practice to new

members. This request may be faxed to Provider Affairs at (312) 938-6463 or mailed to: Blue Cross and Blue Shield of Illinois

Provider Affairs Department 300 East Randolph, 25th Floor Chicago, Illinois 60601

3. Designated Provider Affairs staff will assess:

a) The total number of BlueChoice members in the physician’s practice. b) If member enrollment is less than 50, the following will be considered:

• The reason for the practice closure; • The actual waiting time for scheduling appointments for non-urgent care; • The actual time period for scheduling follow-up or urgent care; • The PCP’s practice status, (group or individual) and enrollment capacity.

4. If the request is approved, the PCP closure date will be effective 30 days after receipt of PCP written

notification.



Practice Closure/ Patient Termination or Refusal/Provider Network Termination Page 2 of 2 5. If the request is not approved the provider will be notified by the designated Provider Affairs staff. 6. To re-open a practice, notification must be submitted in writing. If the practice is re-opened, it must

remain open for at least a six month period. B. Patient Termination or Refusal 1. The PCP must notify the Plan and the member in writing within one business day of the refusal to

accept, or the termination, of a patient / provider relationship. 2. The PSP must notify the PCP and the member as soon as possible, but not more than one business

day of the decision to refuse to accept or terminate a BlueChoice member as a patient. 3. Notice to the Plan can be faxed to Provider Affairs at (312) 938-6463 or mailed to:

Blue Cross and Blue Shield of Illinois Provider Affairs Department 300 East Randolph, 25th Floor Chicago, IL 60601

4. The PCP may be required to provide medical care to the member for up to 30 days following the date of written notification.

C. Provider Network Termination and Member Notification: 1. BlueChoice members are notified in writing by the member services unit when:

• a PCP leaves the BlueChoice network Note: Applies to all members assigned

• a PSP or specialty group leaves the BlueChoice network Note: Applies only to members receiving ongoing services

2. Should you have questions or concerns about this policy, please contact the Customer Assistance

Unit at (800) 582-3392 or (312) 653-7433.



Policy Name: Provider Rights and Responsibilities Policy Number: Reference – 13 Effective Date: 10/1/06 Revision Date: 11/1/08 Review Date: Approval Signature: Senior Medical Director Vice President–Network

Management BlueChoice Replaces HCM Ref 6 Provider Rights and Responsibilities Approved QI: 11/5/08 Approved P&P:10/9/08

Policy: Blue Cross and Blue Shield of Illinois (BCBSIL) will furnish Providers a statement of the Provider’s Rights and Responsibilities. Purpose: To identify the rights and responsibilities of BlueChoice providers. Procedure:

Provider Rights Provider Responsibilities • To apply to the BlueChoice networks and

receive notification of appointment / reappointment to the network within 30 calendar days of the Plan’s decision.

• To submit a fully completed and signed State of Illinois Health Care Professional Credentialing and Business Data Gathering Form and BlueChoice contract.

• To hold a valid professional license in the state of Illinois or the state in which the Provider renders services to members.

• Providers must obtain professional certification for their contracted specialties. Providers are not required to be board certified at the time of appointment but should be in the process of attaining Board Certification. Board Certification is required within two years of the initial credentialing effective date. For PCPs this would be the American Board of Family Practice, Internal Medicine, Pediatrics, or Obstetrics and Gynecology.

• To be on staff at a BlueChoice Hospital with full and unrestricted admitting privileges, if admitting privileges are applicable.

• To maintain a current professional and comprehensive general liability insurance policy with the appropriate limits, covering the Provider and his/her employees and agents against liability arising in connection with the Provider’s performance.

• To participate in the BCBSIL PPO program.

• To receive names of BlueChoice Hospitals

and other BlueChoice Network Providers access through the Provider Finder® at www.bcbsil.com.

• To use BlueChoice Hospitals and other BlueChoice

Network Providers for all care required by members.



Provider Rights and Responsibilities Page 2 of 4

• To receive monthly Eligibility Lists of

BlueChoice members who have selected the PCP.

• PCPs are responsible for referring, authorizing,

coordinating, and monitoring all specialty, facility and/or institutional care.

• The PSP will receive a clear and complete

referral from the BlueChoice member’s PCP.

• The PSP agrees to perform only those services which

are specified in any referral from the PCP.

• To communicate with members without

restriction regarding treatment options in order to assist members in making informed and educated decisions regarding their medical care.

• To inform members of appropriate or medically

necessary treatment options for their conditions, regardless of cost or benefit coverage.

• Network physicians are responsible for rendering care

to members who have selected them, within the scope of their practice.

• Medical care must be provided in the same manner as

to those patients who are not BlueChoice members and consistent with the BlueChoice Member Rights and Responsibilities.

• To receive the BlueChoice Policy and

Procedures visit the BCBSIL Provider Web site at www.bcbsil.com/provider/.

• On a monthly basis BCBSIL will post updated policy and procedures on the Web under “Updates”. Go to www.bcbsil.com/provider/index.htm to view the updated policies.

• To comply with all requirements specified in the

BlueChoice policies and procedures.

• To apply for a referral waiver from the

BCBSIL Medical Director or his/her designee, in accordance with the requirements of the BlueChoice Policies and Procedures.

• To direct a member to network physicians, specialists,

facilities and other providers listed in the Provider Finder® at www.bcbsil.com to ensure in-network benefits for the member.

• To have access to BCBSIL’s Medical

Management Department.

• To request pre-certification of any inpatient admissions,

or for designated outpatient services. • To cooperate with utilization and quality improvement

activities as designated by BCBSIL including all requirements of the BlueChoice Policies and Procedures.

• To have all Quality Improvement site visits

scheduled in advance as mutually agreed upon.

• To cooperate with the Quality Site Visit / Facility Review

Standards.



Provider Rights and Responsibilities Page 3 of 4 • To close enrollment to new members if

BlueChoice enrollment exceeds 50 members*. (*excludes OB/GYN PCPs )

• To provide written notification to BCBSIL not less than

60 calendar days in advance of the closing of enrollment to new members. If 60 calendar days notice is not given, practice closure is subject to the Network Management approval.

• To have confidentiality of all information

related to patient care and quality maintained.

• To comply with all regulatory requirements regarding the

use, disclosure and confidentiality of protected health information of members.

. • To bill a member for services NOT covered

under the contract and for any co-payments, deductibles or coinsurance amounts.

• To bill only BCBSIL, and not the member, for any

services covered under the member’s contract, except for any co-payments, deductibles or coinsurance amounts.

• To receive timely payment for covered

services rendered to the member as described in the member’s applicable health care benefit contract.

• To accept BCBSIL’s reimbursement as full payment for

each covered service under the member’s contract. • To recognize that all payments are subject to BCBSIL’s

“Coordination of Benefits” (COB) provisions. • Not to charge the member for the fees associated with

any part of an inpatient hospital stay, or an outpatient procedure or other service which is determined by BCBSIL not to be medically necessary.

• To access BCBSIL’s appeal process for

administrative and patient care issues.

• To provide BCBSIL with the necessary documentation

regarding any appeal.



Provider Rights and Responsibilities Page 4 of 4

• To be listed as a Provider in the Provider Finder® at www.bcbsil.com.

• To authorize the use of information regarding the provider in the Provider Finder® at www.bcbsil.com.

• Not to distribute BCBSIL communications to members

without the approval of BCBSIL. • Not to use or display BCBSIL’s service marks without

prior written consent of BCBSIL. • To notify BCBSIL 30 days prior to any change of

address, hospital affiliation, tax id number, hours of operation or change in employment status, such as retirement or relocation.

• To promptly notify BCBSIL of any of the following

involuntary occurrences: → loss, suspension or limitation of state license or

certification to practice medicine as required by BCBSIL;

→ any lapse or material change in liability insurance coverage required by BCBSIL;

→ any indictment or conviction of a felony or any criminal charge related to the provider’s practice;

→ loss, suspension or limitation of material staff or admitting privileges at a BlueChoice Network Hospital;

→ loss, suspension or limitation of eligibility to participate in the Medicare and/or Medicaid Programs;

→ any judgment or finding against provider which might materially impair his/her ability to perform.

• To receive prior notification of workshops and

educational meetings conducted by BCBSIL. Workshop schedules are available in the monthly Blue Review newsletter or online at www.bcbsil.com/provider/training.htm to view the schedule and register.

• To attend or assign a representative to attend at least one training or educational meetings conducted by BCBSIL.

• To terminate a physician / member relationship for cause at any time.

• To notify BCBSIL, and the member in writing within one business day of refusal to accept a member.

• To terminate the Provider contract. • To provide prior written notice of termination to the Plan

and its members 90 calendar days before the effective date by a Group, PCP and/or PSP.

• To advise members seeking medical care after the date

of termination with BCBSIL that he/she is no longer a participating provider.

Should you have questions or concerns about this policy, please contact the Provider Telecommunications Center (PTC) at (800) 972-8088 or your Provider Network Consultant.



Policy Name: Participating Specialist Physician (PSP) Departicipation Member Notification Process

Policy Number: Reference - 31 Effective Date: 9/3/03 Revision Date: 11/1/08 Review Date: Approval Signature:


Approved QI: 11/5/08 Approved P&P:10/9/08

Policy: Blue Cross and Blue Shield of Illinois (BCBSIL) may elect to departicipate those Participating Specialist Physicians (PSPs) who do not meet the established BlueChoice network standards or a BlueChoice PSPs may elect, for any reason, to terminate their BlueChoice contract. In either case, BCBSIL will notify the BlueChoice member of PSP departicipation. Purpose: To provide a process that will ensure that contracted Primary Care Physicians (PCPs) and BlueChoice members receive notification of the departicipation of BlueChoice contracted PSPs in order to ensure that there is no disruption to services being provided to BlueChoice members. Procedure: 1. Providers seeking to departicipate from the network will be required to inform BCBSIL via fax or

mail of their intent within: • Ninety days prior notification if the provider is an individual practitioner. • Ninety days prior notification for group practices.

2. On a monthly basis a listing of departicipated PSPs will be posted on our Provider Web site at

http://www.bcbsil.com/provider/manual.htm. The list will be posted under “BlueChoice Documents”. The list will reflect PSPs departicipated from the network during the prior month.

3. On a weekly basis the BCBSIL mainframe system will identify members who have a referral on file

for any of the PSPs who appear on the departicipation list.

If a referral is found, a system generated letter is sent to the member notifying them that the PSP practitioner is no longer a Participating Specialist with BlueChoice (Attachment I) and to advise the member to contact their PCP to seek a referral to another BlueChoice Network Specialist, if appropriate.

Should you have questions or concerns about this policy, please contact the Provider Telecommunications Center (PTC) at (800) 972-8088.



Participating Specialist Physician (PSP) Departicipation Member Notification Process Page 2 of 2 PSP departure letter example

Here is an example of the letter which will be sent to affected members.

Blue Cross and Blue Shield of Illinois 300 East Randolph Street Chicago, Illinois 60601 Date: MM/DD/CCYY Re: Departure of Participating Specialist Provider (PSP) from the BlueChoice Point-of-Service (POS) Network Member Name: John Doe Group and Subscriber Number: 012345/ABC123456789 Participating Specialist Provider (PSP) Name: James Doe Dear John: At Blue Cross and Blue Shield of Illinois, we take pride in the stability of participating physicians and our low rate of turnover. However, a small number of participating physicians do depart every year. We regret to inform you that Dr. Doe, (specialty), no longer participates in the BlueChoice Point of Service (POS) network. Should you have an open referral to this physician, please call your Primary Care Physician (PCP) and inform him or her of the need to make new referral arrangements. We apologize for any inconvenience this change may cause. If you have any questions, please contact Customer Service at: 1-800-555-5555. Yours sincerely, Customer Service Representative BlueChoice Full Service Unit Review 11/1/08

Eligibility List of BlueChoice Members2 Covering Physician · f. Diagnostic and laboratory...

Documents

Transcript of Eligibility List of BlueChoice Members2 Covering Physician · f. Diagnostic and laboratory...