Advantage Program Provider Operating Guide The Blue Cross Blue Shield of Arizona
The Blue Cross Blue Shield of Arizona Advantage Program Provider Operating Guide January 2015 © 2015 Blue Cross and Blue Shield of Arizona Page: 2 of 75 The BlueCard® Program Provider Operating Guide January 2015 Table of Contents Table of Contents ........................................................................................................................................2 1. Overview .............................................................................................................................................6 2. Definitions............................................................................................................................................7 3. BCBSAZ Advantage Contacts and Quick References ................................................................. 12 3.1 4. 5. 6. Hearing Impaired Services ..............................................................................................................14 BCBSAZ Advantage Products ........................................................................................................ 15 4.1 Preventive Services .........................................................................................................................15 4.2 Plan Benefits ...................................................................................................................................15 4.3 Hospice Benefits..............................................................................................................................15 4.4 Member ID Cards ............................................................................................................................15 4.5 BCBSAZ Advantage Benefit Exclusions ..........................................................................................16 Member Information ........................................................................................................................ 18 5.1 Member Enrollment .........................................................................................................................18 5.2 Member Role and Responsibilities ..................................................................................................18 5.3 Appointment of a Representative ....................................................................................................19 5.4 Member Temporary Out of State .....................................................................................................22 5.5 Notice of Privacy Practices ..............................................................................................................22 Provider Roles and Responsibilities ............................................................................................... 23 6.1 Contracting Process ........................................................................................................................23 6.2 Credentialing Overview....................................................................................................................23 6.2.1 Initial Credentialing Process ............................................................................................................23 6.2.2 Individual Providers Credentialing Process .....................................................................................23 6.2.3 Provider Types ................................................................................................................................24 6.2.4 Institutional Provider Types .............................................................................................................24 6.2.5 Credentialing and Re-Credentialing for All Providers ......................................................................25 6.3 Primary Care Physician Responsibilities .........................................................................................25 6.3.1 Covered Services (PCP)..................................................................................................................26 6.3.2 Laboratory Procedures Allowed in Office (PCP) ..............................................................................26 6.4 Specialist Physician Responsibilities ...............................................................................................26 6.4.1 Covered Services (Specialist)..........................................................................................................27 6.4.2 Laboratory Procedures Allowed in Office (Specialist) ......................................................................28 6.5 Access to Care and Appointment Availability Standards and Monitoring ........................................28 6.5.1 Physician Accessibility/Availability Monitoring .................................................................................28 6.5.2 Physician Office Hours ....................................................................................................................28 6.5.3 After-Hours Answering Systems ......................................................................................................29 6.6 Eligibility Verification ........................................................................................................................29 6.7 Provider Relations ...........................................................................................................................29 Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 3 of 75 The BlueCard® Program Provider Operating Guide January 2015 6.7.1 General Information .........................................................................................................................30 6.7.2 In-Services.......................................................................................................................................30 6.7.3 Education Sessions .........................................................................................................................30 6.8 Network Provider Change Notification .............................................................................................30 6.9 Provider Administrative Dispute Resolution Process .......................................................................31 6.9.1 Dispute Resolution Process for Professional Competence, Conduct, or Quality of Care ................31 7. Claims Submission and Filing Policies .......................................................................................... 33 7.1 Claims Payment Address ................................................................................................................33 7.2 Encounter Data Reporting ...............................................................................................................33 7.3 Institutional Providers ......................................................................................................................33 7.4 Professional Providers .....................................................................................................................33 7.5 Home Health Providers....................................................................................................................34 7.6 Skilled Nursing Facilities ..................................................................................................................34 7.7 Timely Filing ....................................................................................................................................34 7.7.1 Proof of Timely Filing .......................................................................................................................34 7.7.2 Paper Claims ...................................................................................................................................34 7.7.3 Submitting Requested Medical Records ..........................................................................................34 8. 7.8 Prior Authorization and Notification .................................................................................................35 7.9 Modifiers ..........................................................................................................................................35 7.10 Coding Schemes .............................................................................................................................35 7.11 Claim Resources .............................................................................................................................35 7.12 Resubmitting Requested Information ..............................................................................................35 7.13 Request Claim Reconsideration or Adjustment of Adjucated Claims ..............................................36 7.14 National Provider Identification (NPI)...............................................................................................36 7.9 Modifiers ............................................................................................ Error! Bookmark not defined. 7.10 Eligibility Verification .......................................................................... Error! Bookmark not defined. 7.11 Claim Resources ............................................................................... Error! Bookmark not defined. 7.12 Resubmitting Requested Information ................................................ Error! Bookmark not defined. 7.13 Request Claim Reconsideration or Adjustment of Adjudicated ClaimsError! Bookmark not defined. 7.14 National Provider Identifier (NPI) ....................................................... Error! Bookmark not defined. 7.15 Tax Identification Number (TIN) Edits ..............................................................................................37 7.16 Explanation of Payment ...................................................................................................................37 7.17 Fee Schedule Updates ....................................................................................................................37 7.18 Payment Recoupment Policy...........................................................................................................38 7.19 Billing the Member ...........................................................................................................................38 7.20 Coordination of Benefits (COB) .......................................................................................................38 7.21 ICD-10 .............................................................................................................................................38 7.22 Risk Adjustment ...............................................................................................................................39 Medical Management ...................................................................................................................... 40 8.1 Care Management Program ............................................................................................................40 Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 4 of 75 The BlueCard® Program Provider Operating Guide 8.2 January 2015 Case Management ..........................................................................................................................41 8.2.1 Frequently Asked Questions (FAQ) about Care Management ........................................................41 8.2.2 Cultural Competency .......................................................................................................................42 8.2.3 Disease Education...........................................................................................................................42 8.2.4 Interdisciplinary Care Team .............................................................................................................43 8.2.5 How to Refer a Member to a Care Management Program ..............................................................43 8.3 Referral Guidelines ..........................................................................................................................45 8.3.1 Routine Referrals.............................................................................................................................45 8.3.2 Referrals to a Non-Participating Provider (Out-of-Network) .............................................................45 8.3.3 Post-Emergency Room Treatment Follow-up ..................................................................................47 8.3.4 Post-Hospitalization Follow-up ........................................................................................................47 8.3.5 Self-Referrals...................................................................................................................................47 8.3.6 Urgent/Emergent Referrals ..............................................................................................................47 8.4 Organizational Determinations .......................................................... Error! Bookmark not defined. 8.5 Prior Authorizations and Notification Guidelines ..............................................................................47 8.5.1 After Hours Prior Authorization ........................................................................................................48 8.5.2 Services Requiring Prior Authorization ............................................................................................48 9. Quality Management Program and Activities ................................................................................ 51 9.1 Quality Management Program .........................................................................................................51 9.2 Quality Management Program Activities ..........................................................................................52 9.3 Quality Measurement Studies..........................................................................................................52 9.4 Peer Review ....................................................................................................................................52 9.5 Health Promotion and Preventive Care ...........................................................................................52 9.6 Concerns, Complaints and Grievance Review ................................................................................53 9.7 Monitoring Quality Indicators ...........................................................................................................53 9.8 HEDIS Medical Record Review Process .........................................................................................53 9.9 Member Satisfaction ........................................................................................................................54 9.10 Physician Satisfaction Surveys ........................................................................................................54 9.11 Physician Accessibility and Availability Monitoring ..........................................................................54 10. Member Grievances, Appeals, and Non-Contracted Provider Claims Appeals ........................ 56 10.1 Member Grievances and Appeals ...................................................................................................56 10.2 Non-Contracted Provider Claims Appeals ......................................... Error! Bookmark not defined. 11. Pharmacy Benefits .......................................................................................................................... 59 11.1 Pharmacy Benefits and Formulary Overview...................................................................................59 11.2 Formulary Exceptions ......................................................................................................................60 11.3 Quality Assurance and Drug Management Programs .....................................................................60 11.3.1 Utilization Management ...................................................................................................................61 11.3.2 Drug Utilization Review....................................................................................................................61 11.3.3 Medication Therapy Management ...................................................................................................62 11.4 Part D Prescription Drug Benefit......................................................................................................66 Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 5 of 75 The BlueCard® Program Provider Operating Guide January 2015 11.4.1 Part D Prescription Drug Benefit Summary by Benefit Plan ............................................................66 11.4.2 Mail Order Drug Program ................................................................................................................66 12. Compliance Program ....................................................................................................................... 68 12.1 Compliance Program Overview .......................................................................................................68 12.2 Retention of Records and Information Systems ..............................................................................68 12.3 Fraud, Waste and Abuse (FWA) ......................................................................................................68 12.4 Reporting to Government Authorities ..............................................................................................69 12.5 CMS Required Training ...................................................................................................................69 12.5.1 Mandatory Training ............................................................................ Error! Bookmark not defined. 12.5 CMS Required Training ..................................................................... Error! Bookmark not defined. 12.6 Health Insurance Portability and Accountability Act .........................................................................70 12.7 Advance Directives ..........................................................................................................................70 12.8 Medicare Advantage Compliance Program Terms ..........................................................................70 13. Dental Program ................................................................................................................................ 75 Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 6 of 75 The BlueCard® Program Provider Operating Guide January 2015 1. Overview Blue Cross Blue Shield of Arizona Advantage (BCBSAZ Advantage or the Plan) is a locally based Medicare Advantage (MAPD) health plan serving Medicare-eligible residents in Maricopa County, Pima and portions of Pinal Counties. The purpose of the BCBSAZ Advantage Provider Operating Guide is to communicate expectations and set forth policies and procedures. It is intended for use as an administrative tool for providers and office staff and is not meant to be allinclusive. You will periodically receive updates to this manual. To maintain the accuracy and utility of this manual, it is important for these updates to be filed in the manual upon receipt. If the information in the Provider Operating Guide differs from the applicable benefit plan booklet (or Evidence of coverage), the terms of the Member’s benefit plan will apply. Providers requiring details of specific Member benefits should contact the health plan directly. You can also obtain this information online at www.azbluemedicare.com. The BCBSAZ Advantage Provider Operating Guide is incorporated by reference in the professional and institutional/ancillary participation agreements. In the event of a conflict between this Provider Operating Guide and your participation agreement, the participation agreement will govern. BCBSAZ Advantage reserves the right to modify these operating guidelines from time to time at its discretion. Changes in administrative policy or operating guidelines may be communicated to providers through letters, provider newsletter, the BCBSAZ Advantage website, e-mail notices or other formats. Registered users of the provider portal, the online BCBSAZ Advantage resource, can also access a PDF version of this manual on our website at www.azbluemedicare.com. . We value any feedback or comments you may wish to offer regarding this manual or suggestions about other information you would like to see included in future editions. Please share your ideas by e-mailing them to BCBSAZAdvantageProviderRelations@azbluemedicare.com or by contacting your network Provider Relations Representative. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 7 of 75 The BlueCard® Program Provider Operating Guide January 2015 2. Definitions These definitions are useful in understanding BCBSAZ Advantage procedures and administrative functions. Administrative Law Judge Hearing: For the non-contracted provider, this is the third level of appeal for adverse reconsiderations of Part A and Part B claims. AMA: American Medical Association. Appeal: Any of the procedures that deal with the review of adverse organization determinations on the health care services a Member believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the Member), or on any amounts the Member must pay for a service as defined in 42 CFR 422.566(b). These procedures include reconsideration by the Medicare health plan and if necessary, an independent review entity, hearings before Administrative Law Judges (ALJs), review by the Medicare Appeals Council (MAC), and judicial review. Benefit Plan: The documents describing the benefits and terms of coverage provided to a Member. CDT Coding System: The ADA’s Current Dental Terminology coding system is a listing of descriptive terms and identifying codes for reporting dental services and procedures. Centers for Medicare and Medicaid Services (CMS): The federal governmental agency responsible for administering Medicare, Medicaid and several other health related programs. Clean Claim: A claim for payment, which can be processed for payment without obtaining additional information from the provider of service e.g. incorrect CPT code or missing information. A Clean Claim does not include a claim that is under review for coding error or a claim for which services are not Medically Necessary. CMS 1500: The (CMS) Form 1500 (02/12) is used to submit claims for professional services. Coinsurance: The percentage of the allowed amount that a Member must pay for covered services after meeting any applicable deductible. The coinsurance percentage is typically higher when an out-of-network provider is used. Complaint: Any expression of dissatisfaction to BCBSAZ Advantage, provider, facility or Quality Improvement Organization (QIO) by a Member made orally or in writing. This can include concerns about the operations of providers or Medicare health plans such as: waiting times, the demeanor of health care personnel, the adequacy of facilities, the respect paid to Members, the claims regarding the right of the Member to receive services or receive payment for services previously rendered. It also includes a plan’s refusal to provide services to which the Member believes he or she is entitled. A complaint could be either a grievance or an appeal, or a single complaint could include elements of both. Every complaint must be handled under the appropriate grievance and/or appeal process. Contracted Provider: A provider who has an active contract with BCBSAZ Advantage. Copay: A specific dollar amount a Member must pay to the provider for some covered services. When a copay applies to a covered service, the Member must pay it at the time of service. Covered Service: A health care service that is: • A covered benefit of the Member’s benefit plan; • Medically or dentally necessary as defined by the Member's benefit plan; • Not excluded from the Member's benefit plan; • Not experimental or investigational as defined by the Member's benefit plan; • Pre-certified where precertification is required by the Member's benefit plan; • Provided while the Member is eligible for benefits and the Member's benefit plan is in effect; and, • Rendered by an eligible provider under the Member's benefit plan acting within the provider’s scope of practice. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 8 of 75 The BlueCard® Program Provider Operating Guide January 2015 CPT® Coding System: The AMA’s Current Procedural Terminology coding system is a list of codes and related descriptions that are used to report medical services and procedures. Credentialing: The process by which the appropriate committee reviews documentation for each individual provider to determine participation in the health plan or network. Such documentation may include but is not limited to the applicant’s education, training, malpractice history and professional competency. The credentialing process includes verification that the information obtained is accurate and complete Durable Medical Equipment: In general, durable medical equipment is equipment prescribed by an eligible provider and designed to withstand repeated use. The member’s benefit plan will determine what is eligible for coverage. Refer to the Member’s DME Medical Coverage Guidelines for more information. Emergency medical condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: • Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child; • Serious impairment to bodily functions; or • Serious dysfunction of any bodily organ or part. • Emergency medical condition status is not affected if a later medical review found no actual emergency present. Exclusion: Items or services not covered under a benefit plan. Explanation of Benefits (EOB): A document sent to a Member that shows the services billed on a claim, whether the services are covered or not covered, the allowed amount and the application of the Member’s cost-sharing amounts. An EOB message code gives further information about any payment rules used, adjustments applied, and disallowances or non-covered amounts of a claim. Providers receive a remittance advice which includes information similar to that on an EOB. Formulary: A list of covered drugs provided by the health plan. Grievance: Any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which BCBSAZ Advantage or delegated entity provides health care services, regardless of whether any remedial action can be taken. A Member or their representative may make the complaint or dispute, either orally or in writing, to BCBSAZ Advantage. An expedited grievance may also include a complaint that BCBSAZ refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame. In addition, grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. Grievance issues may also include complaints that a covered health service procedure or item during a course of treatment did not meet accepted standards for delivery of health care. HCPCS code: The Health Care Procedure Coding System, released by CMS, is a list of codes and descriptive terminology used to report the provision of supplies, materials, injections and certain services and procedures. HCPCS codes consist of one alphabetic character followed by four digits. They are a supplement to CPT codes. Home Health Care Provider: A Medicare-certified entity that provides intermittent skilled nursing services and other therapeutic services in the home. Home Infusion Therapy Provider: A Medicare-certified entity also licensed as a pharmacy that provides home infusion medication administration therapy services. Hospice: A Medicare-certified entity that is primarily engaged in providing pain relief, symptom management and supportive services to terminally ill patients and their families. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 9 of 75 The BlueCard® Program Provider Operating Guide January 2015 Hospitalist: A Physician or Nurse Practitioner who specializes in treating patients when they are in the hospital and who may coordinate a patient’s care when he or she is admitted at a BCBSAZ Advantage contracted hospital or skilled nursing facility. ICD-9-CM Codes: International Classification of Disease coding system used to document diagnosis(es) and/or facilitybased procedures. Incidental Procedures: Incidental procedures are procedures commonly performed by the same provider, as a component of a total service. Independent Review Entity (IRE): An independent entity contracted by CMS to review BCBSAZ Advantage adverse reconsiderations of organization determinations and Part D plan sponsor denials of coverage determinations. Inquiry: Any oral or written request to a Medicare health plan, provider, or facility, without an expression of dissatisfaction, e.g., a request for information or action by a Member. Inquiries are routine questions about benefits (i.e., inquiries are not complaints) and do not automatically invoke the grievance or organization determination process. Medically Necessary: Any service or supply required for the diagnosis or treatment of an active illness or injury that is rendered by or under the direct supervision of the attending physician and is generally recognized and approved by physicians as appropriate in the treatment or management of the illness or injury. Medicare: The federal health insurance program for people 65 years of age or older, some people under age 65 with disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant.) Medicare Advantage Organization: An organization that has entered into a contract with the Center for Medicaid and Medicare Services (CMS) relating to the provision of one or more Medicare Advantage Plans. Medicare Advantage Plan: The specific health benefits, terms of coverage and pricing structure of a senior health plan product offered to Medicare beneficiaries by a Medicare Advantage Organization pursuant to a contract with CMS. Member: An individual covered under a benefit plan. Member Services: A department within BCBSAZ Advantage responsible for answering questions about your patient’s membership and benefits. Non-Covered Services: All health care services that are not authorized for payment under the Member’s Health Benefit Program. Organization Determination: Any determination made by BCBSAZ Advantage with respect to any of the follow: Payment for temporarily out of the area renal dialysis services, emergency services, post stabilization care, or urgently needed services; Payment for any other health services furnished by a provider other than BCBSAZ Advantage that the Member believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by BCBSAZ Advantage; BCBSAZ Advantage’s refusal to provide or pay for service, in whole or in part, including the type or level of services, that the Member believes should be furnished or arranged for by BCBSAZ Advantage; Reduction, or premature discontinuation of a previously authorized ongoing course of treatment; Failure of BCBSAZ Advantage to approve, furnish, arrange for, or provide payment for healthcare services in a timely manner, or to provide the Member with timely notice of an adverse determination, such that a delay would adversely affect the health of the Member. Out-of-Area (OOA) Hospitals: Hospitals located outside of BCBSAZ Advantage service area. Participating Provider: Health care providers who are under contract, directly or indirectly BCBSAZ Advantage to provide covered services to Members. A participating provider may be an MD, DO, physician’s assistant (PA) or advanced level nurse practitioner (APN). Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 10 of 75 The BlueCard® Program Provider Operating Guide January 2015 Pharmacy Coverage Guidelines: Pharmaceutical and administrative criteria that are developed from reviews of published, peer-reviewed medical and pharmaceutical literature and other relevant information and are used to help determine whether a medication or other products such as medical devices or supplies are eligible for benefits under a Member’s retail or mail order benefit. Primary Care Physician (PCP): A health care professional who is contracted as an internal medicine, family medicine, general practice, or pediatric physician, and is listed in the provider directory as such. All other health care professionals are considered specialists. Prior Authorization: Approval in advance to provide services or prescribe drugs to Members. All out-of-network and out-of-area services require prior authorization except for emergencies, urgently needed care, and out-of-area renal dialysis. Covered drugs that require prior authorization are marked in the formulary. Process Date: The date on which a claim is adjudicated or finalized in the claims processing system. When a claim is adjusted or re-adjudicated, it may be assigned a new process date and may be subject to the current pricing logic. Provider: A properly licensed, certified or registered person or facility, acting within the lawful scope of practice, and furnishing health care to Members; providers include doctors, hospitals, laboratories and other health professionals and facilities. Qualified Independent Contractor (QIC): Entity that contracts with the Secretary in accordance with the Act to perform level 2 appeals, which are called reconsiderations and expedited reconsiderations. Quality Improvement Organization (QIO): Organizations comprised of practicing doctors and other health care experts under contract to the Federal government to monitor and improve the care given to Medicare Members. QIOs review complaints raised by Members about the quality of care provided by physicians, inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Medicare health plans, and ambulatory surgical centers. The QIOs also review continued stay denials for Members receiving care in acute inpatient hospital facilities as well as coverage terminations in SNFs, HHAs and CORFs. Reconsideration: Member's first step in the appeal process after an adverse organization determination; a Medicare health plan or independent review entity may re-evaluate an adverse organization determination, the findings upon which it was based, and any other evidence submitted or obtained. For the non-contracted provider, a reconsideration is the second level of appeal after the first level redetermination on Part A and Part B claims. Requests for reconsideration are submitted by the provider directly to the Qualified Independent Contractor for review. Redetermination: For the member this is the first level of the appeal process, which involves a Part D plan sponsor reevaluating an adverse coverage determination, the findings upon which it was based, and any other evidence submitted or obtained. For the non-contracted provider, a redetermination is the first level of appeal after the initial determination on Part A and Part B claims. It is a second look at the claim and supporting documentation and is made by an employee that did not take part in the initial determination. Referral: The process by which a PCP directs a Member to seek and obtain covered services from a specialist. Skilled Nursing Facility: A Medicare-certified facility that provides inpatient skilled nursing care, rehabilitation services or other related health services. The term “skilled nursing facility” does not include a convalescent nursing home, rest facility or facility that primarily furnishes custodial care. Specialist: A physician who practices in a specific area other than those practiced by primary care providers or physicians who do not elect to be a PCP. UB-04: A standardized institutional claim form used for reporting and billing medical services, as specified by the National Uniform Billing Committee. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 11 of 75 The BlueCard® Program Provider Operating Guide January 2015 Urgent Care: Services for conditions that require prompt medical attention, but are not emergencies and therefore do not require treatment at an emergency room. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 12 of 75 The BlueCard® Program Provider Operating Guide January 2015 3. BCBSAZ Advantage Contacts and Quick References Administrative Office Blue Cross Blue Shield of Arizona Advantage 8220 N. 23rd Avenue – Mailstop C107 Phoenix, AZ 85021-4872 Website: www.azbluemedicare.com BCBSAZ Advantage Member Service For members: 1-800-446-8331, 7 days per week , 8 a.m. to 8 p.m. Central and Mountain Time – October 1 through February 14 and Monday through Friday, 8 a.m. to 8 p.m. Central and Mountain Time – February 15 through September 30th. TTY hearing impaired users call 711 For prospective members: 1-888-274-0367, daily 8 a.m. to 8 p.m. Local Time. TTY users call 711 BCBSAZ Advantage Service Centers BCBSAZ Advantage provides access to neighborhood Service Centers where members can talk face-to-face with a personal representative about their existing BCBSAZ Advantage plan, education classes or inquire about enrolling. There are five conveniently located Service Centers across the valley BCBSAZ Advantage Service. The BCBSAZ Advantage Service Centers can be reached by calling 1-800-446-8331. Mesa – 801 S. Power Road, #112 (Eastside of Power Rd between Southern Ave & Broadway Rd) Sun City – 14805 N. Del Webb Blvd. Ste. 30/31 (Eastside of Del Webb Blvd & Talisman Rd) Sun City West – 13950 W. Meeker Blvd. (North side of Meeker Blvd, West of RH Johnson Blvd) Eligibility Verification 623-974-7430 or 480-684-6167 or 1-800-446-8331 The identification card does not guarantee eligibility or current PCP assignment. Eligibility should be verified at each visit by calling Member Service numbers listed on the back of the ID card. Mailing Address Blue Cross Blue Shield of Arizona Advantage 13950 W. Meeker Blvd Sun City West, AZ 85375 Prior Authorization BCBSAZ Advantage Prior Authorization Department Phone: 1-800-446-8331 Fax: 602-864-3120 BCBSAZ Advantage Prior Authorization List is available at www.azbluemedicare.com Care Management (Case Management, Disease Focused Classes) 1-800-446-8331 Laboratory Services Sonora Quest Laboratories Visit www.sonoraquest.com for locations or call 1-800-766-6721 for the nearest location Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 13 of 75 The BlueCard® Program Provider Operating Guide January 2015 Pharmacy – Prior Authorization MedImpact Phone: 1-800-788-2949 Fax: 858-790-7100 San Diego, CA 92131 Reimbursement Services Claims Inquiry Line: 1-800-446-8331 Electronic Claims Submission: EDI Payer ID: 77078 Professional, Institutional and Hospital Claims Paper Claims Submission: BCBSAZ Advantage Reimbursement Services PO Box 16800 Mesa, AZ 85211 Claims Reconsideration: BCBSAZ Advantage Reimbursement Services Provider Reconsideration P.O. Box 16800 Mesa, AZ 85211 Member Appeals Address: Blue Cross Blue Shield of Arizona Advantage 13950 W. Meeker Blvd. Sun City West, AZ 85375 Provider Relations: (480) 684-7712 Provider Portal: www.azbluemedicare.com Go to: Provider Portal/BCBSAZ Advantage/Register for an account. Once you are registered in the provider portal you will be able to, check member eligibility, find a doctor or specialist, and review policies and guidelines. You will also have access to the Provider Operating Guide, add/ change notification forms, referral and authorization guidelines and forms, re-consideration requests and case management referral forms. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 14 of 75 The BlueCard® Program Provider Operating Guide January 2015 3.1 Hearing Impaired Services Hearing Impaired Service Members with hearing impairments have access to full service with Case Management staff and programs. Case Managers interact with hearing impaired Members through the TTY line and BCBSAZ Advantage contracted interpreter services and are available to provide comparable services for all department programs. Care Management Department performs care coordination and case management activities with hearing impaired Members. All new Members receive information on the TTY line and are encouraged to contact Care Management Department for questions or services. TTY Line: 711 or 1-800-367-8939 Interpreter Service Providers are required to provide interpreter services as needed for Members. Provider may contact the below provider for services: Valley Center of the Deaf 3130 Roosevelt Street Phoenix, AZ 85008 Phone: 602-267-1921 Fax: 602-273-1872 If the Valley Center of the Deaf does not have an available interpreter, Providers may contact: Freelance Interpreting Services 6420 E. Calle de las Estrella Cave Creek, AZ 85331 Phone: 480-595-9515 (available 24 hours/ day) Fax: 480-595-9516 Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 15 of 75 The BlueCard® Program Provider Operating Guide January 2015 4. BCBSAZ Advantage Products BCBSAZ Advantage offers three benefit plans to Medicare eligible Members. 4.1 Blue Medicare Advantage Classic Plan (HMO) Blue Medicare Advantage Plus Plan (HMO) Blue Medicare Advantage Premier Plan (HMO) Blue Medicare Advantage Classic Pima (HMO) (effective 1/1/2015) Preventive Services Covered preventive services are covered benefits that are provided at a $0 copayment for all of the Blue Medicare Advantage plans. A list of covered preventive services can be found at: https://www.azbluemedicare.com/providers 4.2 Plan Benefits Covered Plan Benefits (by benefit plan) can be found at: https://www.azbluemedicare.com/plans/blue-medicareadvantage-hmo-2014 4.3 Hospice Benefits Medicare becomes the primary payer for Part A and Part B services when a Member makes a Hospice election. When care is related to the terminal illness, Hospice provides or arranges for medical services or drugs and accepts financial responsibility. When care is unrelated to the terminal illness, the provider will bill Original Medicare for Part A and Part B services. Upon receipt of the Medicare Explanation of Payment, the claim then should be submitted to BCBSAZ Advantage. BCBSAZ Advantage will return an Explanation of Payment to the provider letting them know the amount of the cost sharing that can be collected from the member, BCBSAZ Advantage is responsible for payment of supplemental benefits (non-Part A or B services) and the Member is then responsible for the cost share for these services. 4.4 Member ID Cards Blue Medicare Advantage – Classic (HMO) Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 16 of 75 The BlueCard® Program Provider Operating Guide January 2015 Blue Medicare Advantage – Plus (HMO) Blue Medicare Advantage – Premier (HMO) INSERT PIMA ID CARDS 4.5 Commented [MP1]: Requested from T. Pettengell and P. McKay BCBSAZ Advantage Benefit Exclusions In addition to any exclusions or limitations described in the Benefits Chart, or anywhere else in the Evidence of Coverage, the following types of items and services are not covered under Original Medicare or by BCBSAZ Advantage (including Blue Medicare Classic, Blue Medicare Advantage Plus, Blue Medicare Advantage Premier benefit plans). Services considered not reasonable and necessary, according to the standards of Original Medicare, unless these services are listed by BCBSAZ Advantage as covered services. Experimental medical and surgical procedures, equipment and medications, unless covered by Original Medicare or under a Medicare-approved clinical research study or by BCBSAZ Advantage. Experimental procedures and items are those items and procedures determined by our plan and Original Medicare to not be generally accepted by the medical community. Please see http://www.accc-cancer.org/advocacy/pdf/PPACA-Coverage-for-Approved-Clinical-Trials.pdf regarding coverage for Individuals Participating in Approved Clinical Trials under the Patient Protection and Affordable Care Act of 1020 (PPACA). Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 17 of 75 The BlueCard® Program Provider Operating Guide January 2015 List of excluded services: Surgical treatment for morbid obesity, except when it is considered medically necessary and covered under Original Medicare. Private room in a hospital, except when it is considered medically necessary. Private duty nurses. Personal items in the Member’s room at a hospital or a skilled nursing facility, such as a telephone or a television. Full-time nursing care in your home. Custodial care is care provided in a nursing home, hospice, or other facility setting when the Member does not require skilled medical care or skilled nursing care. Custodial care is personal care that does not require the continuing attention of trained medical or paramedical personnel, such as care that helps you with activities of daily living, such as bathing or dressing. Homemaker services include basic household assistance, including light housekeeping or light meal preparation. Fees charged by the Member’s immediate relatives or members of the Members household. Meals delivered to the Member’s home. Elective or voluntary enhancement procedures or services (including weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance), except when medically necessary. Cosmetic surgery or procedures, unless because of an accidental injury or to improve a malformed part of the body. However, all stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance. Routine dental care, such as cleanings, fillings or dentures. However, non-routine dental care required to treat illness or injury may be covered as inpatient or outpatient care. Chiropractic care, other than manual manipulation of the spine consistent with Medicare coverage guidelines. Routine foot care, except for the limited coverage provided according to Medicare guidelines. Orthopedic shoes unless the shoes are part of a leg brace and are included in the cost of the brace or the shoes are for a person with diabetic foot disease. Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease. Routine hearing exams, hearing aids, or exams to fit hearing aids. Eyeglasses, routine eye examinations, radial keratotomy, LASIK surgery, vision therapy and other low vision aids. However, eyeglasses are covered for people after cataract surgery. Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies. Acupuncture. Naturopath services (uses natural or alternative treatments). Services provided to veterans in Veterans Affairs (VA) facilities. However, when emergency services are received at VA hospital and the VA cost sharing is more than the cost sharing under BCBSAZ Advantage, BCBSAZ Advantage will reimburse veterans for the difference. Members continue to be responsible for BCBSAZ Advantage cost-sharing amounts. BCBSAZ Advantage will not cover the excluded services listed above. Even if the Member receives the services at an emergency facility, the excluded services will not be covered. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 18 of 75 The BlueCard® Program Provider Operating Guide January 2015 5. Member Information 5.1 Member Enrollment In general, an individual is eligible to elect BCBSAZ Advantage when each of the following requirements is met: 1. 2. 3. 4. 5. 6. The individual is entitled to Medicare Part A and enrolled in Part B, provided that he/she will be entitled to receive services under Medicare Part A and Part B as of the effective date of coverage under the plan, exceptions may apply; The individual has not been medically determined to have ESRD prior to completing the enrollment request exceptions may apply; The individual permanently resides in the service area of BCBSAZ Advantage, exceptions may apply; The individual or his/her legal representative completes an enrollment request and includes all the information required to process the enrollment or meets alternative conditions for enrollment specified by CMS; The individual is fully informed of and agrees to abide by the rules of BCBSAZ Advantage that were provided during the enrollment request; and The individual makes a valid enrollment request that is received by BCBSAZ Advantage during an election period. BCBSAZ Advantage may not impose any additional eligibility requirements as a condition of enrollment other than those established by CMS. Upon enrollment the Member chooses a PCP. This physician’s name is located on the Member’s Identification card. The PCP is responsible for coordination of the Member’s health care. Members may change their PCP by contacting Member Service and are generally allowed to change PCPs monthly. Members that change their primary care physician by the 20 th of the month will be effective with that PCP the first of the next month. If the member calls after the 20 th of the month, the change will become effective the first of the following month. Example: Member requests change in their PCP Nov 20, the change will be effective Dec 1. Member requests change Nov 29, the change will be effective Jan 1. Only Members are able to request a PCP change, providers are not allowed to request PCP changes for Members. PCP changes are only effective on the 1st of the month EXCEPT in the case of a provider termination. 5.2 Member Role and Responsibilities BCBSAZ Advantage must honor the rights of Members of the BCBSAZ Advantage Plans. BCBSAZ Advantage must: Provide information in a way that works for the Member (in languages other than English, in Braille, in large print, or other alternate formats, etc.) Treat Members with fairness and respect at all times Ensure that Members get timely access to covered services and drugs Protect the privacy of the Member’s personal health information Give Members information about the plan, its network of providers, and the member’s covered services Support the Member’s right to make decisions about their care Have the right to make complaints and to ask BCBSAZ Advantage to reconsider decisions BCBSAZ Advantage has made Treat Members fairly and respect their rights Provide Members with information about their rights Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 19 of 75 The BlueCard® Program Provider Operating Guide January 2015 Members of BCBSAZ Advantage must: 5.3 Become familiar with covered services and rules the Member must follow to get these covered services Tell BCBSAZ Advantage if the Member has other health insurance coverage or prescription drug coverage in addition to BCBSAZ Advantage Tell their doctor and other health care providers that they are enrolled in BCBSAZ Advantage Help doctors and other providers help Members by giving them information, asking questions, and following through on their care Be considerate by respecting the rights of other patients and act in a way that helps the smooth running of the doctor’s office, hospitals, and other offices Pay what is owed Tell BCBSAZ Advantage if you move Call Member Services for help if you have questions or concerns Appointment of a Representative Members may name another person to act for them as their “representative” to ask for a coverage decision or make an appeal. The Authorized Representative may be someone who is already legally authorized to act as the Member’s representative under State law. If the Member wants a friend, relative, their physician or other provider, or other person to be their representative, call Member Service and ask for “Appointment of Representative” form. This form is also available on the Medicare Website at: www.cms.hhs.gov/cmsforms/downlads/cms1696.pdf or on our website at: www.azbluemedicare.com or below (see next page): Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Appointment of Representative Form: Department of Health and Human Services Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0950 Appointment of Representative Name of Party Medicare or National Provider Identifier Number Section 1: Appointment of Representative To be completed by the party seeking representation (i.e., the Medicare beneficiary, the provider or the supplier): I appoint this individual, to act as my representative in connection with my claim or asserted right under title XVIII of the Social Security Act (the “Act”) and related provisions of title XI of the Act. I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my appeal, wholly in my stead. I understand that personal medical information related to my appeal may be disclosed to the representative indicated below. Signature of Party Seeking Representation Date Street Address Phone Number (with Area Code) City State Zip Code Section 2: Acceptance of Appointment To be completed by the representative: I, , hereby accept the above appointment. I certify that I have not been disqualified, suspended, or prohibited from practice before the department of Health and Human Services; that I am not, as a current or former employee of the United States, disqualified from acting as the party’s representative; and that I recognize that any fee may be subject to review and approval by the Secretary. I am a / an (Professional status or relationship to the party, e.g. attorney, relative, etc.) Signature of Representative Date Street Address Phone Number (with Area Code) City State Zip Code Section 3: Waiver of Fee for Representation Instructions: This section must be completed if the representative is required to, or chooses to waive their fee for representation. (Note that providers or suppliers that are representing a beneficiary and furnished the items or services may not charge a fee for representation and must complete this section.) I waive my right to charge and collect a fee for representing before the Secretary of the Department of Health and Human Services. Signature Date Section 4: Waiver of Payment for Items or Services at Issue Instructions: Providers or suppliers serving as a representative for a beneficiary to whom they provided items or services must complete this section if the appeal involves a question of liability under section 1879(a)(2) of the Act. (Section 1879(a)(2) generally addresses whether a provider/supplier or beneficiary did not know, or could not reasonably be expected to know, that the items or services at issue would not be covered by Medicare.) I waive my right to collect payment from the beneficiary for the items or services at issue in this appeal if a determination of liability under §1879(a)(2) of the Act is at issue. Signature Form CMS-1696 (Rev 06/12) ____ Date Charging of Fees for Representing Beneficiaries Before the Secretary of the Department of Health and Human Services An attorney, or other representative for a beneficiary, who wishes to charge a fee for services rendered in connection with an appeal before the Secretary of the Department of Health and Human Services (DHHS) (i.e., an Administrative Law Judge (ALJ) hearing, Medicare Appeals Council review, or a proceeding before an ALJ or the Medicare Appeals Council as a result of a remand from federal district court) is required to obtain approval of the fee in accordance with 42 CFR §405.910(f). The form, “Petition to Obtain Representative Fee” elicits the information required for a fee petition. It should be completed by the representative and filed with the request for ALJ hearing or request for Medicare Appeals Council review. Approval of a representative’s fee is not required if: (1) the appellant being represented is a provider or supplier; (2) the fee is for services rendered in an official capacity such as that of legal guardian, committee, or similar court appointed representative and the court has approved the fee in question; (3) the fee is for representation of a beneficiary in a proceeding in federal district court; or (4) the fee is for representation of a beneficiary in a redetermination or reconsideration. If the representative wishes to waive a fee, he or she may do so. Section III on the front of this form can be used for that purpose. In some instances, as indicated on the form, the fee must be waived for representation Authorization of Fee The requirement for the approval of fees ensures that a representative will receive fair value for the services performed before DHHS on behalf of a beneficiary, and provides the beneficiary with a measure of security that the fees are determined to be reasonable. In approving a requested fee, the ALJ or Medicare Appeals Council will consider the nature and type of services rendered, the complexity of the case, the level of skill and competence required in rendition of the services, the amount of time spent on the case, the results achieved, the level of administrative review to which the representative carried the appeal and the amount of the fee requested by the representative. Conflict of Interest Sections 203, 205 and 207 of title XVIII of the United States Code make it a criminal offense for certain officers, employees and former officers and employees of the United States to render certain services in matters affecting the Government or to aid or assist in the prosecution of claims against the United States. Individuals with a conflict of interest are excluded from being representatives of beneficiaries before DHHS. Where to Send This Form Send this form to the same location where you are sending (or have already sent): (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision. If additional help is needed, contact your Medicare plan or 1-800-MEDICARE (1-800-633-4227). According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0950. The time required to prepare and distribute this collection is 15 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the beneficiary. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Form CMS-1696 (Rev 06/12) Page: 22 of 75 The BlueCard® Program Provider Manual 5.4 January 2015 Member Temporary Out of State CMS defines a temporary move as: An absence from the BCBSAZ Advantage approved service area of six months or less, and Maintaining a permanent address/residence in the service area. A member is covered while temporarily out of the BCBSAZ Advantage approved service area for emergent, urgent, post-stabilization and out-of-area dialysis services. If a member permanently moves out of BCBSAZ Advantage service area or is absent for more than six months, the member will be dis-enrolled from BCBSAZ Advantage. 5.5 Notice of Privacy Practices With respect to confidentiality and accuracy of member records, for any medical records or other health and enrollment information it maintains with respect to Members, BCBSAZ Advantage has established procedures to abide by all Federal and state laws regarding confidentiality and disclosure of medical records or other health and enrollment information. BCBSAZ Advantage safeguards the privacy of any information that identifies a particular member and has procedures that: Specify for what purposes the information will be used within the organization; and Specify to whom and for what purposes it will disclose the information outside the organization; Ensure that medical information is released only in accordance with applicable Federal or state law or pursuant to court orders or subpoenas; Require the maintenance of records and information in an accurate and timely manner; and Ensure timely access by Members to the records and information that pertain to them. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 23 of 75 The BlueCard® Program Provider Manual January 2015 6. Provider Roles and Responsibilities 6.1 Contracting Process Providers are required to complete a provider information form located at www.azbluemedicare.com. The provider information form may be: Emailed to BCBSAZadvantageproviderrelations@azbluemedicare.com: Mailed to: BCBSAZ Advantage Provider Relations, 8220 N. 23rd Ave, Mailstop C107, Phoenix AZ 85021; or Faxed to: 602-864-7830 Submission of the request does not guarantee participation with BCBSAZ Advantage. The request will be carefully reviewed and a determination of a network need will be made. A representative from BCBSAZ Advantage Provider Relations will contact you within 60 days. If approved, notification will be sent to the provider and an appropriate Provider Participation Agreement will be extended, for review and signature, once credentialing has been completed. Generally, a credentialing application will also be included. The credentialing application and supporting documents should be returned directly to BCBSAZ Advantage credentialing per the application cover letter. Refer to Section 6.b. of this manual for the credentialing process. Failure to return the credentialing application and/or requested attachments, and/or the Participating Provider Agreement will result in a termination of the contracting and credentialing process. At any time, should the Provider fail to meet BCBSAZ Advantage credentialing or re-credentialing, quality management or utilization management criteria, or fails to comply with Plan policies and procedures communicated to Provider, including the Provider Operating Guide, the contract may be terminated by BCBSAZ Advantage. Providers will generally not be compensated for services provided to BCBSAZ Advantage Members until the contracting and credentialing process has been completed. You will be notified in writing of your participating provider status. If a request to participate with BCBSAZ Advantage is denied, a letter stating the reason for the denial will be mailed to the provider by the Provider Relations Department or the Credentialing Department. 6.2 Credentialing Overview 6.2.1 Initial Credentialing Process The Credentialing Department will review all eligible providers for credentialing purposes based on quality of care and quality of service. 6.2.2 Individual Providers Credentialing Process The BCBSAZ Advantage Credentials Committee oversees the BCBSAZ Advantage credentialing process which includes: Reviewing the credentialing application, Verifying education, training, experience, licensure, malpractice insurance coverage, DEA certificate and sanctions/malpractice history, Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 24 of 75 The BlueCard® Program Provider Manual January 2015 Verifying OIG and SAM websites to ensure no Medicare/Medicaid Sanctions or excluded from receiving Medicare funds for any reason. Verifying the Medicare Opt Out list to assure Medicare participation, Reviewing all files against criteria developed by the Credentials Committee. The Credentials Committee reviews and discusses files not meeting the minimum criteria. Certain exceptions to criteria (e.g., licensing restrictions) may result in automatic denial without committee review. The Credentials Committee determines whether the credentials are approved or denied, based on BCBSAZ Advantage‘s standards. 6.2.3 Provider Types BCBSAZ Advantage credentials these provider types: Medical Doctors (MDs) Doctors of Osteopathy (DOs) Doctors of Dental Surgery (DDS/DMDs) Doctors of Podiatric Medicine (DPMs) Doctors of Chiropractic (DCs) Optometrists (ODs) Psychologists (PhDs/EdDs) Nurse Practitioners (NPs) Certified Nurse Midwives (CNMs) Certified Registered Nurse Anesthetists (CRNAs) Certified Physician Assistants (PAs) Registered Nurse First Assist (RNFA) Certified Registered Nurse First Assist (CRNFA) Physical Therapists (PT) Occupational Therapists (OT) Speech-Language Pathologists (Speech Therapists - ST) Behavioral Analyst (BCBA – Autism) Licensed Clinical Social Worker (LCSW) Licensed Independent Substance Abuse Counselor (LISAC) Licensed Marriage Family Therapist (LMFT) Licensed Professional Counselor (LPC) Registered Dietician (RD) Audiologist (AuD) Lactation Specialist (IBCLC) Note: BCBSAZ Advantage does not credential providers who are hospital based health care professionals who provide services to Members incident to hospital services, unless those professionals are separately identified in Member literature as available to Members (for example: Emergency Room physicians) 6.2.4 Institutional Provider Types Only the following list of institution/entity types are credentialed for BCBSAZ Advantage, even though additional facility types are listed in the provider directory: Ambulatory Surgery Centers (ASC) Behavioral Health Inpatient Facilities Birthing Centers Cardiac Rehabilitation Programs Diabetic Training Dialysis Treatment Centers Extended Active Rehabilitation Facilities Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 25 of 75 The BlueCard® Program Provider Manual January 2015 Home Health Agencies Home Infusion Therapy Hospice Hospitals Laboratories Mammography Centers MRI Centers Pain Management Clinics PET Centers Radiation Therapy Clinics Radiology Centers Recovery Care Centers Rehabilitation Treatment Centers Skilled Nursing Facilities (SNF) Sleep Labs Ultrasound Centers Urgent Care Facilities 6.2.5 Credentialing and Re-Credentialing for All Providers Individual and institutional providers must be credentialed before BCBSAZ Advantage will execute a contract, and re-credentialed at least once every three years thereafter. Providers are considered re-credentialed unless otherwise notified. All required information must be submitted before the credentialing process can be completed. Providers who do not submit the required information with their application will be placed in an “inactive” status. These providers will be notified in writing of the information that is needed and the date by which they must respond. If the provider does not respond, the provider will be discontinued from the credentialing process, and any existing participation contracts will be terminated. 6.3 Primary Care Physician Responsibilities The PCP is the principal manager of healthcare delivery for health plan Members. The PCP is responsible for determining the healthcare needs of his/her patients, for directly providing many of these needs and for coordinating the services of other providers. Each PCP accepts the following responsibilities when seeing or treating Members with BCBSAZ Advantage benefits: Acts, at all times, to support the highest professional and ethical standards. Understands supports and cooperates with the managed care efforts as defined and supported by BCBSAZ Advantage Care Management team in concert with the BCBSAZ Advantage Benefit Plans. Provides care that is medically appropriate and proficiently delivered to produce optimal patient outcomes and satisfaction. Coordinates the Member’s access to high quality, cost effective health care delivery, makes all reasonable efforts to provide diagnostic and treatment care within his/her scope of practice and refers the patient to participating BCBSAZ Advantage network specialists in the Provider Directory. Be available twenty-four (24) hours a day, seven (7) days a week or arrange coverage with a participating physician to provide patient access during his/her absence. Demonstrates his/her commitment to the patient-physician relationship by taking complete patient history information and communicating effectively with regard to recommended medical treatments and/or lifestyle changes and in concert with the patient or patient representative to develop a plan of care. Cooperates with all BCBSAZ Advantage Utilization and Quality Management policies and procedures; demonstrates a willingness to examine his/her practice patterns as it pertains to feedback from BCBSAZ Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 26 of 75 The BlueCard® Program Provider Manual January 2015 Advantage and remains open to the possibility of modifying his/her clinical behavior in accordance with professional norms. Complies with the terms of BCBSAZ Advantage’s prior authorization and credentialing requirements as well as all other contract terms, policies and procedures, and the Provider Operating Guide. Complies with the terms of the physician services agreement that prohibits billing Members for anything except copays, deductibles, and/or coinsurance specified in a Member’s applicable benefit plan. Notifies BCBSAZ Advantage in writing of any changes to his/her practice, including but not limited to, address changes, tax identification changes, practice closures to new patients and terminations. Advises Members before each service is provided when service(s) is not covered and obtain written evidence generally with an Advanced Beneficiary Notice of Non-coverage (ABN) (signature of Member acknowledging non-covered services prior to service). Comply with all medical record documentation requirements and submit appropriate claim/encounter data. During a PCP transition, when requested, forward medical records in a timely manner to a new PCP. Prescribes from the appropriate Prescription Drug Formulary. Requests non-formulary medications according to Plan policies and procedures. Interacts with all Members in a culturally competent manner that exemplifies dignity and respect as initial assessments are made, to determine the Member’s needs. Assessments include identification of hearing impairment, vision impairment, limited English proficiency, limited reading skills, and cultural and ethnic diversity. 6.3.1 Covered Services (PCP) The PCP must obtain Prior Authorization in accordance with the prescribed authorization guidelines, as necessary. Reimbursement for such services will be paid according to the Provider Participation agreement. 6.3.2 Laboratory Procedures Allowed in Office (PCP) Providers are allowed to perform in office laboratory tests, when the office has the applicable CLIA certification and the tests are in a waived status under CLIA. The listing of these CLIA waived laboratory tests can be found at: http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf 6.4 Specialist Provider Responsibilities When specialty care or services are needed to treat a patient, the PCP shall coordinate and arrange a referral to Specialists who are contracted with BCBSAZ Advantage. If the PCP wishes to refer the patient to a non-contracted Specialist, prior authorization is required. When a specialist determines a referral to another specialist is needed, the specialist must communicate this to the Member’s PCP and the PCP is responsible for making the referral to another specialist. Participants are allowed to self-refer to contracted Specialists in the following cases: Gynecology and obstetrics & gynecology services Mental health and substance abuse care Annual, routine eye exam Dialysis Each Specialist accepts the following responsibilities when seeing or treating BCBSAZ Advantage Members: Provides only those specialty services requested by the PCP. Acts, at all times, to support the highest professional and ethical standards. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 27 of 75 The BlueCard® Program Provider Manual January 2015 Understands supports and cooperates with the managed care efforts as defined and supported by BCBSAZ Advantage Medical Services. Maintains an office that is clean, accessible, safe, and supportive of patient privacy and confidentiality. Demonstrates his/her commitment to the patient-physician relationship by taking medical history information, and communicating effectively with regard to recommended medical treatments and/or lifestyle changes and in concert with the patient or patient representative to develop a plan of care. Cooperates with all BCBSAZ Advantage Utilization and Quality Management policies and procedures; demonstrates a willingness to examine his/her practice as it pertains to feedback from BCBSAZ Advantage and remains open to the possibility of modifying his/her clinical behavior in accordance with professional norms. Contacts the PCP to discuss treatment recommendations and to obtain additional referrals or authorizations if services beyond those originally contemplated by the PCP are needed. Works closely with the PCP to enhance continuity of care services to the patient to maximize health and well-being of the patient. Follows each consult visit with a letter to the PCP stating findings and recommendation with respect to an appropriate treatment program. Uses only contracted hospitals, outpatient surgical facilities, laboratories, radiology facilities and pharmacy providers, unless otherwise indicated. Complies with the terms of BCBSAZ Advantage’s prior authorization and credentialing requirements as well as all other contract terms, policies and procedures, and the provider manual. Advises Members before each service is received when service(s) is not covered and obtains a signed Advanced Beneficiary Notice of Noncoverage (ABN) (written evidence (signature of Member’s agreement to pay for specific non-covered services prior to rendering services). Complies with the terms of the physician services agreement that prohibits billing Members for anything except copays, deductible, and/or coinsurance specified in a Member’s applicable benefit plan. During a Specialist transition, when requested, forward medical records timely to a new Specialist. Uses the appropriate BCBSAZ Advantage formulary unless medically contraindicated. Requests non-formulary medications according to BCBSAZ Advantage’s policies and procedures. Obtains specified co-payments from participants for office visits. Bills BCBSAZ Advantage on the most current CMS 1500 form. Reports encounter information accurately and timely, as applicable. Interacts with all Members in a culturally competent manner that exemplifies dignity and respect as initial assessments are made, to determine the Member’s needs. Assessments include identification of hearing impairment, vision impairment, limited English proficiency, limited reading skills, and cultural and ethnic diversity. 6.4.1 Covered Services (Specialist) Specialty providers, who receive either a valid referral from the PCP or prior authorization from BCBSAZ Advantage, if required, will be paid according to their Provider Participation Agreement for Covered Services. Member eligibility is not guaranteed. If membership lapses during course of treatment, the former Member/participant is generally financially responsible for services after the date of termination. Contact the Plan for more information. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 28 of 75 The BlueCard® Program Provider Manual January 2015 6.4.2 Laboratory Procedures Allowed in Provider Offices Providers are allowed to perform in office laboratory tests, when the office has the applicable CLIA certification and the tests are in a waived status under CLIA. The listing of these CLIA waived laboratory tests can be found at: http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf 6.5 Access to Care and Appointment Availability Standards and Monitoring All providers must ensure that, when medically necessary, services are available 24 hours a day, 7 days a week. This includes requiring primary care physicians to have appropriate backup for absences. Participating Providers are required to provide appointment availability to each member as follows: Emergency services – immediately Urgent Care – Same Day Non-emergent or urgently needed services but in need of medical attention – within one week Routine and preventive care – within 30 days All PCPs (Internal Medicine, Family Medicine, General Practice and OB/GYNs electing to act as PCPs) and specialists contracted with BCBSAZ Advantage must provide or arrange for medical care 24 hours a day, seven days a week for BCBSAZ Advantage Members. The provider or the designated covering physician or health care professional must be available to provide care personally, or direct member to the most appropriate treatment setting. Call coverage does not include referrals to the emergency department. 6.5.1 Physician Accessibility/Availability Monitoring Physician Accessibility/Availability is monitored through various means to ensure that established standards for reasonable geographical location, number of practitioners, hours of operation, appointment availability, and provision for emergency care and after-hours services are measured. Monitoring activities may include: Physician office surveys On-site visits, when applicable Evaluation of Member/patient satisfaction surveys Evaluation of concern/complaint/grievance reports Monitoring of closed PCP panels Specific deficiencies are addressed with a corrective action plan, and a follow-up activity is conducted to reassess compliance. Data is presented to the QM Committee and the governing body. 6.5.2 Physician Office Hours Office hour information and after hours instructions must be easily accessible and available to BCBSAZ Advantage Members. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 29 of 75 The BlueCard® Program Provider Manual January 2015 6.5.3 After-Hours Answering Systems In order for Members to access their physician after regular office hours, all PCPs and specialists (listed in the directory) must have a telephone answering system or answering service available. Providers who use answering machines for after-hour services are required to include: Urgent/emergent instructions (as the first point of instruction) Information on contacting a covering provider Telephone number for after-hours physician access Call coverage does not include referrals to the emergency department. Authorization is not required for urgent or emergent care, whether in or out of the service area. BCBSAZ Advantage Members should call 911 or go to the nearest hospital in case of an emergency. 6.6 Eligibility Verification Providers can confirm eligibility and benefits by calling the Member Service number 623-974-7430 480684-6167 or 1-800-446-8331, on the back of the Member’s ID card. Copays, coinsurance, deductibles and abbreviated benefit descriptions may vary by benefit plan. Member ID cards include the following information (See Section 4.d. for Member ID card examples): • • • • • • • • Member name (contract holder) and ID number, including alpha prefix RX Group number Abbreviated benefit descriptions and general cost share information Benefit Plan name Plan website address Network affiliation Member Service Prescription claims processor number (if applicable) The identification card does not guarantee eligibility or current PCP assignment. Eligibility should be verified at each visit by calling Member Service numbers listed on the back of the ID card. 6.7 Provider Relations The purpose of Provider Relations is to support network providers. The Provider Relations Representative is the primary liaison between the contracted provider, the provider’s administrative staff and contracted health plans. Provider Relations Representatives make telephonic contact or on-site visits to the provider’s office location or facility to provide information on and assist with: • • • • • • • • • BCBSAZ Advantage policies and procedures Contracting and credentialing processes Updates from Participating Provider Access to provider directories and validate/update your directory listing content Initial and ongoing provider education Problem resolution Benefit Plan interpretation Maintaining and supplying pertinent materials such as Provider Operating Guides, referral forms, formularies, etc. Developing and distributing provider communications Assisting with provider appeals and grievances process Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 30 of 75 The BlueCard® Program Provider Manual January 2015 6.7.1 General Information Your network Provider Relations Representative is also available to help you with information regarding: • • • • • • Requests for participation in the BCBSAZ Advantage network Current provider status General contracting questions Provider specialty updates and changes Dispute resolution processes Corrected claim submission guidelines 6.7.2 In-Services Once you have received written approval to participate BCBSAZ Advantage, a network Provider Relations Representative will contact your office to schedule an appointment in order to answer any questions you or your administrative staff may have. 6.7.3 Education Sessions Education sessions are held periodically and are open to both participating physician office staff and physicians. A typical agenda includes information such as updates related to healthcare industry changes, claims payment, medical management, and referral and authorization guidelines. Notices with meeting dates and times are faxed or mailed to physician offices to RSVP their attendance. 6.8 Network Provider Change Notification Contracted network providers are required to inform BCBSAZ Advantage as indicated below should any of the following changes occur as related to its contracted providers: • • • • • • • • • • Name change – 30 days in advance of the change National Provider Identifier (NPI) – 30 days in advance of the change Addition or termination of a provider in a group contract – 60 days in advance of the change – immediately Change in tax identification number (a copy of the W-9 is required) – 30 days in advance of the change Change in address, phone numbers, billing service and other demographic changes – 30 days in advance of the change Loss of or change in hospital privilege status - immediately Loss of or change in professional liability insurance - immediately Loss of or change in licensure of a physician or other provider - immediately Practice closure to new patients – 30 days in advance of the change Any other change that may affect a provider’s status as a contracted provider, thus affecting the provider’s status – 30 days in advance of the change Changes must be submitted by completing a Provider Change Form at least thirty (30) days prior to the effective date of the change. The Provider Change Form may be obtained by contacting Provider Relations or at www.azbluemedicare.com. You may send the completed form to BCBSAZ Advantage via one of the following communication formats: Email: BCBSAZAdvantageProviderRelations@azbluemedicare.com Fax: 480-684-7871 Attention: Provider Relations Mail: Provider Relations, 8220 N. 23rd Ave, Mailstop C107, Phoenix, AZ 85021 Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 31 of 75 The BlueCard® Program Provider Manual January 2015 If written notice of a provider's change of address is not received, BCBSAZ Advantage will continue sending correspondence, including claim payments, to the address currently listed in our systems. 6.9 Provider Administrative Dispute Resolution Process An administrative dispute resolution process is available to all BCBSAZ Advantage providers. A provider administrative dispute may be initiated by BCBSAZ Advantage or by a participating BCBSAZ Advantage provider. The provider dispute resolution process is not intended for resolution of quality of care issues. Examples of provider administrative disputes include, but are not limited to: • • • • Non-compliance with administrative terms of the Provider Participation Agreement or BCBSAZ Advantage Provider Operating Guide Billing the Member improperly Failure to submit requested medical records Network accessibility issues If the administrative dispute is identified by BCBSAZ Advantage, the provider will receive a written notification detailing the issue, via registered mail. Should the provider oppose the issue detailed in the dispute, a reconsideration of the issue may be requested in writing, within 30 days from the date of the written notice provided by BCBSAZ Advantage. The request for reconsideration can be submitted via mail or by fax to: ATTN: Provider Relations BCBSAZ Advantage 8220 N. 23rd Ave, Mailstop C107 Phoenix, AZ 85021 Fax: 480-684-7871 Upon receipt, the provider’s request for reconsideration will be reviewed by BCBSAZ Advantage or if needed, reviewed by other committee/persons not involved in the initial decision. A recommendation will then be determined. Determination of the reconsideration by BCBSAZ Advantage is final and will be communicated to the physician in writing, via registered mail, within 30 calendar days of receipt of the request for reconsideration. Copies of the initial administrative dispute, the provider’s request for reconsideration and the final determination letter will be placed in the provider’s file. If you have questions, Provider Relations can be reached at: Phone: (480) 684-7712 6.9.1 Dispute Resolution Process for Professional Competence, Conduct, or Quality of Care Contracted providers may dispute BCBSAZ Advantage’s decision to terminate a contract for lack of professional competence for professional misconduct. Examples of these disputes include, but are not limited to: • • • • Belief that a quality of care issues exists Adverse action taken by a hospital Disciplinary action taken by a licensing board Trend or pattern of quality of care issues Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 32 of 75 The BlueCard® Program Provider Manual January 2015 6.9.2 Fair Hearing The provider is notified if the Peer Committee recommends a corrective action plan, remediation or termination and the BCBSAZ Advantage Executive Board accepts the recommendations. The provider may request a fair hearing in writing to BCBSAZ Advantage within 30 days of receiving written notification of the adverse actions. A panel of three peers not in direct competition with the involved provider is appointed by the Chief Medical Officer (CMO) to conduct the hearing within 30 days of receiving the request from the provider. The Peer Review Committee will conduct the hearing no sooner than 30 days after receiving the provider’s request for hearing. Both BCBSAZ Advantage and the provider are fully entitled to legal representation. Expert testimony and presentation of supporting documents are allowed. The panel, after hearing arguments from both parties, decides by majority vote to uphold or overturn the BCBSAZ Advantage recommendations. The CMO notifies the provider verbally and in writing of the outcome with 72 hours of receiving notice for the panel on their decision. Appeals to the final decision may be considered by the Peer Review Committee if new evidence is presented that is likely to change the final outcome of the decision. 6.9.3 Immediate Suspension or Termination If the BCBSAZ Advantage CMO believes a provider is practicing in a manner that poses a significant risk to the health, welfare, or safety of consumers, BCBSAZ Advantage will either immediately suspend or terminate the provider. • • • If the circumstances require an investigation for BCBSAZ Advantage to know whether the concerns are justified, BCBSAZ Advantage will immediately suspend the provider contract and conduct an expedited investigation. If the circumstances do not require an investigation for BCBSAZ Advantage to know whether the concerns are justified, BCBSAZ Advantage will immediately terminate the provider contract. Examples of circumstances that might result in immediate suspension or termination include, but are not limited to: Insufficient or no professional liability insurance Sanction by Medicare/Medicaid Exclusion from any Federal Programs A change in license status Fraudulent activity 6.9.4 Suspension or Termination When it is necessary to suspend or terminate a provider the following occurs: The provider is immediately removed from the provider directory. The provider is notified of the suspension or termination in writing. The notification includes the reason for the suspension or termination. The provider may request reconsideration in writing not later than 30 calendar days after receipt of notice of termination from BCBSAZ Advantage. A panel, consisting of at least 3 qualified individuals, who did not participate in the original decision, with at least one participating provider who is a clinical peer, will consider the reconsideration request. The panel notifies the provider within 10 business days of the decision. If the provider is not satisfied with the panel’s decision, a second level appeal may be requested no later than 30 calendar days of the receipt of the Committee decision. A panel of three individuals, who did not participate in the first level decision, including at least one participating provider who is a clinical peer, will consider the second level appeal. The panel’s decision is final and will be communicated to the provider in writing, via certified mail, within 10 business days. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 33 of 75 The BlueCard® Program Provider Manual 7.0 January 2015 Claims Submission and Filing Policies • • • • • • 7.1 Always verify the member’s eligibility on the date of service. Check the Member’s ID card to see if the plan has changed. It may be necessary to contact BCBSAZ Advantage Member Service to verify which services have copayments. Collect the copayment at the time of service whenever possible. Member materials instruct the Members to pay their copayments at the time of service. Physician professional claims should be billed on the most current CMS 1500 form using the servicing provider’s National Provider Identifier (NPI). Enter the NPI in box J on the CMS 1500. If you are a Facility, claims should be billed on the most current CMS UB form using the Facility’s NPI. Physicians and facilities billing for Ambulatory Surgical Services can use a CMS 1500 form for each service, however the facility fee must be uniquely identified. Claims should be billed on industry standard, most current CMS 1500 or UB forms and should include all of the ICD-9 codes to the highest level of specificity along with the appropriate procedure codes and modifiers (if required). Claims Payment Address Refer to the back of the Member’s ID card for the appropriate claim submission address. ONLY claims from Arizona providers for BCBSAZ Advantage benefit plans should be submitted to this address for payment. BCBSAZ Advantage PO Box 16800 Mesa, AZ 85211 EDI Payer ID: 77078 Professional and Institutional/Hospital submissions Please be aware of the separate benefit plans when submitting electronic claims. If claims are combined, or submitted with the incorrect identification (Member or Payor ID) they may be directed to the wrong claims system and ultimately denied. Note: Box 32 on the CMS 1500 form must be filled in with the physical address of the site of service. Claims received with a P.O. Box or the word “SAME” in box 32 will be denied. 7.2 Encounter Data Reporting BCBSAZ Advantage requires all providers of care to submit encounter data regardless of the payment methodology. Encounter data is defined by CMS as all data necessary to characterize the content and purpose of each encounter between a Medicare Member and a provider, supplier, and/or physicians. Billed charges should always be reflected on the claim form. Claims with “0” billed charges will be returned to the provider for correction. 7.3 Institutional Providers All institutional providers (Hospitals, SNF, ASC, etc.) are required to submit claims electronically. 7.4 Professional Providers Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 34 of 75 The BlueCard® Program Provider Manual January 2015 BCBSAZ Advantage encourages all providers to submit claims through electronic transmission, however; physicians and other professional providers may submit claims on the most current CMS 1500 (02/12)paper claim forms using OCR red ink (PMS 192). 7.5 Home Health Providers Home Health Providers are required to bill BCBSAZ Advantage using a UB-04 billing form. Reimbursement for these services is based on the contractual arrangement. 7.6 Skilled Nursing Facilities Skilled Nursing Facilities are required to bill BCBSAZ Advantage using a UB-04 billing form. Reimbursement for these services is based on the contractual arrangement. 7.7 CLAIM Timely Filing BCBSAZ Advantage requires complete and accurate claims to be submitted and received by BCBSAZ Advantage within one year of the date of service, including weekends and holidays, to be considered for payment and to avoid timely filing denials. Corrected claims may be submitted within one year of the date of service, including weekends and holidays and to be considered for payment and to avoid timely filing denials. Generally, BCBSAZ Advantage will deny payment of any claims received more than one year after the date of service. Members are not liable for payment of a claim on which payment was refused due to lack of timely filing. 7.7.1 CLAIM Proof of Timely Filing For claims denied under timely filing provision, examples of proof of timely submission may include: Electronic Claims A copy of the report showing receipt of a clean claim within one year of the date of service 7.7.2 Paper Claims A copy of a computer screen print showing that the claim was submitted within one year of the date of service, plus the following information: Dates of timely follow-up conversations with a BCBSAZ Advantage Reimbursement Services staff member documenting date of call and person contacted Any previous contacts with BCBSAZ Advantage Reimbursement Services staff within one year of the date of service regarding the claim (i.e., copies of letters, etc.) 7.7.3 Submitting Requested Medical Records BCBSAZ Advantage may require medical records to determine benefits. BCBSAZ Advantage requires providers to promptly submit requested records in order to process claims timely. If you receive a request for records, please respond within the time indicated in the letter. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 35 of 75 The BlueCard® Program Provider Manual 7.8 January 2015 Prior Authorization and Notification Authorization and Notifications are required as listed in Section 8. Claims with services that require prior authorization will be denied, if no authorization number was obtained. The prior authorization number is to be entered in box 23 of the CMS 1500 form and in box 63 of the facility UB claim form. Refer to Section 8 for a complete list of services that require authorization and/or a referral. 7.9 Modifiers If applicable, providers must use standard CPT and HCPCS modifiers to describe the service performed. Modifiers indicate that a service or procedure that is performed has been altered by some specific circumstance, but has not changed in its definition or code. 7.10 Coding Schemes BCBSAZ Advantage providers are required to use appropriate coding schemes, as referenced by the coding resources below, in accordance with provider type and services rendered: • • • • • • CPT – Current Procedural Terminology CDT – Current Dental Terminology HCPCS – Health Care Procedure Coding System ICD-9-CM Diagnosis Codes – International Classification of Diseases, 9th Revision ICD-10 CM Diagnosis Codes – International Classification of Diseases, 10th Revision, effective 10/1/2014 UB-04 Revenue Codes – National Uniform Billing Data Element Specifications 7.11 Claim Resources We encourage providers to reference the following resources: • • • AMA’s most current CPT coding book, which is published each October and contains the new, revised and discontinued CPT codes for the upcoming year The annual alpha-numeric HCPCS update on the CMS website at: http://cms.hhs.gov/hcpcsreleasecodesets/01_overview.asp. At the end of each October, the CMS website lists the new, revised and discontinued alpha-numeric codes for the upcoming year. The ADA CDT coding book or ADA website at: http://ada.org 7.12 Resubmitting Requested Information To avoid delays in processing, BCBSAZ Advantage makes every effort to use information already available in our records and files before sending a new records request to a provider. BCBSAZ Advantage will advise you if we have located the information or if we need you to resubmit it. If resubmission is required, BCBSAZ Advantage will give you verbal or written confirmation of receipt. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 36 of 75 The BlueCard® Program Provider Manual January 2015 7.13 Contracted Provider Request for Claims Reconsideration of an Adjudicated Claim A provider may request reconsideration or adjustment of an adjudicated claim if the provider disagrees with the adjudication. BCBSAZ Advantage may also adjust an adjudicated claim if it is determined that the claim was incorrectly paid or denied. If a provider disagrees with a payment or denial, they must submit a request for claim reconsideration within 120 days from the date of the explanation of benefits, including weekends and holidays, directly to the BCBSAZ Advantage Reimbursement Services address at: Attn: Reimbursement Services Provider Reconsideration BCBS of Arizona Advantage P.O. Box 16800 Mesa, AZ 85211 Providers have one year from the date of service to submit a corrected claim. BCBSAZ Advantage must notify the provider of an overpayment within one year from the date of payment. Both the provider and BCBSAZ Advantage must give written notice of a request for reconsideration or an adjustment. Currently, adjustments beyond the one year period are allowed in the following circumstances: • • • • • • Claims involving “fraud” which means, without limitation, a claim that includes or is based on a willful misstatement or omission of material fact by a Member or provider, resulting in incorrect adjudication of a claim, and includes, without limitation, failure to disclose other applicable coverage, use of CPT codes that do not accurately reflect services provided, billing for services not rendered, billing for services under the name of a provider other than the provider who actually rendered the service. Claims where a longer period of time is required by applicable state or federal law, including, without limitation, adjustments required because of federally mandated changes in Medicare reimbursement rates, federal requirements that certain government payers be secondary payer or payer of last resort, and federal laws prohibiting providers from accepting more than the Medicare limiting charge. Claims where BCBSAZ Advantage is under a lawful order to adjust a claim because a Member or provider has prevailed on a health care appeal. The request should include the Remittance Advice, if applicable, and a brief written description of the reason for the request. All written requests are reviewed on a first in, first out basis. Any adjustments to claim payments or claim denials will be according to Claim Payment Policies and Procedures. If a decision is made to adjust a claim, you will receive an Explanation of payment showing the adjusted claim information. Providers will receive written notification if a request for claims payment reconsideration is not upheld. Non-contracted providers that are in dispute, of an initial claim adjudication, must follow the Redetermination process found in Section 10 of this manual. 7.14 National Provider Identification (NPI) The NPI is a unique identification number for providers to use. The NPI is a lifetime number that follows an individual health care provider anywhere he or she practices, and an organizational health care provider for as long as the organization exists. Providers MUST bill under their own NPI number and are not allow to bill under another physician or a midlevel provider’s NPI number. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 37 of 75 The BlueCard® Program Provider Manual January 2015 Electronic HIPAA Transactions: • You are required to use your NPI number on all HIPAA transactions, including electronic claims; otherwise the transaction will be rejected. For detailed instructions on using the NPI in HIPAA transactions, please refer to either the HIPAA transaction Implementation Guides, which are available electronically from the Washington Publishing Company’s website at www.wpc-edi.com. Paper Claims: • • BCBSAZ Advantage encourages all providers to submit claims electronically. For paper claims submissions, BCBSAZ Advantage has designated the NPI as the provider identification number. Except for providers that are not required to use NPI numbers, all providers must use the NPI on all paper claims. Lack of an NPI may delay claim processing and could result in a returned claim if BCBSAZ Advantage is unable to process the claim without the NPI. 7.15 Tax Identification Number (TIN) Edits TIN edits are in place to reject claims with one or more of the following errors: • • • • Rendering and billing provider Tax ID are not the same. Billing tax ID not on file. Tax ID not valid for date of service. Tax ID/NPI combination not on file. 7.16 Explanation of Payment BCBSAZ Advantage adheres to Medicare’s prompt payment requirements for all clean claims. Reimbursement will be at the contracted rate and copayments will be deducted from the reimbursement. A detailed Remittance Advice is issued to contracted providers for each claim that details how each service line was processed for payment. Covered Services A provider may obtain reimbursement only for those services covered under a Member’s health benefit plan for medically appropriate, in person, direct patient treatment, tests, services, medications, supplies or equipment. Benefit structure, Member contract limitations and other factors impact reimbursement. Reimbursements for telephonic consults are covered. 7.17 Fee Schedule Updates BCBSAZ Advantage reviews and updates its Medicare fee schedules for most services at least quarterly or per Medicare guidelines. Notification of updates appears in the provider newsletter, bulletins, individual provider letters or other publications available to providers. Notifications may also appear on the BCBSAZ Advantage website, www.azbluemedicare.com. Fee schedule changes that affect Participating Provider Agreements will be communicated by your Provider Relations Representative. See Section 6.a. for an overview of the contracting process. Guarantee of Payment The existence of a fee or rate, or information about eligibility for benefits, does not guarantee payment or that a particular service is a covered service. Health benefit plan structure, Member contract limitations and exclusions, and other factors impact reimbursement. Payment decisions are not made until a claim has been processed. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 38 of 75 The BlueCard® Program Provider Manual January 2015 7.18 Payment Recoupment Policy BCBSAZ Advantage may need to recoup reimbursement paid to a provider claim for a variety of reasons. When BCBSAZ Advantage recoups reimbursement, we attempt to recover it from the same provider and practice that received the original payment. If the practice has changed or is no longer active, BCBSAZ Advantage will recover it from the individual contracted provider who was paid incorrectly, regardless of changes in location, affiliation or tax identification number made in the interim. • Credit transactions: Most provider contracts authorize BCBSAZ Advantage to recover any overpayments or incorrect payments by credit transaction. Overpayments or incorrect payments are automatically deducted from the provider’s payment and are identified on an explanation of payment (EOP)/ remittance advice. If a recovery results in a balance owed to BCBSAZ Advantage greater than the provider’s payment, the balance will be carried forward and applied to future payment(s) until the balance is paid. BCBSAZ Advantage reserves the right to recover any amounts due through legal means. Provider notification: A letter with an explanation/reason for the recovery action is sent to providers. Some offsets may be deducted from the provider’s payment the same day the letter is mailed. • 7.19 Billing the Member You may only bill Members for co-payments, coinsurance, deductibles, and cost sharing amounts and/or non-covered services previously agreed upon by the Member. Balance billing is not permitted. 7.20 Coordination of Benefits (COB) Coordination of Benefits (COB) and Subrogation Coordination of Benefits (COB) is the process of determining if a Member has more than one health plan available to pay medical bills. When benefits are coordinated, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer a determination will be made by BCBSAZ Advantage to determine which insurance company bears the primary responsibility to provide care and which company has the secondary responsibility. Subrogation procedures are used when a Member has an illness or injury, which is caused by a third party. BCBSAZ Advantage has the legal right to recover any claims payment from the responsible party or their insurance company. This includes, but is not limited to, one or more of the following: • • • • Employer group health plan Worker’s compensation No-fault or liability insurer Federal Black Lung program Providers should treat Members as they normally would and notify BCBSAZ Advantage of any possible COB or subrogation situations. All claims and copies of explanations of benefits from other carriers should be sent to BCBSAZ Advantage Reimbursement Services for processing. 7.21 ICD-10 The Centers for Medicare and Medicaid Services (CMS) has mandated the conversion from ICD-9-CM to ICD-10-CM (diagnosis) and ICD-10-PCS (hospital procedure) code sets by Oct. 1, 2014. All healthcare organizations must also be compliant with the American National Standards Institute (ANSI) Transaction Version 5010 (ANSI v5010) and the National Council for Prescription Drug Programs standard, Version Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 39 of 75 The BlueCard® Program Provider Manual January 2015 D.0, for electronic transactions which has been required since Jan. 1, 2012. ANSI v5010 is a prerequisite for the use of ICD-10 codes. These mandates may require substantial changes to the information technology systems for providers, clearinghouses, and practice management vendors. Differences in code length, alphanumeric characters and increased details captured by the codes are just some of the changes that are part of the new code set. All providers must meet government deadlines and requirements for ICD-10 coding. Check CMS’s ICD-10 dedicated website for helpful downloads, resources, upcoming presentations, and up-to-date information at www.cms.hhs.gov/ICD10. 7.22 Risk Adjustment Risk adjustment was mandated by the Balanced Budget Act of 1997. The methodology requires collecting data reported through claims/encounter data for services provided in the current year to establish cost of patient care and resources for the next year. CMS chose a “risk model” based on measuring chronic conditions; the more chronic conditions a patient has the more care they may require. Each patient is assigned a Risk Adjustment Factor (RAF), which is a numeric value assigned by CMS to identify the health status of the patient. The model includes criteria for age/sex, additional risk factors for Medicaid status or if the patient was eligible for Medicare due to a disability; and a RAF for the total of all chronic conditions. Health status is one of the primary factors of CMS reimbursement. All chronic conditions must be assessed, addressed and documented in the medical record annually for all Medicare Advantage patients. Proper documentation and coding of these chronic diseases can help ensure that RAF scores accurately reflect the health status of your patients. If the condition is not documented, it cannot be coded and if it cannot be coded, it cannot be reported. In addition, coding must be at the highest level of specificity - accuracy is essential. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 40 of 75 The BlueCard® Program Provider Manual January 2015 8.0 Medical Management 8.1 Care Management Program BCBSAZ Advantage encourages providers to refer Members who have complex medical and social needs to the Case Management Program. The goals of the program are to focus on improving the ability for selfcare and maintaining or enhancing their ability to remain home and independent through the use of Case Managers. Members have the right to decline or refuse Case Management Services or Disease and Health Education classes. Services that Case Managers Provide Include: • Comprehensive needs assessment and initiation of interventions for Members • Coordination of care across the health care continuum including the emergency department, acute medical/surgical area, skilled nursing, custodial settings and the physician office • Assistance with Member access to health plan and community resources as well as financial assistance programs • Intense education and reinforcement of medical treatment plans • Facilitation of family interventions to transition patients to a safe environment that may include higher level of care i.e. assisted living or group home setting • Assistance with referrals for behavioral health needs to include counseling services and support groups • Initiation of appropriate referrals to disease focused educational classes. Medical Management Programs BCBSAZ Advantage Medical Management activities include the Utilization Review functions that can be categorized into prospective, concurrent and retrospective components. Physicians who are board certified and/or Medicare/Medicaid certified in family practice, internal medicine and OB/GYN coordinate and facilitate the total care of each Member. Standardized protocols are used to identify appropriate providers and settings of care beyond the PCP level. Significant time and resources are devoted to keeping Members well and teaching them to independently manage their health. In order to improve patient safety, we address potential safety issues that are identified as well as complex clinical situations. These high risk Members are identified by Utilization Review functions through prior authorization request, inpatient stay review, transition of care requests and by analysis of resource utilization. These cases are referred to the Case Management department via a Case Management referral and the case managers assist these Members with their ongoing health maintenance needs. Medical management of hospitalized Members is performed by care coordination teams consisting of physicians, registered nurses and social workers. Care coordination teams, consisting of social workers, discharge planners and case managers, provide support. The Member’s PCP is notified when an admission occurs to promote continuity of care. Standardized criteria are utilized to determine medical necessity of admission, appropriate length of stay/level of care and readiness for discharge. Out of network/out of area admissions are reviewed by registered nurses; on site visits as needed, within Maricopa County; telephonically for out of area, as delegated. These nurses coordinate discharge planning and facilitate back transfers to in-network facilities when medically and financially appropriate to do so. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 41 of 75 The BlueCard® Program Provider Manual January 2015 Utilization Review staff performs claim reviews and analyze data. Retrospective review determinations are made solely on the medical information available to the physicians at the time the medical care was rendered. 8.2 Case Management Case Managers facilitate identification and treatment of Members with complex or serious medical conditions through individualized assessment. Case Management is intended to provide a proactive approach early identification and interventions for healthier outcomes and ensure health care is delivered at the appropriate level. Case Management proactively identifies Members with complex or serious medical conditions through established referral sources: • • • • • • Initial assessments Physician referrals (PCP or Specialist) Case Managers (hospital inpatient, skilled nursing facilities, Emergency Department, Home Health) Customer Service Identification of High Risk/ Chronic disease states such as: Diabetes, CHF, COPD, CVD Transitions of care between levels of care The Case Manager will request assistance from the Medical Director as needed to provide ongoing development of the care plan. Upon referral, the Case Manager will: • • • • • Contact the Member, conduct assessment and identify most appropriate resource and needs. Recommends resources for education, information, and other elements within the program. Schedules ongoing follow up and encouragement of self-management Refers Members to disease specific education programs when appropriate Develops an individualized care plan, in conjunction with the Member, physicians, family/caregiver, to address identified needs with specific goals that identified the expected date of goal completion. The care plan incorporates the Member/family/caregiver’s goals and preferences. Members must give consent to entering into the case management program and do have the right to decline or refuse Case Management services or disease focused educational classes. 8.2.1 Frequently Asked Questions (FAQ) about Care Management Q. Which patients in my office would benefit by a referral to the Care Management Program? A. Patients who have the following: • Multiple related hospital admissions • Diagnosis of a catastrophic or chronic illness that results in major changes in lifestyle, living arrangements or caregiver roles • Suspected emotional, social or financial problems complicating health status • Suspected knowledge deficit about disease process • Non-adherence with medication, diet, medical treatment or appointments • Cognitive/behavioral issues that contribute to poor self-care or impaired decision making Q. What is the difference between the Case Management Program and referring to Home Health? A. Home Health would be utilized when a skilled nurse is required to physically assess a member and report back medical findings, or to actually provide the skilled nursing care required in the home for dressing changes, injections, infusion care, therapy, etc. and is typically a reimbursable service under the plan benefits. The Case Management Program nurse will evaluate the social risk of the home/family situation and intervene to promote appropriate outpatient resources to assist the member to remain Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 42 of 75 The BlueCard® Program Provider Manual January 2015 healthy and safe in their home environment for as long as possible. Case management nursing support is not a reimbursable service under the plan benefits, but is a service available to members under the administrative functions of the plan. Q. Why would my patient benefit from this program? A. Case managers perform comprehensive screening and assessment of the member and identify needs that can be addressed. They facilitate member compliance with established medical treatment plans or initiation of new treatment plans in collaboration with the physician. Case managers help members maximize the appropriate utilization of their health plan benefit as well as obtain appropriate services from community resources or programs. Q. How can my patient receive services from this program? A. Either you or your staff member can complete a Case Management Referral form and fax to the number indicated at the bottom of the form. The Case Manager will contact your patient by telephone and arrange an appointment. Please inform your patient that a referral has been made, this will facilitate the Member’s cooperation to the initial call made by the Case Manager and conform to confidentiality standards and release of information rules. Q. How will I know when my patient has been contacted by the Care Manager? A. Referring offices receive a summary from the Case Manager that details the initial assessment, needs identification and interventions recommended. This communication initiates collaboration between the physician, Member and case manager to meet the member’s needs. 8.2.2 Cultural Competency Case Management interacts with all Members in a manner that exemplifies dignity and respect as initial assessments are made, to determine the Member’s needs. Assessments include identification of hearing impairment, vision impairment, limited English proficiency, limited reading skills, and cultural and ethnic diversity. The Case Management staff in conjunction with the Member determines an appropriate plan of care and accommodation unique to the Member’s needs and culture. Member’s needs may be accommodated through individualized classroom instruction, one-on-one demonstration opportunities, modified instruction with an interpreter, educational material with varied reading levels, education materials in preferred language, when available, TTY and translator services. 8.2.3 Disease and Health Education Classes BCBSAZ promotes health and wellness through disease and health education classes. Information gathered from the initial assessment is utilized to identify those Members that have chronic cardiovascular, respiratory or diabetes, encouraging Members with these disease processes to participate in disease focused educational classes. Referrals into these programs may come from the Member, hospital case management, customer services, social workers, physicians and other referral sources. Through the use of predictive modeling, BCBSAZ Advantage is able to identify Members for these disease educational classes and manage early in the disease process. The Case Management department contacts the Member, conducts an assessment and identifies the most appropriate resources and needs. Follow up and ongoing calls are scheduled with the member to encourage of their chronic disease. Programs offered by BCBSAZ Advantage include: COPD, Diabetes, and Heart Healthy. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 43 of 75 The BlueCard® Program Provider Manual January 2015 8.2.4 Interdisciplinary Care Team BCBSAZ Advantage has established an Interdisciplinary Care Team (ICT) approach to develop a comprehensive individualized care plan that addresses the Member’s particular needs and supports the physician’s medical plan. ICT is available to any Member needing assistance with complex issues. The individualized care plan includes measurable goals developed by the ICT with input from the member, Member’s family or caregiver, and the treating physician, as applicable. The care plan ensures an on-going evaluation and assessment of the member to facilitate case management services appropriate to the Member’s needs. Participants in the ICT may include a clinical pharmacist, case manager, medical director, registered dietician, social worker, business support analyst, member and primary care and/or specialist physicians. 8.2.5 How to Refer a Member to a Care Management Program Members can be referred into a Care Management program by completing the Care Management Referral form below (see next page) and faxing it to the Case Management Department. You may also call Case Management Department directly with your referral. Care Management Referral forms can also be found at www.azbluemedicare.com. Care Management phone: 800-446-8331 Care Management fax: 602-864-4274 Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Independent Licensee of the Blue Cross and Blue Shield Association CARE MANAGEMENT REFERAL FORM Member’s Name: ____________________________________________ Date: ____________________ Address: _________________________________________________ DOB: _____________________ Phone: _______________________________________ PCP: ________________________________ Diagnosis: ______________________________________________________________________ Network: Banner Health Network Pima County Scottsdale Health Plan Network BCBSAZ Advantage ID# ___________________________ Medicare HIC# ___________________ PLEASE CHECK THE FOLLOWING REASON(S) FOR Care Management REFERRAL 1. Frequent hospitalizations or ED visits 2. Inability for member/family caregiver to “teach back”/ explain follow up care at home. 3. Missed/no show office appointments 4. Concern that your patient cannot manage independently for a variety of reasons - lack of support; disabilities; lack of transportation; visually and /or hearing or memory impaired; overwhelmed with health care needs 5. Member/family/caregiver assistance with obtaining resources for in-home care, long term placement (Assisted Living nursing facility), transportation, financial (not filling drugs/relies upon samples), legal, hearing or visual aids, and/or support groups 6. Any safety concerns either with taking medications or in the home 7. Member with mental/physical decline - poor hygiene, weight loss, inappropriately dressed, falls 8. Discussion and providing advanced directives documents and long term planning 9. Explanation of how to access or use BCBSAZ Advantage benefits 10. Discussions with your patient about the services provided through Hospice/palliative care 11. Not understanding or managing disease processes or medications 12. Enroll in the following disease management program(s) 13. Other______________________________________________________________________ Diabetes Cardiovascular Education COPD 14. Please provide information regarding current clinical conditions and needs: ___________________ Referral Source Name: ______________________________________ Phone: ____________________ FAX to 602-864-4274 or Call Care Management at 1-800-446-8331 Page: 45 of 75 The BlueCard® Program Provider Manual 8.3 January 2015 Referral Guidelines The following guidelines establish minimum standards of evaluation and care that must be met prior to the PCP referring the Member to a Specialist. All services that cannot be provided within BCBSAZ Advantage networks require prior authorization, and must be requested through the PCP. 8.3.1 Routine Referrals An adequate medical evaluation should precede a referral. This should include appropriate history, physical exam, baseline testing as indicated, and a working assessment plan. All information should accompany the referral and is considered an introduction of the Member to the Specialist. This evaluation should anticipate the possible need for surgery. If surgery is likely, medical clearance should be granted and documented prior to referral. Communication between the PCP and Specialist is vital. Relevant x-rays, lab and clinical notes should be provided to the specialist at the time of the referral. 8.3.2 Referrals to a Non-Participating Provider (Out-of-Network) Prior Authorization must be requested from BCBSAZ Advantage prior authorization department if the patient requires services that are not available through one of the BCBSAZ contracted providers. Complete the appropriate authorization form below (see next page) and Phone: to 800-466-8331 or fax to 602-864-5811 for review. Include the name and findings of any providers that have already been consulted. Provide sufficient rationale as to why a non-participating provider would be required. The Prior Authorization request will be evaluated on a case by case basis. Documentation/information submitted assists in determining the need for the service to be provided outside the network. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage REFERRAL FORM ATTENTION MEMBER: THIS IS YOUR REFERRAL FORM. THE SPECIALIST MAY REFUSE TO SEE YOU WITHOUT IT. Date: _____________________________ Planned Date of Service: _____________________ Member Name: __________________________________________________ DOB:_____________________ Member’s BCBSAZ Advantage Benefit Plan: ______________________ ID# __________________ Phone Number #_________________________ Referral to: ____________________________________________ (Full Name) (MUST be contracted with BCBSAZ Advantage or requires prior authorization on separate form) Specialty:___________________________________________ Phone# ___________________________ Fax# ________________________________ Referring Provider: ______________________________ Phone# _________________ Fax# ____________ (Full Name) Office Contact Name: _____________________________Phone# ________________ Fax# ____________ (Referring Provider Office) Requested Action by Specialist (Optional for PCP to Complete): Consultation: (Please send the member back for follow-up and treatment) [ ] Confirm Diagnosis [ ] Advise as to Diagnosis [ ] Suggest Medication or Treatment Referral: (Please provide PCP with summaries of subsequent visits) [ ] Assume management for this particular problem and return member after conclusion of care. [ ] Assume future management of patient within your area of expertise. Diagnosis/ICD-9: _______________________________________________________________________ Reason for Visit:_______________________________________________________________________ Submit Information, if any: _________________________________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________ _________ ______________________________________________ ________________________________ Provider Signature Date The Primary Care Physician should refer to a contracted provider. To ensure recommended provider is contracted, call the BCBSAZ Advantage Service center at 800-446-8331 or go on the web: hhtp://www.azbluemedicare.com Referral is good for 12 months after referral date The information contained in this facsimile message is confidential and intended only for the use of the individual(s) named above. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify us by telephone and destroy facsimile. Thank you Page: 47 of 75 The BlueCard® Program Provider Manual January 2015 8.3.3 Post-Emergency Room Treatment Follow-up A referral is not required for the initial visit to a network Specialist post-emergency room treatment if referred by the emergency room physician. Subsequent visits require a referral from the PCP . 8.3.4 Post-Hospitalization Follow-up A referral is not required for the initial visit to a network Specialist after hospitalization. Subsequent visits require a referral from the PCP. 8.3.5 Self-Referrals Member/patients may self-refer for the following specialists/services: Annual exam with a contracted Gynecologist Screening mammography at an appropriate contracted BCBSAZ Advantage facility Behavioral/Mental health service with a contracted provider or within a contracted BCBSAZ Advantage facility Dialysis while member is temporarily traveling outside of the service area 8.3.6 Urgent/Emergent Referrals There are times when a referral directly to the specialist is indicated and does not require a visit in the PCP office prior to the referral. Example of such referral: diagnosed fracture by the Emergency Department requiring orthopedic follow-up. In such instances, contact the specialist by telephone in order to facilitate the transfer of care. 8.5 Prior Authorizations and Notification Guidelines 8.5.1 Organization Determinations BCBSAZ Advantage has established procedures for making timely organization determinations regarding the benefits a Member is entitled to receive under the plan. These benefits include basic benefits, mandatory and optional supplemental benefits and the amount, if any that a Member is required to pay for a health services. When a Member, or a provider, has made a request for a services, BCBSAZ Advantage must notify the Member and the provider of its determination as expeditiously as the Member’s health condition requires, but no later than 14 calendar days after the date the organization receives the request for a standard organization determination and 72 hours after the organization receives the request for an expedited organization determination. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 48 of 75 The BlueCard® Program Provider Manual January 2015 8.5.2 After Hours Prior Authorization Authorization is not required for emergency room services. The BCBSAZ Advantage answering service will direct members experiencing a medical emergency to hang up and dial “911.” Requests for after hours prior authorization of non-emergent services are processed by the answering service in the following manner: Answering service operator transcribes caller's name, telephone number and affiliation (e.g., East Valley Dialysis Center). Information is promptly forwarded, to the BCBSAZ Advantage on call registered nurse. The BCBSAZ Advantage registered nurse contacts the caller and facilitates the prior authorization, utilization management, or Member needs. When appropriate to do so, the BCBSAZ Advantage registered nurse coordinates care through the established ancillary network (e.g., contact home health, arrange transportation, etc.) Calls forwarded to the on-call prior authorization nurse are triaged for urgency. Requests of a non-urgent nature will be processed the next business day. Emergency services do not require prior authorization; however notification of the admission is required. All radiology, cardiopulmonary, therapy, ancillary, and laboratory services should be provided at a contracted facility. To obtain the most up to date list and to locate currently contracted BCBSAZ Advantage providers, visit www.azbluemedicare.com 8.5.3 Services Requiring Prior Authorization Durable Medical Equipment, Prosthetics, Medical Supplies o Durable Medical Equipment (>$500.00) o Prosthetics (>$500.00) o Medical Supplies (>$500.00) Skilled Nursing Facility Admissions Cardiac and Pulmonary Rehabilitation Occupational Therapy Services Physical Therapy Services Speech Language Pathology Services Pain Management o Pain Management Assessment (Evaluation and Management only) o Pain Management Treatment Plan Epidurals Pain Blocks Injections Wound Care Clinic Sleep Studies Outpatient Diagnostic and Therapeutic Radiological Services o CT, MRI, MRA, SPECT o EECP, TTT and Virtual Capsule Enteroscopy o PET scan o Radiation Therapy Outpatient Hospital Services o Chemotherapy Infusion Visit o Hyperbaric Oxygen Treatment Non-emergency Transportation o Includes ground, water and air ambulance services Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 49 of 75 The BlueCard® Program Provider Manual January 2015 Notification is required for all inpatient admissions no later than 48 hours of admission (includes acute hospital emergent and elective, inpatient rehabilitation, long term acute care and skilled nursing facilities). Notification must be called to Member service at 1-800-446-8331. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage PRIOR AUTHORIZATION REQUEST FORM Please see BCBSAZ Advantage Prior Authorization List Incomplete forms will not be processed and will be returned to sending provider. Planned Date of Service: ___________________ (Recommend not scheduling until authorization is obtained) Patient: __________________________________________________ DOB:__________________________ Patient’s Health Plan: _____________________________ ID# _________________ Phone #:_____________ Requested Provider: ___________________________________________TIN#_______________________ (Full Name) Specialty:___________________________________ ____ Out of Network____ Inpt ___Outpt____Office___ Phone# ___________________________ Fax# ________________________________ Place of Service:_______________________________________________TIN#________________________ (Facility Name) Referring Provider: ____________________________ Phone# _________________ Fax# ______________ (Full Name) Office Contact Name: _____________________________Phone# ________________ Fax# _____________ (Referring Provider Office) Diagnosis/ICD-9: ___________________________________________________________________________ Treatment/Procedure with CPT/HCPCS codes:__________________________________________________ Submit Information to justify request: List units being administered, Notes, labs, x-rays ___________________________________________________________________________ _________________________________________________________________________ __ _________________________________________________________________________ __ Provider Signature Date The Primary Care Physician should refer to a contracted provider. To ensure recommended provider is contracted, call BCBSAZ Adv Service Center at 800-446-8331 or go on the web www.azbluemedicare.com For Office Use Only BCBSAZ Advantage Prior Authorization Dept Phone: 480-684-7716 or 800-446-8331 Fax: 480-684-7820 The information contained in this facsimile message is confidential and intended only for the use of the individual(s) named above. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby n otified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify us by telephone and destroy facsimile. Thank you Page: 51 of 75 The BlueCard® Program Provider Operating Guide 9.0 January 2015 Quality Management Program and Activities 9.1 Quality Management Program The Quality Management (QM) Committee is committed to continuously improve the quality of care and services provided through their health care delivery system. Quality improvement efforts focus on developing an integrated management system through policy and projects that is designed to engage participating physicians in the responsibility of key cross-functional improvement objectives. Complementing this strategic approach and focusing principally on quality of care and service the QM Committee employs quality management methods. The Quality Management (QM) Chairman, who reports to the Chief Medical Officer, establishes standards that encompass all quality activities. Goals and Objectives Promote and build quality into the organizational structure and processes to facilitate continuous improvement in quality care, quality of service, and cost effectiveness. • • • Facilitate a partnership of those individuals receiving and providing health care for the continuous improvement of quality health care delivery. Continuously improve communication and education to support these efforts. Consider and facilitate achievement of public health goals in the areas of health promotion, prevention and early detection and treatment. Provide effective monitoring and evaluation of patient care and services to ensure that care provided by the affiliated physicians/providers meets the requirements of good medical practice and is positively perceived the members. • • • • Develop, implement and evaluate guidelines for medical practice. Develop, implement and evaluate medical and pharmacy care guidelines related to quality management activities (i.e., access/availability, credentialing/re-credentialing, peer review). Conduct surveys to gather satisfaction with the quality of services provided for both the Member and practitioner. Develop, define and maintain data systems adequate to support quality improvement activities. Ensure prompt identification and analysis of opportunities for improvement with implementation of actions and follow-up. • Identify and assess important aspects, problems and concerns of health care services provided. • Continually improve the QM Management Program. • Provide periodic feedback and education to the participating physicians and customers/Members regarding measurement and outcome of quality management activities. Coordinate risk management and quality management activities. • Provide a regular means by which risk management aggregated data may be included in the development of quality assurance initiatives, consistent with applicable state law requirements regarding such processes. • Share action plans to ensure consistency and to avoid duplication. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 52 of 75 The BlueCard® Program Provider Operating Guide January 2015 Maintain compliance with local, state, and federal regulatory requirements and accreditation standards. • Monitor regulatory requirements for quality management/risk management and respond as needed. • Ensure the reporting system provides adequate information for meeting the regulatory external review and accreditation requirements of mandatory and voluntary review bodies. 9.2 Quality Management Program Activities Quality Management activities utilize a variety of mechanisms to measure and evaluate the total scope of services provided to the individuals within the network . The following activities are used to conduct reviews that reflect the important aspects of care. 9.3 Quality Measurement Studies Quality Improvement Projects are designed to objectively and systematically monitor and evaluate the quality and appropriateness of care and service provided to Members. Topics for routine monitoring and for special studies are chosen based on relevant demographic and epidemiological characteristics of the BCBSAZ Advantage Membership. Scientifically based criteria are utilized for specific conditions, as identified by the organization, Centers for Medicare & Medicaid (CMS), state Quality Improvement Organization (QIO), Member feedback, and nationally recognized organizations. A population-based assessment whenever appropriate, is utilized and will be supplemented by focused medical record review and/or patient surveys. Data collected, reviewed, and analyzed for trends and opportunities for improvement. These data are then presented to the QM Committee for review and recommendations. 9.4 Peer Review Peer review is the mechanism utilized to conduct review of suspected substandard or inappropriate care or inappropriate professional behavior by a physician/provider while providing care. If the findings of the independent investigation indicate that a physician/provider who is subject to investigation has provided substandard or inappropriate patient care, or has exhibited inappropriate professional conduct, action will result based upon the Quality Management Committee recommendation to the Governing Body. The process and the scope of the actions that can be taken are identified in the Quality Management Program defining the peer review and appeal process. The scope of actions that may be taken if a quality issue is identified may include, but are not limited to, development of a corrective plan with time frame for improvement, education, counseling, monitoring and trending of data, sanctions on the practitioner’s is considered confidential. 9.5 Health Promotion and Preventive Care The objective of the preventive care guidelines review is to monitor the use of scientifically -based preventive care guidelines for improving the quality of care provided by Primary Care and Specialty Care Physicians. The Quality Management Committee will develop and distribute adult preventative guidelines upon review by the Committees. The QM Committee reviews and endorses the adult preventive care guidelines which are developed using the most current and reasonable medical evidence available from the U.S. Preventive Services Task Force, the Centers for Disease Control and Healthy People, National Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 53 of 75 The BlueCard® Program Provider Operating Guide January 2015 Health Promotion and Disease Prevention Objectives. The basic components are not meant to be comprehensive, but provide a minimum guideline against which measurement can be performed. To encourage the use of appropriate preventive measures, the promotion of patient focused educational programs. These programs are designed to involve Members in decisions about their health care. Programs are developed to inform Members of preventive care and screening needs, and targets high-risk members to manage their illness, condition or risk factors. 9.6 Concerns, Complaints, and Grievance Review Data related to administrative, quality of service and quality of care issues are collected, reviewed and analyzed in aggregate for trends and opportunities for improvement. This data is presented to the QM Committee for review and recommendations. Process improvements instituted under the direction of the QM Committee are reported to the governing body. Concerns, complaints and grievance review objectives are to: • • Monitor, evaluate, and timely and effectively resolve Member concerns Identify opportunities for improvement in the quality of care and services rendered to participating individuals. Qualities of care concerns are identified through a variety of ways either through complaints, grievances, appeals, and satisfaction survey. Quality of care concerns, complaints and grievances are investigated with assistance of the Medical Director. The QM Committee will review issues of significance. 9.7 Monitoring Quality Indicators The quantitative monitoring of healthcare processes by utilizing indicators is designed to reveal trends and performance opportunities in specific arenas and to facilitate organizationally wide improvements. To achieve this, a variety of indicators will be monitored to effect improvements in care and service. The indicators chosen by the QM Committee are derived from many sources as appropriate for the population and service needs. These quality indicators are measurable, based on reasonable research, and use currently accepted quality methodologies. Examples of monitoring indicators may include tracking of admission rates for acute and chronic conditions, HEDIS, CAHPS, nationally recognized performance measurements, access performance measurement, or specific indicator events reflecting local health demographics . 9.8 HEDIS Medical Record Review Process CMS requires BCBSAZ Advantage to collect and submit Healthcare Effectiveness Data and Information Set (HEDIS) data annually. HEDIS provides a mechanism to accurately gather and report data that is uses to assess health plan performance over time on standardized measures for the Medicare population, support health plan Quality Improvement Project measurement activities, and fulfill selected business responsibilities of the health plan. HEDIS data collection and reporting is conducted annually by BCBSAZ Advantage in fulfillment of requirements outlined in section 1852(e)(3) of the Social Security Act. BCBSAZ Advantage must collect and report data that permits the measurement of health outcomes and other indices of quality. Quality Management is accountable to perform HEDIS medical record review (MRR) and reporting activities in accordance with NCQA HEDIS requirements and to ensure that the process is conducted in a HIPAA compliant fashion. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 54 of 75 The BlueCard® Program Provider Operating Guide January 2015 When MRR is delegated, a formal process is established to monitor and ensure that the delegated agency performs all functions in accordance with the prescribed HEDIS data collection and reporting requirements. A Business Associate Agreement will be obtained, ensuring that the vendor meets necessary HIPAA requirements. Provider’s offices must collaborate with the required chart audits scheduling processes and provide access to charts for medical review within in the timeframe indicated on the request, allow copying and/or scanning of the paper medical records and/or printing of electronic medical records as needed for the completion of the audit. Provider Offices will not be reimbursed for copying of records. When a HEDIS auditor requests a “convenience sample” of records, ten records with associated data abstraction results, the provider will comply with this request within one week of initiating the medical review. 9.9 Member Satisfaction Member Satisfaction is assessed through the evaluation of surveys, PCP changes, Consumer Assessment of Health Plan Survey (CAHPS) and complaint and grievance information. Satisfaction surveys, disenrollment surveys and routine monitoring indicators are designed to measure performance and to assess Member satisfaction with the plan services. Member survey data is used for continuous quality improvement in several key areas: 1) to establish benchmarks and monitor local health plan performance, 2) assess overall levels of satisfaction as an indication of whether the plan is meeting customer expectations, and 3) to assess service performance in comparison to competitors. PCP changes and Member concerns, complaints and grievance information is trended to identify potential opportunities for improvement. Trending and analysis will be correlated with Member survey data or other indicators in assessment and development of action plans. Member survey results are summarized and forwarded to the Medical Director and/or Quality Management Committee. Action plans to address opportunities for improvement is developed as necessary. 9.10 Physician Satisfaction Surveys Physician/Office Satisfaction Surveys are designed to assess what services are important and to determine the level of satisfaction. Results are summarized and presented to the QM Committee. The QM Committee and areas for improvement review these results and subsequent action plans are developed. Provider satisfaction may be assessed through other mechanisms as well. 9.11 Physician Accessibility and Availability Monitoring Physician Accessibility/Availability is monitored through various means to ensure that established standards for reasonable geographical location, number of practitioners, hours of operation, appointment availability, and provision for emergency care and after-hours services are measured. Monitoring activities may include: • • • Physician surveys On-site visits Evaluation of Member satisfaction surveys Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 55 of 75 The BlueCard® Program Provider Operating Guide • • January 2015 Evaluation of concern/complaint/grievance reports Monitoring of closed PCP panels Specific deficiencies are addressed with a corrective action plan, and a follow-up activity is conducted to reassess compliance. Data is presented to the QM Committee and the governing body. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 56 of 75 The BlueCard® Program Provider Operating Guide January 2015 10.0 Member Grievances and Appeals/ Non-Contracted Provider Claims Appeals 10.1 Member Grievances A member or a member’s authorized representative may file a complaint. BCBSAZ Advantage accepts complaints both orally and in writing. The complaint must include a complete description of the issue including details such as name, date, and time of the event. All grievance request s are acknowledged in writing to the member. The Grievance and Appeals Department accepts all complaints from members or their authorized representatives either orally or in writing at: Blue Cross® Blue Shield® of Arizona Advantage Attention: Grievance and Appeals Department 13950 W. Meeker Blvd. Sun City West, AZ 853751800-446-8331 Toll-Free Phone 480-684-6034 Fax The Grievance and Appeals Department conducts an investigation concerning the member’s complaint to identify the grievance category. The complaint is processed under the appropriate procedure. BCBSAZ Advantage must address the complaint as quickly as the case requires based on the member’s health status, but no later than 30 calendar days after receiving the complaint. BCBSAZ Advantage may extend the timeframe by up to 14 calendar days if the member asks for the extension or if BCBSAZ Advantage justifies a need for additional information and the delay is in the member’s best interest. BCBSAZ Advantage accepts both oral and written grievance requests no later than 60 days after the event unless a good cause extension is requested. At that time, BCBSAZ Advantage reviews the circumstances surrounding the late filing to determine if there was good cause for missing the filing timeframe. If the member is filing an expedited grievance because BCBSAZ Advantage denied the member’s request for an expedited organization determination, expedited reconsideration, or extended a process timeframe up to 14 calendar days, BCBSAZ Advantage will process the grievance and give the member an answer within 24 hours. 10.2 Member Appeals Members have the right to file an appeal anytime they disagree with BCBSAZ Advantage concerning a part C or D pre-service denial or denial for a request for payment. For the purpose of an appeal, a member may file an appeal on their own behalf or they may assign someone to speak and act for them. This includes a provider that has waived any right to payment from the member. BCBSAZ Advantage will accept appeal requests from providers on the member’s behalf if: 1. The appeal request comes from the member’s primary care provider within the BCBSAZ Advantage network; OR 2. The appeal request comes from a contracted or non-contracted provider and the member’s records show that they have visited this provider at least once before. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 57 of 75 The BlueCard® Program Provider Operating Guide January 2015 A member has 60 days from the date on the Notice of Denial of Medical Coverage or Payment to file an appeal with BCBSAZ Advantage, unless a good cause extension is requested. At that time BCBSAZ Advantage will review the circumstances surrounding the late filing to determine if there was good cause for missing the filing timeframe. At any time, during the appeal process, the member has the right to withdraw their request. This must be done prior to forwarding a decision to deny to the Independent Review Entity for a second level appeal and must be received in writing. The member also has the opportunity to present evidence and allegations of fact or law related to the issues in dispute. BCBSAZ Advantage will take all information received into consideration prior to rendering a final decision. All appeal requests are reviewed by a physician with expertise in the field of medicine that is appropriate for the services requested. It may not always be possible to get physicians of the same specialty or sub-specialty to review the original denial. However, our physicians are diligent in gathering pertinent information during the review process. The reviewing physician will not have been part of the decision making during the initial request. BCBSAZ Advantage has 30 calendar days to process a request for an appeal for services that have not yet been provided and 60 calendar days to process a request for an appeal for reimbursement/payment for services that have already been provided. During this process BCBSAZ Advantage will make every effort to obtain all necessary medical records and other information prior to rendering a decision. The member is notified, in writing, prior to the end of the allowed timeframe, of the decision. If the member or a provider requests an expedited appeal for services not yet provided, BCBSAZ Advantage will make a decision within 72 hours of the request. The member is notified orally as to the final decision followed by a written notice within 3 calendar days of the oral notice. If the expedited appeal request does not meet criteria to be processed as expedited, it will be changed to the standard process. The member is notified in writing of this change and is notified of their right to file an expedited grievance if they disagree with the decision. BCBSAZ Advantage may extend a request for an appeal or expedited appeal up to 14 calendar days if the member requests an extension or if BCBSAZ Advantage justifies a need for additional information and how the extension is in the best interest of the member. The member is notified in writing of this extension and is notified of their right to file an expedited grievance if they disagree with the decision. Any time BCBSAZ Advantage issues a decision to deny or misses the review timeframes for appeals, the entire case record is forwarded to the Independent Review Entity (IRE) for a second level appeal. The member will receive a Notice of Appeal Status to inform them of this. The IRE for BCBSAZ Advantage is MAXIMUS Federal Services. 10.3 Non-Contracted Provider Claims Appeals Providers contracted with BCBSAZ Advantage do not have appeal rights per CMS rules and regulations. A non-contracted service provider has 120 days (plus 5 days for mail) from the date of receipt of the notice of the initial claim determination to file a claim dispute, unless a request for a good cause extension is requested. If a claims appeal is filed after the 125 days and the provider includes reasons for the late filing, BCBSAZ Advantage reviews the appeal for good cause. If good cause criteria is met, BCBSAZ Advantage accepts the late filing and processes the request. A request for redetermination must be filed with BCBSAZ Advantage in writing containing the following information. The member’s name. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 58 of 75 The BlueCard® Program Provider Operating Guide January 2015 The member’s ID number. BCBSAZ Advantage claim (HIC) number. The specific service(s) and item(s) for which the appeal is requested and the specific date(s) of service. The name and signature of the party or representative of the party filing the request. A copy of the original claim. A copy of the Explanation of Benefits (EOB) with the remittance advice. Medical records that support the charges billed. These requests are to be sent to BCBSAZ Advantage by mail or by fax to: Blue Cross® Blue Shield® of Arizona Advantage ATTN: Grievance and Appeals Department 13950 W. Meeker Blvd. Sun City West, AZ 85375 FAX: 480-684-6034 Once a non-contracted provider claims appeal is received by BCBSAZ Advantage, BCBSAZ Advantage has 60 days to complete and mail a redetermination notice to the requesting provider. The BCBSAZ Advantage claim appeal analyst performing the appeal review is not the same person who made the initial decision to deny payment. During the claim appeal review process BCBSAZ Advantage accepts and considers any additional documentation submitted after the dispute is received. However, any additional documentation submitted after the initial request is received will automatically extend the 60 day decision making timeframe up to 14 additional days. If BCBSAZ Advantage rules in favor of the disputing provider, payment is issued within 30 days of the decision. BCBSAZ Advantage reserves the right to dismiss a claim appeal request for any of the following reasons: 1. 2. 3. 4. 5. 6. 7. 8. The party filing the appeal withdraws the request prior to the decision. The party requesting an appeal is not a proper party. The party requesting an appeal does not otherwise have a right to an appeal. The provider failed to file the appeal within the 125 day timeframe and good cause was not established. The appointment of representative information is missing or defective. The party fails to make a valid request. The member expires while the request is pending and the surviving spouse or estate has no remaining financial interest in the case; no other individual with financial interest in the case wishes to pursue the appeal; OR No other party filed a valid and timely appeal request. Once BCBSAZ Advantage issues the notice of dismissal, the entire appeal case is forwarded the Qualified Independent Contractor (QIC), within 60 days of the decision, to determine if the dismissal is correct. MAXIMUS Federal Services is the Part A Qualified Independent Contractor (QIC). C2C Solution is the Part B and durable medical equipment (DME) QIC. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 59 of 75 The BlueCard® Program Provider Operating Guide January 2015 11.0 Pharmacy Benefits 11.1 Pharmacy Benefits and Formulary Overview The BCBSAZ Advantage plan provides covered drugs for all BCBSAZ Advantage members. Covered drugs are listed in the BCBSAZ Advantage formulary, a list of covered drugs selected by BCBSAZ Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. BCBSAZ Advantage will generally cover the drugs listed in in the formulary as long as the drug is medically necessary; the prescription is filled at a BCBSAZ Advantage network pharmacy and other plan rules are followed. Generally, if a member is taking a drug on the BCBSAZ Advantage formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect Members who are currently taking the drug. It will remain available at the same cost-sharing for those Members taking it for the remainder of the benefit coverage year. We feel it is important that the Member has continued access for the remainder of the benefit coverage year to the formulary drugs that were available when you chose BCBSAZ Advantage, except for cases in which you can save additional money or we can ensure your safety. If a drug is removed from our formulary, or prior authorization is added to the drug, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we will notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the Member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to Members who take the drug. You may access the BCBSAZ Advantage formulary at: www.azbluemedicare.com. Updated information about the drugs covered by BCBSAZ Advantage can be found at the w ebsite address listed above. In the event that BCBSAZ Advantage‘s formulary changes mid-year, affected Members will be notified 60 days prior to the change being effective. The BCBSAZ Formulary lists drugs in two different ways: 1. By Medical Condition – For example: drugs used to treat a heart condition are listed under the category: Cardiac Drugs. 2. By Alphabetical Listing – Both brand name drugs and generic drugs are listed in the Index with a corresponding page number where it may be found. BCBSAZ Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient(s) as the brand name drug. Generally, generic drugs cost less than brand name drugs. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 60 of 75 The BlueCard® Program Provider Operating Guide January 2015 Some drugs may have additional requirements or limits on coverage. Refer to the BCBSAZ Formulary to verify any restrictions. Over the Counter (OTC) drugs are non-prescription drugs that are not covered under the Pharmacy benefit plan. 11.2 Formulary Exceptions Members may ask BCBSAZ Advantage to make an exception to our coverage rules. There are several types of exceptions that the member can ask us to make. • • • The member can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and the Member would not be able to ask us to provide the drug at a lower cost-sharing level. The member can ask us to cover a formulary drug at a lower cost-sharing level if this drug is covered in Tier 4. The Member can ask us to cover it at the cost-sharing amount that applies to drugs in Tier 3 instead. This would lower the amount the member must pay for the drug. The member can ask us to waive coverage restrictions or limits on the drug. For example, for certain drugs, BCBSAZ Advantage limits the amount of the drug that we will cover. If the member’s drug has a quantity limit, they can ask us to waive the limit and cover a grea ter amount. Generally, BCBSAZ Advantage will only approve a member’s request for an exception if the alternative Drug is included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating the member’s condition and/or would cause the member to have adverse medical effects. The Member should contact us to ask us for an initial coverage decision for a formulary, tier or utilization restriction exception. When the member requests a formulary, tier or utilization restriction exception the provider should submit a statement supporting this request. Providers may request a Formulary Exception on behalf of the member. Generally, we must make our decision within 72 hours of getting receiving the prescriber’s supporting statement. The member can request an expedited (fast) exception if the member or the prescribing doctor believe that the member’s health could be seriously harmed by waiting up to 72 hours for a decision. If the request to expedite is granted, BCBSAZ Advantage must give the member a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. To request an exception to the BCBSAZ formulary, complete the Request for Medicare Prescription coverage Determination form. You must include supporting medical information. The request should be faxed to the BCBSAZ Advantage pharmacy benefit manager at: MedImpact (858) 790-7100. Request for Medicare Prescription Coverage Determination forms are located on at the end of this section or by going to www.azbluemedicare.com. 11.3 Quality Assurance and Drug Management Programs Physician/Office Satisfaction Surveys are designed to assess what services are important and to determine the level of satisfaction. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 61 of 75 The BlueCard® Program Provider Operating Guide 11.3.1 January 2015 Utilization Management For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that members use these drugs in a safe and effective way and help control drug plan costs. A team of doctors and/or pharmacists developed these requirements and limits for BCBSAZ Advantage to help provide quality coverage to our members. Please consult the BCBSAZ formulary for more information about these requirements and limits. The formulary can be found at www.azbluemedicare.com. The requirements for coverage or limits on certain drugs are listed below: Prior Authorization: In some cases, BCBSAZ Advantage require the physician to first try certain drugs to treat medical conditions before covering another drug for that condition. For example, if Drug A and Drub B both treat the medical condition BCBSAZ Advantage may not cover Drug B unless Drug A is tried first. If Drug A does not work for the member, BCBSAZ Advantage would then cover Drug B. Quantity Limits: BCBSAZ Advantage may limit the amount of the drug that is covered per prescription or for a defined period of time. Example: BCBSAZ Advantage will provide up to nine tablets per 28 days for Drug A. Step Therapy: In some cases, BCBSAZ Advantage requires the provider to first try one drug to treat the medical condition before we will cover another drug for that condition. Ex ample: if Drug A and Drug B both treat the medical condition, BCBSAZ Advantage may require the provider to prescribe Drug A first. If Drug A does not work, then we will cover Drug B. Generic Substitution: When there is a generic version of a brand-name drug available, network pharmacies may recommend or provide the generic version, unless the provider indicates the brand-name drug must be taken and BCBSAZ Advantage has approved the request. You can find out if drugs are subject to these additional requirements or limits by looking in the formulary. If the drug is subject to one of these additional restrictions or limits and the Member is not able to meet the additional restriction or limit for medical necessity reasons, the Provider or the Member may request an exception (a type of coverage determination). See Formulary Exceptions. 11.3.2 Drug Utilization Review BCBSAZ Advantage conducts drug utilization reviews for all members to ensure that they are receiving safe and appropriate care. These reviews are important for members who have more than one doctor prescribing medications. BCBSAZ Advantage conducts drug utilization reviews each time a prescription is filled and on a regular basis by reviewing records. During these reviews, identification of medication problems are identifies, such as: • • • • • • Possible medication errors Duplicate drugs that are unnecessary because the Member is taking another drug to treat the same medical condition Drugs that are inappropriate because of the age of the Member or their gender Possible harmful interactions between drugs Drug allergies Drug dosage errors. If a medication problem is identified during the drug utilization review, we will work with the provider to correct the problem. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 62 of 75 The BlueCard® Program Provider Operating Guide 11.3.3 January 2015 Medication Therapy Management Members that meet the conditions listed below are encouraged to participate in the Blue Cross Blue Shield of Arizona Advantage medication Therapy Management Program. The member will meet personally or on the telephone with a clinical pharmacist, who will review the medications the member has been prescribed, answer any questions that they may have and make suggestions on how to improve their drug therapy and/or reduce its cost. The pharmacist will communicate any suggestions that you have agreed to with the member’s doctor. The member’s doctor will make the decision on whether or not to make any changes to the member’s medications. If the member meets the criteria, a staff member from BCBSAZ Advantage Pharmacy will contact the member to set up an appointment at once of the BCBSAZ Advantage offices or on the telephone. Or the member may call BCBSAZ Advantage Pharmacy Services at: 480-684-7747. This program is voluntary, the member may decline to participate, however; BCBSAZ Advantage encourages members to participate. Members must have at least three of the conditions listed below: Multiple Chronic Diseases – minimum number of chronic diseases: 3 • • • • • • • Bone Disease-Arthritis-Osteoporosis Chronic Heart Failure (CHF) Diabetes Dyslipidemia (high Cholesterol) Hypertension (high blood pressure) Mental Health – Depression Respiratory Disease – Chronic Obstructive Pulmonary Disease Members must be taking at least seven prescription medications on a regular basis • • Multiple Covered Part D drugs Minimum number of Covered Part D Drugs – 7 The total cost of the prescription drugs (Chronic/maintenance drugs apply) of more than $3,017 in three months. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Medication Therapy Management (MTM) PERSONAL MEDICATION LIST This medication list is intended to help members keep track of their medications and how to use them the right way. Use blank rows to add new medications. Then fill in the dates the member started using them. Cross out medications when the member no longer uses them. Then write the date and why the medication was stopped. Update this list every member visit Keep this list up-to-date with: Part D prescription medications Part D over the counter drugs Part D herbals Part D vitamins Part D minerals If the member goes to the hospital or emergency room, encourage the member to take this list with them. Encourage the member to share this with their family or caregivers. DATE PREPARED: Allergies or side effects: PERSONAL MEDICATION LIST FOR: (Member’s Name) Medication: How I use it: Why I use it: Prescriber: Why I stopped using it: Date I stopped using it: Medication: How I use it: Why I use it: Prescriber: Why I stopped using it: Date I stopped using it: Medication: How I use it: Why I use it: Prescriber: Why I stopped using it: Date I stopped using it: Medication: How I use it: Why I use it: Prescriber: Why I stopped using it: Date I stopped using it: Medication: How I use it: Why I use it: Prescriber: Why I stopped using it: Date I stopped using it: Medication: How I use it: Why I use it: Prescriber: Why I stopped using it: Date I stopped using it: Medication: How I use it: Why I use it: Prescriber: Why I stopped using it: Date I stopped using it: Medication: How I use it: Why I use it: Prescriber: Why I stopped using it: Date I stopped using it: Medication: How I use it: Why I use it: Prescriber: Why I stopped using it: Date I stopped using it: Instruct the Member to call the physician, pharmacist, or medication therapy management provider with any questions . 10680 Treena Street Suite 500 San Diego, CA 92131 Phone: (800) 788-2949 Fax: (858) 790-7100 Medicare Part D Coverage Determination Request Form This form cannot be used to request: Medicare non-covered drugs, including fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations). Plan Name: Patient Information Patient Name: Prescriber Information Prescriber Name: Member ID# DEA# Address: Address: City: State City: Home Phone: Zip: Office Phone# Sex (circle): M F DOB: State: Office Fax: New Prescription OR Date Therapy Initiated: Diagnosis and Medical DirectionsInformation for use: (Frequency & Strength): Expected Length of Therapy: Route of Administration Height/Weight: Prescriber’s Signature: Drug Allergies: MD Specialty Medication: Zip: Contact Person: Qty: Qty per month: Diagnosis: Date: Rationale for Exception Request or Prior Authorization □ Alternate drug(s) contraindicated or previously but with adverse outcomeREQUIRED (i.e., toxicity, allergy, or therapeutic FORM CANNOT BEtried, PROCESSED WITHOUT failure) EXPLANATION Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s); □ Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) is stable on current drug(s); high risk of significant adverse clinical outcome with medication change Specify below: Anticipated significant adverse clinical outcome □ Medical need for different dosage form and/or higher dosage Specify below: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason □ Prior Authorization: Prior Authorization guidelines or Step Requirements Exception Request (ME, FE, QE, CF, CE): Specify below: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome □ Medical Exception (ME) – Member would suffer adverse events if subject to the PA requirement □ Formulary Exception (FE) – Medication not on the plan’s list of covered drugs □ Quantity Exception (QE) – For a quantity different from the number of doses available under a dose restriction □ Compound Formulary Exception (CF) – Review for a nonformulary compound Request for Expedited Copay TierFOR Exception (CE) – Reduction in the member’s copay/cost sharing Other: _ _ _ □ EXPEDITED REVIEW [24 HOURS] □ REQUEST REQUEST FOR EXPEDITED REVIEW [24 HOURS] BOX AND SIGNING ABOVE, I CERTIFY THAT APPLYING THE 72 HOUR BY BYCHECKING CHECKINGTHIS THIS BOX AND SIGNING ABOVE, I CERTIFY THAT APPLYING THE 72 HOUR STANDARD REVIEW TIME FRAME MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR STANDARD REVIEW TIME FRAME MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE THE MEMBER’S ABILITYTO REGAIN MAXIMUMREGAIN FUNCTION MEMBER OR THE MEMBER’S ABILITYTO MAXIMUM FUNCTION Information is protected Health Information and subject to all privacy and security Informationononthis thisform form is protected Health Information and subject to all privacy andregulations security under regulations under HIPAA. Created: 07/08 Reviewed/ Revised: 11/2012 12/7/2012 3:14 PM HIPAA. Created: 07/08 12/7/2012 3:14 PM Review Reviewed/ Revised: 11/2012 D Explain below REQUIRED EXPLANATION: Page: 66 of 75 The BlueCard® Program Provider Operating Guide January 2015 11.4 Part D Prescription Drug Benefit Each individual enrolled in a BCBSAZ Advantage plan has Part D prescription drug coverage; however, the coverage is not the same for all plans. There are four different “stages”, which apply to all the plans. The drug costs depend on which “stage” the Member is in, as well as which BCBSAZ Advantage plan he or she is enrolled in. The following is a description of each drug coverage. STAGE 1: Yearly Deductible Stage Because BCBSAZ Advantage has no yearly deductible for any of our 3 plans, this stage does not apply to our Members. STAGE 2: Initial Coverage Stage The Member begins this stage when the first prescription of the year is filled. Each time the Member gets a prescription filled, the cost of the drug (this is the amount shared by both the Member and BCBSAZ Advantage is tracked by BCBSAZ Advantage., The Member stays in the Initial Coverage Stage – until the Member’s year-to-date (out of packet) drug costs reach the initial coverage dollar limit for the benefit plan. This amount differs, depending on which plan the member is enrolled. Once the member reaches this limit, the member moves into Stage 3. STAGE 3: Coverage Gap Stage Once the member is in the Coverage Gap Stage, the Member will pay 47.5% of the price (plus the dispensing fee) for brand name drugs and 72% of the price for generic drugs. The member stays in this stage until the year-to-date “true out-of-pocket costs” (the member’s payments only) towards your Part D covered drugs, reach a total of $4550. Once the member has reached this amount, the Member moves into Stage 4. STAGE 4: Catastrophic Coverage Stage During this stage, BCBSAZ Advantage will pay most of the cost of the Member’s drugs for the rest of the calendar year (through December 31,), and the member’s share of cost will be the greater of: $2.55 for generic drugs OR 5% of the cost of the drug $6.35 for all other drugs OR 5% of the cost of the drug Blue Cross Blue Shield of Arizona Advantage pays the rest of the cost. 11.4.1 Part D Prescription Drug Benefit Summary by Benefit Plan Part D Prescription Drug Benefit Summaries by Benefit Plan can be found at: www.azbluemedicare.com. 11.4.2 Mail Order Drug Program Postal Prescription Services (PPS) is the provider of mail order drugs to BCBSAZ Advantage members. For a member to obtain drugs through the PPS mail order pharmacy, the member must first register with PPS Mail Order Pharmacy. To register, the Member must provide the address to which the Member want the drugs delivered and billing information to PPS Mail Order Pharmacy. Members can register on-line at www.ppsrx.com or complete a mail order form with the member’s paper prescriptions. To order refills, if applicable, the Member may order a refill by phone by calling PPS at: (800) 5526694 or by going to www.ppsrx.com Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 67 of 75 The BlueCard® Program Provider Operating Guide January 2015 To order a new prescription(s) the Member must complete the Postal Prescription Service Mail Service Order Form and mail it to PPS. Complete one form per person, include payment (check, money order or credit card information) with the completed order form, include a prescription for a 90 day supply, plus refills for up to one year. The order form can be found at: https://www.ppsrx.com/ppsrx/display_new_refill.do PPS – Postal Prescription Service P.O. Box 2718 Portland, OR 97208-2718 Contact Postal Prescription Service Member Services with any questions. They can be reached at 1-800-552-6694 24 hours a day, 7 days a week. 1 Postal Prescription Services (Inc.) is an independent company contracted with BCBSAZ Advantage to provide mail order pharmacy services. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 68 of 75 The BlueCard® Program Provider Operating Guide January 2015 12.0 Compliance Program 12.1 Compliance Program Overview BCBSAZ Advantage is committed to the very highest standards of ethics and integrity to ensure compliance with all applicable Federal and State standards including the False Claims Act, anti kickback statute and standards issued by the Centers for Medicare & Medicaid Services (CMS). BCBSAZ Advantage has created the BCBSAZ Advantage Compliance Program to ensure compliance with all applicable Federal and State standards including the requirements of Medicare Parts C and D. The BCBSAZ Advantage Compliance Program is designed to set standards, provide information, and confirm performance. The BCBSAZ Advantage Compliance Program was developed utilizing Federal and State laws, rules and regulations along with performance standards and reporting requirements appl icable to BCBSAZ Advantage’s Medicare Advantage contract with CMS. Implementation of the BCBSAZ Advantage Compliance Program enables BCBSAZ Advantage to monitor consistent compliance with these regulations, standards and requirements. The BCBSAZ Advantage Compliance Program utilizes a Code of Conduct, Conflict of Interest statement and other basic components as its foundation. 12.2 Retention of Records and Information Systems BCBSAZ Advantage has established policies and procedures regarding the creation, distribution, retention, storage, and retrieval and destruction of documents. BCBSAZ Advantage and contracted entities are required to maintain books, records, documents and other evidence of accounting procedures and practices for a period of 10 years following the end of the CMS contract year as required by Federal statute. All State and Federal regulations related to privacy, standardization and security are to be followed. 12.3 Fraud, Waste and Abuse (FWA) BCBSAZ Advantage has several internal systems in place to prevent, detect and investigate FWA. Staff training is conducted at the time of employment and annually thereafter on techniques to identify potential FWA. This training includes all employees including Board members. First tier, downstream and related entities (FDRs) are responsible for training their own staff and management, An allegation of fraud, waste or abuse may be reported from a variety of sources including staff, members, first-tier, downstream and related entities and government agencies. The Pharmacy Benefit Manager is required to report all suspected cases to BCBSAZ Advantage for investigation. All allegations are documented and investigated by the Compliance Officer in accordance with BCBSAZ Advantage policies and procedures. If substantiated, appropriate action is taken that may include contract amendment, re-education, policy and procedure revision, contract termination and, ultimately, reporting to State and Federal authorities as required by law . The Utilization Management and the Pharmacy and Therapeutics Committees review over and underutilization reports. Reports are compared to professionally recognized utilization standards. If indicated, the identifying committee initiates additional investigation and/or correcti ve action to identify and correct FWA. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 69 of 75 The BlueCard® Program Provider Operating Guide January 2015 The Pharmacy Benefit Manager (PBM) provides reports to the Compliance Officer and to the Pharmacy Department. These reports identify unusual and/or excessive pharmacy claims activity from analyses of Members, prescribers and pharmacies utilization data. Should an investigation uncover intentional and systematic fraud, abuse, and/or waste of the BCBSAZ Advantage system or be in violation of federal or state statutes, corrective action will be taken and appropriate documentation is forwarded to the MEDIC and/or appropriate government agency 12.4 Reporting to Government Authorities The Compliance Officer, following a thorough investigation of each reported incident, ensures that appropriate administrators/departments/committees are notified of the findings when illegal activities, non-compliance, or FWA violations are found and also provides a comprehensive report to the MEDIC, as well as State and Federal government authorities as required by law and/or policy 12.5 CMS Required and Mandatory Training CMS requires BCBSAZ Advantage to communicate with and to provide training for employees/contractors including first tier, downstream, and related entities. For Participating Providers, an authorized representative having responsibility directly or indirectly for all employees, board members, officers, subcontractors and contracted personnel affiliate d with the organization, must complete the required training. In addition, Providers must maintain records that show they have met these requirements. These records must be maintained for 11 years. The provider may be called upon by BCBSAZ Advantage or CMS to provide such documentation upon request, including: • Internal emails or memos to employees/contractors about the BCBSAZ Advantage Code of Conduct and Conflict of Interest policy • Descriptions of the methods used to implement compliance and Fraud, Waste and Abuse training that includes training logs and copies of training materials • A description of the method used for sanction checking and a copy of a sanction check report for an employee/contractor. 12.5.1 Code of conduct/Conflict of Interest Policy Awareness First Tier, Downstream and Related Entities (FDRs) must provide a Code of Conduct (including the Conflict of Interest) Policy to their employees and any subcontractors with 90 days of entering into a contractual agreement with BCBSAZ Advantage. You may access the BCBSAZ Advantage Code of Conduct on the Provider tab on the BCBSAZ Advantage Website at www.azbluemedicalre.com/providers/ 12.5.2 FWA and Compliance Training FDRs must provide and complete compliance program training and fraud, waste, and abuse training to any employees or subcontractors with 90 days of entering into a contractual agreement with BCBSAZ Advantage and annually, thereafter. Training materials can be located on the BCBSAZ Advantage Website at https://www.azbluemedicare.com/providers or another source as Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 70 of 75 The BlueCard® Program Provider Operating Guide January 2015 long as CMS requirements are met. CMS provides training at https://www.cms.gov under the MLN Provider compliance section. 12.5.3 Exclusion/Sanction/Debarment Checks FDRs must also review federal exclusion lists (HHS_OIG and GSA) at the time of hire or contracting with current employees or contractors to ensure that staff and contractors are not excluded from participating in Federal health care programs. For information or access to the exclusion databases, go to http://oig.hhs.gov/exclusions/index.asp 12.6 Health Insurance Portability and Accountability Act Contracted BCBSAZ Advantage Physicians are expected to comply with all provisions of Health Insurance Portability and Accountability Act of 1997 as amended (HIPAA) Privacy Standards Transaction and Code Set Standards, and Security Standards. HIPAA impacts what is referred to as covered entities; specifically, providers, health plans and health care clearinghouses that transmit health care information electronically. HIPAA has established national standards addressing the security and privacy of health information, as well as standards for electronic health care transactions and national identifiers. All Providers are required to adhere to HIPAA regulations. For more information about these standards, please visit http://www.hhs.gov/ocr/hipaa/ 12.7 Advance Directives Providers are required to comply with federal and state law regarding advance directives for members. The advance directive must be displayed in the member’s medical record. Requirements include: Providing written information to members regarding each individual’s rights under state law to make decisions regarding medical care and any provider written policies concerning advance directives (including any conscientious objections). Documenting in the member’s medical record whether or not the adult Member has been provided the information and whether an advance directive has been executed. Not discriminating against a member because of his or her decision to execute or not execute an advance directive and not making it a condition for the provision of care. Life Care Planning Packet (Advance Directives) documents are created by the office of Arizona Attorney General. This packet is available to assist Arizona residents to take charge of their future healthcare decisions. The most up to date forms are downloadable via the website: http://www.azag.gov/life_care/LCP_Packet.pdf. 12.8 Medicare Advantage Compliance Program Terms The regulations governing the Medicare Advantage program set forth required terms for both Medicare Advantage plans and contracted providers. In order to make contracted providers aware of such terms, the Center for Medicare & Medicaid Services (“CMS”) has created a contracting checklist for Medicare Advantage plans to follow in developing providers’ contracts and related policies and procedures. That checklist is included in Chapter 11 of the CMS Medicare Managed Care Manual (Section 100.4), a copy of which is available on the CMS website. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 71 of 75 The BlueCard® Program Provider Operating Guide January 2015 In certain cases, regulatory language must be included in the actual contractual document governing the relationship between the Medicare Advantage plan and the provider. In other cases, CMS allows a Medicare Advantage plan to include required terms in its policies and procedures that are made available to contracted providers. The provisions that follow are a complete listing of the required Medicare Advantage compliance terms that may be included in policies and procedures. Provider is required to comply with all such provisions, including, but not limited to, taking all necessary actions as may be specifically noted or such actions as may be required and requested by BCBSAZ Advantage in order for BCBSAZ Advantage to meet its obligations as a Medicare Advantage plan. All requirements set forth in this document shall apply to all Medicare Advantage plans, including BCBSAZ Advantage. 1. Provider will safeguard the privacy of any information that identifies a particular member and will, and acknowledges that BCBSAZ Advantage has procedures to maintain records in an accurate and timely manner. Pursuant to 42 C.F.R. §422.118, or its successor, the following shall apply: (a) BCBSAZ Advantage must establish and maintain procedures to, and Provider must, abide by all Federal and State laws regarding confidentiality and disclosure of medical records, or other health and enrollment information; (b) BCBSAZ Advantage and Provider must safeguard the privacy of any information that identifies a particular member; (c) BCBSAZ Advantage must establish and maintain procedures, and Provider must comply with the procedures that specify, (i) for what purposes the information will be used within the organization and (ii) to whom and for what purposes it will disclose the information outside the system; (d) BCBSAZ Advantage must establish and maintain procedures to, and Provider must, ensure that medical information is released only in accordance with Federal or State law, or pursuant to court orders or subpoenas; (e) BCBSAZ Advantage must establish and maintain procedures to, and Provider must, maintain records and information in an accurate and timely manner; and (f) BCBSAZ Advantage must establish and maintain procedures to, and provider must, ensure timely access by Medicare Advantage members to the records and information that pertain to them. (Required by 42 C.F.R. §422.118 or its successor). 2. BCBSAZ Advantage may offer benefits in a continuation area for those members who move permanently “out of area.” (Required by 42 C.F.R. §422.54(b) or its successor). 3. Provider will not deny, limit or condition the furnishing of a service to a member, and BCBSAZ Advantage will not deny, limit or condition the coverage or furnishing of benefits to an individual eligible to enroll in BCBSAZ Advantage’s Medicare Advantage plan(s), on the basis of any factor that is related to health status, including, but not limited to, the following: (a) medical condition, including mental as well as physical illness; (b) claims experience; (c) receipt of health care; (d) medical history; (e) genetic information; (f) evidence of insurability, including conditions arising out of acts of domestic violence; and (d) disability. (Required by 42 C.F.R. §422.110(a) or its successor). 4. BCBSAZ Advantage will make timely and reasonable payment to or on behalf of the member for emergency and urgently needed services obtained by a member from a non-contracted provider or supplier as provided in 42 C.F.R. §422.100(b)(1)(ii) or its successor. (Required by 42 C.F.R. §422.100(b)(1)(ii) or its successor). 5. BCBSAZ Advantage will make timely and reasonable payment for renal dialysis provided by a non-contracted provider while a member is temporarily outside BCBSAZ Advantage’s service area. (Required by 42 C.F.R. §422.100(b)(1)(iv) or its successor). 6. BCBSAZ Advantage provides Members with direct access (through self-referral) to mammography screening and influenza vaccine. (Required by 42 C.F.R. §422.100(g)(1) or its successor). Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 72 of 75 The BlueCard® Program Provider Operating Guide January 2015 7. BCBSAZ Advantage will not impose, and Provider will not collect any, cost-sharing on members for influenza and pneumococcal vaccines. (Required by 42 C.F.R. §422.100(g)(2) or its successor). 8. BCBSAZ Advantage does and will maintain and monitor a network of appropriate providers that is supported by written agreements and is sufficient to provide adequate access to meet the needs of the member population served. (42 C.F.R. §422.112(a)(1) or its successor). 9. BCBSAZ Advantage gives members who are women direct access to a women’s health specialist within its provider network for routine and preventive services provided as basic benefits. (Required by 42 C.F.R. §422.112(a)(3) or its successor). 10. BCBSAZ Advantage will ensure that (a) the hours of operation of its contracted providers are convenient to the members served and do not discriminate against Medicare Members; and (b) plan services are available 24 hours a day, 7 days a week, when medically necessary. (Required by 42 C.F.R. §422.112(a)(7) or its successor). As applicable, Provider will maintain business hours and/or ensure Provider’s services are available in accordance with the preceding requirements. 11. BCBSAZ Advantage will adhere to the CMS marketing provisions contained in 42 C.F.R. §422.80(a), (b) and (c), or its/their successor(s). 12. BCBSAZ Advantage will ensure that services are provided in a culturally competent manner to all members including those with limited English proficiency or reading skills and diverse cultural and ethnic backgrounds. (Required by 42 C.F.R. §422.112(a)(8) or its successor). 13. BCBSAZ Advantage will ensure continuity of care and integration of services through arrangements to include procedures to ensure that members are informed of specific health care needs that require follow-up and receive, as appropriate, training in self-care and other measures that members may take to promote their own health. (Required by 42 C.F.R. §422.112(b)(5) or its successor). As applicable, Provider will comply with these procedures. 14. BCBSAZ Advantage has written policies regarding the implementation of advance directive rights, including, but not limited to, a statement that providers shall document in a prominent place in the applicable Member’s medical record if the Member has executed an advance directive. (Required by 42 C.F.R. §422.128(b)(1)(ii)(E) or its successor). Provider will comply, as applicable, with that policy. 15. BCBSAZ Advantage’s contract with CMS will contain a provision that it will provide all benefits covered by Medicare, and Provider must render services, in a manner consistent with professionally recognized standards of health care. (Required by 42 C.F.R. §422.504(a)(3)(iii) or its successor). 16. BCBSAZ Advantage will provide, and Provider shall comply with all, policies and procedur es and contractual requirements providing for continuation of member health care benefits (a) for all members, for the duration of the contract period for which CMS payments have been made; and (b) for members who are hospitalized on the date BCBSAZ Advantage terminates, or in the event of insolvency, through discharge. Such requirements may be met in any manner as described in 42 C.F.R. §422.504(g)(3) or its successor. (Required by 42 C.F.R. §422.504(g)(2)(i) and (ii), and §422.504(g)(3) or its/their successor(s)). 17. All provider payment and incentive arrangements must be specified in the contractual arrangement between BCBSAZ Advantage and Provider. (Required by 42 C.F.R. §422.208 or its successor). 18. The payments that Provider receives from BCBSAZ Advantage for covered services rendered to members enrolled in a Medicare Advantage are, in whole or part, from federal Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 73 of 75 The BlueCard® Program Provider Operating Guide January 2015 funds and, and therefore, Provider and BCBSAZ Advantage are subject to certain laws as applicable to individuals and entities receiving federal funds. (Required by 42 C.F.R. §422.504(h) or its successor). 19. BCBSAZ Advantage is required to disclose information to members in the manner and the form prescribed by CMS as required under 42 C.F.R. §422.111. (Required by 42 C.F.R. §422.504(a)(4) or its successor). 20. BCBSAZ Advantage is required to disclose all information that is necessary for CMS to administer and evaluate BCBSAZ Advantage’s Medicare Advantage program(s) and to simultaneously establish and facilitate a process for current and prospective members to exercise choice in obtaining Medicare services. (42 C.F.R. §422.64(a) and §422.504(f)(2) or its/their successor(s)). Such information includes, but is not limited to, plan quality and performance indicators for the benefits under BCBSAZ Advantage’s Medicare Advantage program(s) including (a) disenrollment rates for members electing to receive benefits under such program for the previous two years, 42 C.F.R. §422.504(f)(2)(iv)(A) or its successor; (b) information on member satisfaction, 42 C.F.R. §422.504(f)(2)(iv)(B) or its successor; and (c) information on health outcomes, 42 C.F.R. §422.504(f)(2)(iv)(C) or its successor. As required and/or requested, Provider will cooperate with BCBSAZ Advantage and CMS in providing any of the preceding information that is under its control and/or in its possession. 21. BCBSAZ Advantage must make a good faith effort to provide notice of termination of a contracted Provider at least 30 calendar days before the termination of the effective date to all members who are patients seen on a regular basis by the applicable provider whose contract is terminating (which in the case of a primary care provider, means all members who are patients of such provider), irrespective of whether the termination was for cause or without cause. (Required by 42 C.F.R. §422.111(e) or its successor). 22. BCBSAZ Advantage must comply with reporting requirements in 42 C.F.R. §310(d) (3)-(4) & (e), or its/their successors, for submitting risk adjustment data; and reporting requirements in 422.516 42 C.F.R. §422.516, or its successor, and 42 C.F.R. §422.504(l)(2) & (l)(3), or its/their successor(s), for submitting and certifying data to CMS. Provider will certify the accuracy, completeness and truthfulness of all data that BCBSAZ Advantage is obligated to submit to CMS. (Required by 42 C.F.R. §422.504(a)(8), and §422.504(l)(2) & (l)(3) or its/their successor(s)). As required and/or requested, Provider will further cooperate with BCBSAZ Advantage and CMS in providing any of the preceding information that is under its control and/or in its possession. BCBSAZ Advantage shall maintain such records and any related contracts for ten (10) years from the final date of the final contract period for BCBSAZ Advantage contract with CMS or from the date of completion of any audit, whichever is later. HHS, the Comptroller General/GAO, CMS, or their designees the right to audit, evaluate, and inspect any pertinent information for any particular contract period, including, but not limited to, any books, contracts, computer or other electronic systems (including medical records and documentation of Provider, Downstream, and Related Entities to Plan) through ten (10) years from the final date of the final contract period of Plan MA Contract or from the date of completion of any audit, whichever is later. (Required by 42 C.F.R. §422.504(d)-(e), or its/their successor). 23. BCBSAZ Advantage must establish a formal mechanism to consult with the physicians who have agreed to provide services under BCBSAZ Advantage’s Medicare Advantage program(s), regarding BCBSAZ Advantage’s medical policy, quality assurance programs and medical management procedures and ensure that the following standards are met: (a) practice guidelines and utilization management guidelines are – (i) based on reasonable medical evidence or a consensus of health care professionals in the particular field; (ii) consider the needs of the enrolled population; (iii) are developed in consultation with contracted physicians; and (iv) are reviewed and updated periodically; (b) decisions with respect to utilization management are communicated to providers and, as appropriate, to members; and (c) decisions with respect to utilization management, member education, coverage of services, and other areas to which guidelines apply are consistent with such Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 74 of 75 The BlueCard® Program Provider Operating Guide January 2015 guidelines. (Required by 42 C.F.R. §422.202(b) or its successor). In addition, BCBSAZ Advantage must operate a quality assurance and performance improvement program and have an agreement for external quality review as required by 42 C.F.R. Subpart D or its successor. (Required by 42 C.F.R. §504(a)(5) or its successor). Provider shall cooperate with all such medical policy, medical management procedures and quality assurance and performance improvement programs. 24. BCBSAZ Advantage will give a physician written notice of the following when and if BCBSAZ Advantage suspends or terminates an agreement under which the physician provides services to members. The written notice must include the following: (a) the reasons for the action, including, if relevant, the standards and profiling data used to evaluate the physicians and numbers and mix of physicians needed to maintain an adequate network; and (b) the affected physician’s right to appeal the action and the process and timing for reque sting a hearing. (Required by 42 C.F.R. §422.202(d)(1) or its successor). 25. Any without cause termination by BCBSAZ Advantage or Provider requires at least sixty (60) days prior written notice. (Required by 42 C.F.R. §422.202(d)(4) or its successor). 26. BCBSAZ Advantage and Provider must comply with Federal laws and regulations designed to ameliorate fraud, waste, and abuse, including, but not limited to, applicable provisions of Federal criminal law; the False Claims Act (31 U.S.C. §3729 et. seq.); and the anti-kickback statute (42 U.S.C. §1320a-7b(b)). (Required by 42 C.F.R. §422.504(h)(1) or its successor). 27. BCBSAZ Advantage and Provider may not employ or contract with an individual (which in the case of BCBSAZ Advantage includes, as applicable, Provider) who is excluded from participation in Medicare under section 1128 or 1128A of the Social Security Act, or with an entity (which in the case of BCBSAZ Advantage includes, as applicable, Provider) that employs or contracts with such an individual, for the provision of any of the following: (a) health care; (b) utilization review; (c) medical social work; and/or (d) administrative services. (Required by 42 C.F.R. §422.752(a)(8) or its successor). 28. BCBSAZ Advantage has established and will maintain (a) a grievance procedure as described in 42 C.F.R. §422.564, or its successor, for addressing issues that do involved organization determinations; (b) a procedure for making timely organization determinations; and (c) appeal procedures that meet the requirements of this subpart for issues that involve organization determinations. BCBSAZ Advantage will ensure that all members receive notification about the (a) grievance and appeal procedures that are available to them; and (b) complaint process available to the member under the QIO process as set forth under 1154(a)(14) of the Social Security Act. (Required by 42 C.F.R. §422.562(a) or its successor). Provider will comply with Medicare requirements regarding Member grievances, appeals, and complaints and will cooperate with BCBSAZ Advantage in meeting its obligations to include, but not be limited to, the gathering and forwarding of information in a timely manner as well as compliance and adherence to any decisions rendered. Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage Page: 75 of 75 The BlueCard® Program Provider Operating Guide January 2015 13.0 Dental Program 13.1 Dental Overview All BCBSAZ Advantage Members have non-routine dental care and oral surgery benefit coverage. These non-routine dental benefits are limited to: • • • • Surgery of the jaw or related structures, Setting fractures of the jaw or facial bones, Extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or Services that would be covered when provided by a physician Providers of these services are included in the BCBSAZ Advantage Provider Network. Dentemax is an independent company contracted with BCBSAZ Advantage to provide Members access to its Medicare dental network. It is a dental network manager, not an insurance company. Dentemax does not pay claims or determine eligibility and benefits. Its network is leased by BCBSAZ Advantage for use in our dental benefit plans. Paper Claims are submitted to: BCBSAZ Advantage P.O. Box 16800 Mesa, AZ 85211 Electronic Claims Submissions: EDI Payer Id 77078 Benefit or Claims Questions: (623) 974-7430 (West Valley) (480) 684-6167 (East Valley) 1-800-446-8331 13.2 Blue Medicare Advantage Dental Benefits Under the BCBSAZ Advantage preventative dental care includes: • • • One (1) routine oral exam, One (1) Prophylaxis (cleaning), and; One (1) set of dental x-rays (Bite-wing). Questions? Contact (800) 446-8331 www.azbluemedicare.com © 2015 Blue Cross Blue Shield of Arizona Advantage
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