2014 BlueChoice HealthPlan PROVIDER OFFICE ADMINISTRATIVE MANUAL

Transcription

2014
BlueChoice HealthPlan
PROVIDER OFFICE
ADMINISTRATIVE MANUAL
Administrative Manual ǀ Table of Contents
Effective April 1, 2014
Revised August 22, 2014
Page 2
Table of Contents
SECTION 1 ................................................................................................................................................................................ 7
®
BLUECHOICE DIRECTORY................................................................................................................................................................... 8
BLUECHOICE WEBSITE ....................................................................................................................................................................... 9
CONTACTING BLUECHOICE ............................................................................................................................................................... 10
Voice Response Unit (VRU) .................................................................................................................................................... 10
STATchat ................................................................................................................................................................................ 11
SECTION 2 .............................................................................................................................................................................. 12
MEMBERSHIP AND BENEFIT PLANS..................................................................................................................................................... 13
PRIMARY CARE PHYSICIAN SELECTION................................................................................................................................................. 16
MEMBER PHARMACY BENEFITS ......................................................................................................................................................... 16
MAIL-SERVICE PHARMACY ............................................................................................................................................................... 17
BLUECARD (OUT-OF-STATE CARE) ..................................................................................................................................................... 17
HEALTH INSURANCE MARKETPLACE (EXCHANGE) PLANS ........................................................................................................................ 17
Benefit Overview ................................................................................................................................................................... 18
Other Information ................................................................................................................................................................. 18
SECTION 3 .............................................................................................................................................................................. 20
REFERRALS .................................................................................................................................................................................... 21
Initial Referrals to Specialists................................................................................................................................................. 21
Web Referrals ........................................................................................................................................................................ 21
Referral Partner Authorization Form ..................................................................................................................................... 21
Follow-Up Visits to Specialists ............................................................................................................................................... 22
Specialist Referral Extensions on the Web............................................................................................................................. 22
Expiration Dates for Referrals ............................................................................................................................................... 22
Specialist Referrals to Other Specialists................................................................................................................................. 23
Exceptions to the Standard Referral Process ......................................................................................................................... 23
Ask Health Care Services ....................................................................................................................................................... 24
SECTION 4 .............................................................................................................................................................................. 25
PRIOR AUTHORIZATION FOR SERVICES AND PROCEDURES ....................................................................................................................... 26
ONLINE PRIOR AUTHORIZATION ........................................................................................................................................................ 29
PHARMACY DRUG PRIOR AUTHORIZATION........................................................................................................................................... 31
STEP THERAPY................................................................................................................................................................................ 35
QUANTITY MANAGEMENT ................................................................................................................................................................ 35
SPECIALTY DRUG PRIOR AUTHORIZATION ............................................................................................................................................ 35
IN-OFFICE APPROVED LABS .............................................................................................................................................................. 36
LABCORP STAT LABS MENU.............................................................................................................................................................. 37
GENETIC LAB TESTING SERVICES ........................................................................................................................................................ 37
PATHOLOGY .................................................................................................................................................................................. 37
DME AND HOME CARE SERVICES ...................................................................................................................................................... 38
PULMONARY FUNCTION TESTS .......................................................................................................................................................... 38
DIABETES EDUCATION, INSULIN PUMPS, AND SUPPLIES .......................................................................................................................... 38
ASTHMA SUPPLIES .......................................................................................................................................................................... 40
MENTAL HEALTH AND SUBSTANCE ABUSE PRIOR AUTHORIZATION ........................................................................................................... 40
INPATIENT CARE PRIOR AUTHORIZATION ............................................................................................................................................. 40
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BLUECHOICE CARE CALLS .............................................................................................................................................................. 41
EMERGENCY MEDICAL CARE ............................................................................................................................................................. 41
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SECTION 5 .............................................................................................................................................................................. 44
OBSTETRICAL AUTHORIZATION PROCEDURES........................................................................................................................................ 45
Great Expectations Maternity ............................................................................................................................................... 45
Global Maternity Authorization ............................................................................................................................................ 45
Services Included in the Maternity Authorization ................................................................................................................. 45
Services Provided In the OB Office That Require Prior Authorization .................................................................................... 45
Services Provided Outside the OB Office That Require Prior Authorization .......................................................................... 46
Referrals to Specialists........................................................................................................................................................... 46
Laboratory ............................................................................................................................................................................. 46
Pathology .............................................................................................................................................................................. 47
Genetic Lab Testing Services ................................................................................................................................................. 47
Filing Claims for Maternity Services ...................................................................................................................................... 47
Special Considerations ........................................................................................................................................................... 48
SECTION 6 .............................................................................................................................................................................. 49
CLAIMS AND BILLING INFORMATION ................................................................................................................................................... 50
Filing Claims........................................................................................................................................................................... 50
Superbill ................................................................................................................................................................................. 51
My Remit Manager ............................................................................................................................................................... 51
Checking Claim Status ........................................................................................................................................................... 52
Assistant Surgeon and Co-Surgeon Claim Filing .................................................................................................................... 52
Bilateral Procedure Claim Filing ............................................................................................................................................ 52
Multiple Procedure Claim Filing ............................................................................................................................................ 52
Unlisted J-Code Claim Filing................................................................................................................................................... 52
ANESTHESIA CLAIM FILING ............................................................................................................................................................... 52
MEMBER RESPONSIBILITY GUIDELINES ................................................................................................................................................ 54
MEMBER FINANCIAL RESPONSIBILITY .................................................................................................................................................. 54
Copayments ........................................................................................................................................................................... 54
Coinsurance and Deductibles ................................................................................................................................................ 54
Balance Billing ....................................................................................................................................................................... 54
Coordination of Benefits (COB) .............................................................................................................................................. 55
MEDICARE AND COB ...................................................................................................................................................................... 56
SUBROGATION ............................................................................................................................................................................... 57
WORKERS’ COMPENSATION.............................................................................................................................................................. 57
SECTION 7 .............................................................................................................................................................................. 58
NETWORK STATUS AND CREDENTIALING ............................................................................................................................................. 59
Change In Status.................................................................................................................................................................... 59
Provider Credentialing ........................................................................................................................................................... 59
Credentialing Rights .............................................................................................................................................................. 60
SECTION 8 .............................................................................................................................................................................. 61
QUALITY IMPROVEMENT .................................................................................................................................................................. 62
Quality Improvement Program and Report ........................................................................................................................... 62
Primary Care Physician Office Access Goals .......................................................................................................................... 62
Improving Patient Satisfaction by Decreasing Wait Time ..................................................................................................... 62
Preventive Health Services .................................................................................................................................................... 63
Practice Guidelines ................................................................................................................................................................ 63
Medical Office Site and Records Review ................................................................................................................................ 63
Member Satisfaction Surveys ................................................................................................................................................ 64
APPEALS ....................................................................................................................................................................................... 65
Medical Necessity Criteria ..................................................................................................................................................... 66
Coverage for Appropriate Services ........................................................................................................................................ 67
Our Privacy Practices ............................................................................................................................................................. 67
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Disclosure of Protected Health Information (PHI) for HEDIS Purposes .................................................................................. 67
Communication Between Physicians ..................................................................................................................................... 68
Health Care Services .............................................................................................................................................................. 68
Solicited Records.................................................................................................................................................................... 68
SECTION 9 .............................................................................................................................................................................. 69
GREAT EXPECTIONS® HEALTH AND ..................................................................................................................................................... 70
DISEASE MANAGEMENT PROGRAMS .................................................................................................................................................. 70
Alcohol ................................................................................................................................................................................... 70
Asthma .................................................................................................................................................................................. 70
Back Care ............................................................................................................................................................................... 70
Case Management ................................................................................................................................................................ 70
Childhood Obesity.................................................................................................................................................................. 71
Children’s Health ................................................................................................................................................................... 71
Chronic Kidney Disease .......................................................................................................................................................... 71
Chronic Obstructive Pulmonary Disease (COPD) ................................................................................................................... 71
Depression ............................................................................................................................................................................. 71
Diabetes................................................................................................................................................................................. 71
Heart Disease ........................................................................................................................................................................ 72
Heart Failure .......................................................................................................................................................................... 72
High Blood Pressure............................................................................................................................................................... 72
High Cholesterol .................................................................................................................................................................... 72
Irritable Bowel Syndrome (IBS) .............................................................................................................................................. 72
Maternity............................................................................................................................................................................... 72
Men’s Health ......................................................................................................................................................................... 73
Migraine ................................................................................................................................................................................ 73
Pre-conception....................................................................................................................................................................... 73
Pre-Diabetes .......................................................................................................................................................................... 73
Quit Smoking ......................................................................................................................................................................... 73
Weight Management ............................................................................................................................................................ 74
Women’s Health .................................................................................................................................................................... 74
APPENDIX .............................................................................................................................................................................. 75
PHYSICIAN OFFICE ACCESSIBILITY STANDARDS ...................................................................................................................................... 76
PREVENTIVE HEALTH GUIDELINES FOR CHILDREN AND ADULTS ................................................................................................................ 77
BLUECHOICE.................................................................................................................................................................................. 80
2014 CLINICAL PRACTICE GUIDELINES ................................................................................................................................................ 80
Asthma .................................................................................................................................................................................. 80
Behavioral Health .................................................................................................................................................................. 80
Cancer.................................................................................................................................................................................... 80
Chlamydia .............................................................................................................................................................................. 80
Chronic Heart Failure ............................................................................................................................................................. 81
Chronic Obstructive Pulmonary Disease ................................................................................................................................ 81
Coronary Artery Disease ........................................................................................................................................................ 81
Diabetes................................................................................................................................................................................. 81
High Blood Cholesterol .......................................................................................................................................................... 82
Human Papillomavirus .......................................................................................................................................................... 82
Hypertension ......................................................................................................................................................................... 82
Kidney Disease ....................................................................................................................................................................... 82
Obesity and Overweight: Adults ............................................................................................................................................ 82
Obesity and Overweight: Children ......................................................................................................................................... 83
Perinatal Care ........................................................................................................................................................................ 83
Tobacco Use .......................................................................................................................................................................... 83
Preventive Guidelines ............................................................................................................................................................ 83
MEDICAL RECORD REVIEW CRITERIA .................................................................................................................................................. 84
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MEDICAL OFFICE SITE REVIEW CRITERIA ............................................................................................................................................. 85
Office Physical Environment .................................................................................................................................................. 85
Medical/Emergency Preparedness ........................................................................................................................................ 85
Appointments/Scheduling ..................................................................................................................................................... 86
Medical Record Maintenance................................................................................................................................................ 86
MEMBER RIGHTS AND RESPONSIBILITIES ............................................................................................................................................. 88
Member Rights ...................................................................................................................................................................... 88
Member Responsibilities ....................................................................................................................................................... 88
INSTRUCTIONS FOR REQUESTING AN EXTERNAL INSULIN INFUSION PUMP .................................................................................................. 89
INSTRUCTIONS FOR REQUESTING A CONTINUOUS GLUCOSE..................................................................................................................... 90
MONITORING SYSTEM ..................................................................................................................................................................... 90
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Administrative Manual ǀ Section 1
Section 1
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BlueChoice® Directory
Member Services: Phone 800-868-2528 or fax 803-714-6463
General inquiries, verification of member eligibility, benefits, authorization status and claims status.
Member Services representatives are available by telephone Monday through Friday from 8:30 a.m. until
6 p.m. For 24-hour service, you can access the Voice Response Unit (VRU) or you can visit our website
at www.BlueChoiceSC.com.
Health Care Services: 800-950-5387
Authorizations for referrals and procedures. You can access this number 24 hours a day.
Companion Benefit Alternatives (CBA): 800-868-1032
Mental health and substance abuse referrals and authorizations. CBA is a separate company that
administers mental health and substance abuse benefits on behalf of BlueChoice.
EDI Support Center: 800-868-2505
EDI (Electronic Data Interchange) electronic claims issues
EFT Coordinator: [email protected]
EFT (Electronic Funds Transfer) issues
Education: [email protected] or 803-264-4730
Provider education questions
Workshops and webinars
Provider manuals and quick reference guides
Educational visits to train your staff on plan processes and electronic tool usage
Status changes: [email protected] or fax 803-264-4795
Provider enrollment applications
Provider credentialing questions
Adding a satellite location
TIN (Tax Identification Number) change
Add or terminate provider affiliation
Change in address, phone or fax
Page 8
BlueChoice Website
Please visit our website at www.BlueChoiceSC.com. In keeping with the latest technology, the
information that our physician offices need most often is available on our website.
Using our website is easy. Just follow these simple steps:
• Go to www.BlueChoiceSC.com.
• Click on “Providers.” From this screen you can access general information, resources, forms and
health and wellness items.
• To access specific customer data, continue:
• Go to “My Insurance ManagerSM.”
• Enter your username and password (or “Create New Profile” if this is your first visit).
• For added security we are now requiring at least one profile administrator to manage My Insurance
Manager profiles for your office. The administrator can create, deactivate, approve and decline office
staff profiles.
• Select the desired function from the menu at top.
• Be prepared to enter the member’s ID number and date of birth.
Physicians and their office staff can access this information 24 hours a day, seven days a week:
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Member eligibility and schedule of benefits
Deductible and out-of-pocket status
Claims status
Referrals (primary care physician referrals to specialists) and referral extensions
Online precertification option for many inpatient and outpatient hospital services
View referral and inpatient/facility authorizations
Other health insurance (OHI) status and forms are also available online for members
Verify member’s assigned primary care physician
Communicate online with the Member Services department
Network referral directories (“Doctor & Hospital Finder” includes the option to customize and print a
directory.)
Prescription Drug List, including prior authorization requirements and quantity limits
Specialty pharmaceutical list
Oral drug prior authorization forms
File claims, including corrected claims and faster “Superbill” claims
Remittance information, including “My Remit Manager”
2014 Physician Office Administrative Manual
Disease management program information
Patient education materials
All information on our website is real-time, HIPAA-compliant and My Insurance Manager uses National
Provider Identifier (NPI) numbers. To protect privacy, we use the latest encryption technology to ensure
that no unauthorized person can access customer data. It encrypts all information sent and received so
no one else can read it as it travels over the Internet.
We encourage all our offices to try the website and let us know about their experiences. If you are
interested in a demonstration of our website, please contact Provider Education at 803-264-4730 or
[email protected].
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Contacting BlueChoice
BlueChoice is available to accept calls about utilization management (UM) issues. Members and
providers can call our UM department with any questions they have about the UM process. Use any of
these methods:
Our website www.BlueChoiceSC.com is available 24 hours a day.
Providers and members can contact BlueChoice’s Member Services department at 800-868-2528. This is
a 24-hour Voice Response Unit that allows access to information, such as member eligibility, benefits,
authorization status, claims status and other inquiries of a general nature. A Member Services
representative is available by telephone for more complex issues Monday through Friday from 8:30 a.m.
until 6 p.m.
Providers can contact BlueChoice’s Health Care Services department for authorizations for referrals and
procedures, or for general UM questions at 800-950-5387. This number can be accessed 24 hours a day.
Access via fax is available to providers 24 hours a day at 800-610-5685 or 803-714-6463 if local.
Voice Response Unit (VRU)
BlueChoice: 800-868-2528
Providers can also contact us through our Voice Response Unit (VRU). When the automated operator
answers, follow the prompts, you will be asked to enter your provider Tax Identification Number, the
member’s ID number and date of birth. Then continue following the instructions to access your desired
function:
Press 1 — Eligibility and benefits information
Press 2 — Claims status
Press 3 — Deductible and out-of-pocket max information
Press 4 — Precertification or prior authorization requests
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STATchatSM
STATchat allows you to call a Provider Services representative online. STATchat is a fast, free and
simple way to talk with a Provider Services representative after you’ve searched online for the answer to a
claims status or eligibility question.
If you can’t find the information you need online, STATchat lets you talk to a Provider Services
representative, right over your Internet connection. To use STATchat, simply log into My Insurance
Manager on www.BlueChoiceSC.com. (Users logging in for the first time will need to create a profile,
which takes less than one minute to complete. The Profile Administrator within your practice will review
your profile request and approve or deny access. In order to use STATchat, you will need a headset with
a microphone to connect to your computer.) If you still have a question after viewing claims status or
eligibility and benefits, just click “Ask Provider Services” at the bottom of the page. Click the “Connect”
button at the top of the page, and you’ll soon be speaking to a Provider Services representative online. In
fact, you will receive priority service and be connected to the next available agent!
You can use STATchat during regular business hours. BlueChoice Provider Services representatives are
available to help you Monday through Friday from 8:30 a. m. to 5 p. m.
STATchat is also available for Authorization/Precertification/Referral issues. You can talk to a Health
Care Services representative online to provide clinical information, request an extension and update
authorization information. If you still have a question after accessing
“Authorization/Precertification/Referral,” just click the “Ask Health Care Services” button at the bottom of
the page. Click the “Connect” button at the top of the page, and you’ll soon be speaking to a Health Care
Services representative online.
BlueChoice Health Care Services representatives are available to help you Monday through Friday from 8
a. m. to 5 p. m. To ensure quick service for all STATchat customers, only one issue per call, please.
Page 11
Section 2
Page 12
Membership and Benefit Plans
These are SAMPLE member ID cards only.
MyChoice [Open Access, High Deductible (HDHP) and Advantage Plans]
Individual Health Coverage
MyChoice Open Access Value Plan
Individual Health Coverage
Primary Choice Health Maintenance
Organization (HMO)
ADVANTAGEplus and CarolinaADVANTAGE (Open Access Plans)
ADVANTAGEplus and CarolinaADVANTAGE
High Deductible Open Access Health Plans
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MyChoice® Advantage Individual Health Plans
(New Health Care Exchange Plans)
Business Advantage Small Group Health Plans
(New Health Care Exchange Plans)
For specific member benefit information (copayments, coinsurance, deductibles, etc.) please contact our
Member Services department at 800-868-2528 or visit our website at www.BlueChoiceSC.com.
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Primary Choice:
• Members must select a primary care physician.
• Referrals to specialists required. No benefits for self-referrals. (Specialists are responsible for
making certain they have referrals from the primary care physician.)
• No benefits for out-of-network services. Members must use contracting providers only.
MyChoice Individual Health Coverage (Open Access and High Deductible Health Plans):
• Individual coverage for ages 19 to 64 1/2.
• In- and out-of-network benefits.
• Thirteen plan designs available: eight MyChoice plans and five MyChoice Value Plans.
 Five 80 percent and six 70 percent Open Access plans
Members do not have to select a primary care physician. No referrals to specialists required.
Members can self-refer directly to any contracting specialist without benefit adjustment. Providers
should still follow normal procedures for getting authorization for services and procedures that
require authorization.
 Two 100 percent High Deductible Health Plans (primary care physician selection not required
member can self-refer to in-network providers)
ADVANTAGEplus and CarolinaADVANTAGE (Open Access):
• Members do not have to select a primary care physician.
• No referrals to specialists required. Members can self-refer directly to any contracting specialist
without benefit adjustment.
• Providers should still follow normal procedures for getting authorization for services and procedures
that require authorization.
ADVANTAGEplus and CarolinaADVANTAGE High Deductible Health Plans:
• Members have lower premiums, access to Health Savings Accounts (HSAs) and higher deductibles.
• Works the same as regular ADVANTAGEplus and CarolinaADVANTAGE except member must meet
high deductible before BlueChoice HealthPlan will pay for services for “sick care.”
• Deductibles do not apply to preventive care.
MyChoice Advantage Individual Health Exchange Plans:
• Only NEW individual product lines access the new MyChoice Advantage Network.
• Alpha prefixes are ZCX and ZCJ.
• These ID cards also distinguish the new networks by having “MyChoice Advantage Network” and
“Exclusive Provider Organization” on the cards.
• Benefits are only available in network, unless in the event of an emergency.
Business Advantage Small Group Health Exchange Plans:
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Group product lines access the broad commercial BlueChoice Network
The alpha prefixes are ZCL and ZCG.
These ID cards also distinguish the network by having “Business Advantage” logo on the cards.
The suitcase in the lower right indicates the network that members access when out of state.
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Here is an explanation of each field on the ID card:
ID: The member’s BlueChoice HealthPlan identification number.
HMO: Indicates the member is enrolled in an HMO plan. Members must select a primary care physician
who is then responsible for providing or coordinating all of their health care.
Preferred Provider Organization (PPO): Indicates the member is enrolled in an open access plan.
HDHP: Indicates the member is enrolled in a high deductible health plan. Works the same as regular
ADVANTAGEplus and CarolinaADVANTAGE except member must meet a high deductible amount that
will be indicated on the card. Deductibles do not apply to preventive care.
: Indicates the member is enrolled in BlueCard. BlueCard coordinates benefits for members
traveling outside the BlueChoice service area. Any member who requires urgent or emergency medical
attention can contact BlueCard directly for authorization.
Rx: Indicates the member is enrolled in a pharmacy benefit plan.
Primary Care Physician Selection
Primary Choice: Primary Choice members must select a primary care physician from the current list of
participating physicians.
Open Access: ADVANTAGEplus, CarolinaADVANTAGE and MyChoice Individual Health Plan (both
PPO and High
Deductible) members are not required to select a primary care physician.
Members can change their primary care physicians by contacting our Member Services department or
accessing the BlueChoice HealthPlan website. The change will become effective the same day the
request is made.
Member Pharmacy Benefits
BlueChoice members typically have a three-tier* pharmacy benefit plan for prescription drugs. (Tiers may
be based on fixed copayments or coinsurance depending on the member’s benefit plan.) CVS Caremark
is an independent company that provides pharmacy benefit management on behalf of BlueChoice.
Caremark administers the BlueChoice Prescription Drug List. Pharmacy benefits are outlined in the
Prescription Drug List available on our website, or you can contact Provider Education at 803-264-4730 or
[email protected] for a printed copy of this list. Member copayments vary depending upon
the drug being used. Here is a description of the three-tier pharmacy benefit (for more complete details,
please refer to the Prescription Drug List):
• Generic (tier 1) – Most prescription generic drugs and select OTC (over-the-counter) agents
*Most members now have a pharmacy benefit that includes a two-level generic category:
 Value Generics (generic drugs that cost less than $15 per month and covered OTC drugs)
 Standard Generics (most other generic drugs that cost more than $15 per month)
• Preferred (tier 2) – Select prescription brand-name drugs on the Prescription Drug List
• Non-preferred (tier 3) – Prescription brand-name drugs and occasionally high-priced generic drug
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Mail-Service Pharmacy
Some BlueChoice members have a mail-service benefit available as a part of their prescription benefit.
These members can receive a 90-day supply of certain medications for a specified copayment as outlined
in their individual Schedule of Benefits. Members interested in using their mail-service benefit can contact
BlueChoice Member Services at 800-868-2528 to request a CVS Caremark mail-service order form or
visit the CVS Caremark website at www.Caremark.com.
FastStart is a CVS Caremark program designed to increase mail-service benefit awareness and usage for
members. The program also reduces the administrative burden for doctors and members filling mailservice prescriptions. The program is available at no additional cost to members or their employers.
Mailings consist of letters that explain the benefits of using mail-service for maintenance medications,
such as potential cost savings, convenient home delivery and an extended days’ supply. Members can
call 866-776-5677 to enroll in FastStart.
BlueCard (Out-of-State Care)
BlueCard coordinates benefits for BlueChoice members who are traveling outside of South Carolina. Any
member who requires medical attention due to an urgent or emergency situation can contact BlueCard
directly for authorization. If members are eligible for this benefit, the telephone number for BlueCard will
be on the back of their ID cards.
Health Insurance Marketplace (Exchange) Plans
Health plans in the individual and small group markets are offered through the Federally Facilitated
Marketplace (FFM) and private marketplaces. The federal government manages the FFM and insurance
companies manage private marketplaces. Plans are available to both individuals who may be uninsured,
underinsured or otherwise eligible for federal subsidies and small businesses.
Non-grandfathered health plans within the Health Insurance Marketplace (exchanges) must offer a core
package of items and services called “essential health benefits.”
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Ambulatory patient services
Prescription drugs
Emergency services
Habilitative and rehabilitative services and devices
Hospitalization
Laboratory services
Maternity and newborn care
Preventive and wellness services and chronic disease management
Mental health and substance use disorder services, including behavioral health treatment
Pediatric services, including oral and vision care
Page 17
Benefit Overview
All preventive benefits such as prostate screenings, pediatric oral and vision care are covered at 100
percent. Women’s designated preventive services include, but are not limited to, mammography
screenings and pap smears at 100 percent. The U.S. Preventive Service Task Force (USPSTF) defines
preventive services. Benefits are provided for in-network providers only for individual plan members.
There are no benefits for out-of-network providers unless it is a true emergency.
Individual plan members may be eligible to receive a federal subsidy. This subsidy can be administered
as a tax credit, in which the member pays the entire premium for the year and then receives the credit
when he or she files income taxes. It can also be applied as a credit towards the member’s monthly
premium. The member would pay a portion of the monthly premium and the federal government would
contribute on a monthly basis.
MyChoice Advantage Individual Plans
The individual exchange products we offer are known as MyChoice Advantage and are nongrandfathered products. MyChoice Advantage plans operate under an Exclusive Provider Organization
(EPO), which means it uses a network of participating doctors, hospitals and other health care providers.
If a provider is not in the MyChoice Advantage EPO network, we will not cover services unless in the
event of an emergency. While the range of benefits is the same among plans, the value of benefits will
vary. Always verify coverage for members, as eligibility may change based on premium status. Some
services require prior authorization. Members are not required to obtain a referral to see a specialist.
Transition of Care
If a MyChoice Advantage member is under the care of a physician who is not in the MyChoice Advantage
network, they can request special consideration to have benefits applied at in-network levels. Members
can submit a Transition of Care form for consideration. Upon review by our Utilization Management area,
we may approve a member to continue care with the out-of-network provider for a specified time. You can
find the Transition of Care form on our website or request a form by calling Member Services.
Business Advantage Small Group Plans
The small group exchange products we offer are non-grandfathered products. The small group private
exchange products use the BlueChoice Network.
Other Information
Mental Health
You should get treatment plans through CBA. You can visit www.CompanionBenefitAlternatives.com or
call one of these numbers:
Companion Benefit Alternatives
P.O. Box 100185
Columbia, SC 29202-3185
803-699-7308
800-868-1032
(Outside Columbia)
Page 18
Prescription Drug Plan
Members have drug coverage through Caremark. They have a four-tier plan with either a drug card and/or
mail-service benefits, as well as specialty pharmacy benefits which are also covered through Caremark.
The Preferred Drug List for these members is different from the other BlueChoice plans. You can
download the Preferred Drug List through our website, www.BlueChoiceSC.com.
Benefits and Eligibility
Always verify coverage for members, as eligibility may change based on the premium status. You can
quickly get the most current member eligibility and benefit information by using My Insurance Manager on
our website. You can also call Member Services department at 800-868-2528.
Precertification
Certain categories of benefits require precertification. Failure to get preauthorization may result in us
denying benefits. Precertification is not a guarantee that we will cover the service. Members are not
required to obtain a referral to see a specialist.
For precertification requirements, verify benefits and eligibility through My Insurance Manager. Once you
have verified precertification requirements you can initiate the precertification request in My Insurance
Manager.
Premium Delinquencies
Members who do not have a federal subsidy do not have a delinquency grace period. We will deny claims
immediately upon delinquency.
Members who have an FFM policy and receive a federal subsidy have a three-month grace period. During
the first month of delinquency, we will process all claims and apply benefits accordingly. During the
second and third month of delinquency, claims will pend until the member pays the premiums. If the
premium is not current at the end of the third month (90 days), we will deny claims. We will notify you of a
member’s premium delinquency:
1. When verifying eligibility and benefits through My Insurance Manager and the VRU.
2. When verifying claim status through My Insurance Manager and the VRU.
3. When reviewing your remittance advice.
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Section 3
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Referrals
Initial Referrals to Specialists
Primary choice members must have a referral from their assigned primary care physicians before
seeking the services of specialists (open access members do not need referrals for office visits). Once the
primary care physician has determined a member needs the services of a specialist, the primary care
physician is responsible for notifying our Health Care Services department before sending the member to
the specialist. To make a referral, the primary care physician’s office can either visit our website at
www.BlueChoiceSC.com or use the Referral Partner Authorization Form found in the Providers’ area of
our website. You can also request this form by contacting Member Services at 800-868-2528.
Requests for referrals are not accepted retroactively. Specialists are responsible for making
certain they have valid referrals before seeing members. Therefore, we recommend you use the
Web to ensure BlueChoice has received the referral. Please note: Referrals are required for all
services not performed by a primary care physician for State HMO members.
Web Referrals
The best way for primary care physicians to make referrals to specialists is through our website at
www.BlueChoiceSC.com. Referrals made through our website are loaded instantly and immediately
assigned an authorization number. Just follow these simple steps:
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Go to www.BlueChoiceSC.com.
Log in to Online Services, click on My Insurance Manager.
Enter your username and password (or “Create New Profile” if this is your first visit to our website).
Click on “Authorization/Pre-Certification/Referral.”
Please be prepared to enter the member’s identification number and date of birth. You will also need to
know the specialist’s last name and specialty type. Once the referral is complete, you should print a copy
of the referral confirmation and fax it to the specialist’s office.
Referral Partner Authorization Form
If your office does not have access to the Internet, you can use the Referral Partner Authorization Form
instead. The member’s assigned primary care physician’s office should complete the form. Once the form
is completed, the primary care physician’s office should fax a copy to BlueChoice and the specialist’s
office the same day the referral is made.
Referrals made by the primary care physician only include office visits and office-based procedures that
do not require prior authorization. Referrals do not include approval for procedures/services that require
separate authorization. Please see the list of procedures/services that require prior authorization on
pages 22 and 23 of this manual.
Page 21
You cannot use web referrals and the referral Partner Authorization form to request authorization
for these services:
•
•
•
•
•
Referrals to non-contracting specialists
Referrals for routine vision care
Referrals for mental health and substance abuse services
Durable medical equipment (DME) and home care services
Referrals with diagnosis of obesity, infertility, impotence, or for cosmetic surgery (or any other
possible contract exclusion)
• Inpatient or outpatient facility services
• Procedures or services that require prior authorization
If you would like to request any of these services, please contact our Health care services
department at
800-950-5387 (option #6) to get prior authorization.
Follow-Up Visits to Specialists
The initial referral from the primary care physician is the approval for all medically necessary follow-up
visits and office-based services that do not require prior authorization. (Please see the list of
procedures/services that require prior authorization on pages 22 and 23 of this manual.) It is the
specialist’s responsibility to keep track of the expiration date of the referral. If the specialist needs to see
the member after the initial referral has expired, the specialist must contact us directly to extend the
expiration date. Specialists can fax the Specialist Request for Extension of Visits Form found in the
Providers’ area of our website or call our Health Care Services department directly at 800-950-5387
(option #6). Please allow two business days for approval when using the fax form. The preferred method
is to extend referrals on our website. Extensions you get on our website are valid immediately.
Specialist Referral Extensions on the Web
Primary care physicians and specialists can now request specialist referral extensions on the Web. The
Authorization/Pre- Certification/Referral screen in My Insurance Manager includes additional options. You
can access a request for a referral extension through the “Request Extension” button or by going through
the “Check Status” button. Only approved office visit referrals are available for extension (CPT 9920199255), and specialists can only extend their own referrals.
Please note: If it has been longer than six months since the date the referral expired, the specialist must
contact the primary care physician for a new referral.
Expiration Dates for Referrals
Referrals to specialists are valid for six months from the date the referral is made by the primary care
physician and include all medically necessary follow-up visits.
Page 22
Specialist Referrals to Other Specialists
Typically, only the member’s assigned primary care physician initiates referrals. Here, however, are
instances when the specialist may need to contact BlueChoice directly to initiate a referral to another
specialist:
• Obstetricians — If a member is pregnant, her obstetrician can refer her to other specialists for
conditions related to pregnancy. Please use the Maternity Referral Form found on our website or call
Health Care Services at 800-950-5387 (option #6) for approval.
• Gynecologists — Gynecologists can make referrals to urologists and infertility specialists. (Please
note — not all members have infertility benefits.) Please call Health Care Services at 800-950-5387
(option #6) for approval.
• All specialists — All specialists can make referrals to oncologists and pain management
specialists. Please call Health Care Services at 800-950-5387 (option #6) for approval.
• Oncologists — Oncologists can refer members to other specialists for services related to their
treatment. Please call Health Care Services at 800-950-5387 (option #6) for approval.
• Nephrologists — Nephrologists can refer members to other specialists for services related to their
treatment. Please call Health Care Services at 800-950-5387 (option #6) for approval.
Exceptions to the Standard Referral Process
Initial Maternity Care Visit — Once a woman discovers or suspects that she is pregnant, she can go to
her primary care physician or self-refer to her obstetrician. The physician who verifies the member is
pregnant should complete the Maternity Authorization Form and fax it to BlueChoice. For more details,
refer to “Obstetrical Authorization Procedures” in Section 5 of this manual.
Vision Screenings — No primary care physician referral is necessary for routine vision care. The
Physicians Eyecare Network (PEN) is an independent company that administers vision benefits on behalf
of BlueChoice. Members with vision benefits can go directly to any PEN specialist. Members can call our
Member Services department if they need a listing of the PEN specialists. If a member has a medical
problem related to the eye, however, the primary care physician must contact BlueChoice to make a
referral to a participating specialist for non-routine vision care.
Mental Health and Substance Abuse Referrals — Please contact CBA by calling 800-868-1032 or by
submitting the appropriate form found in CBA’s online Form Resource Center
(https://forms.companionbenefitalternatives.com) to get authorization for mental health and substance
abuse services. Some members may have a different managed behavioral health organization for mental
health referrals. If this is the case, the number will be listed on the back of the member’s ID card.
Chiropractic Referrals — Many BlueChoice members have coverage for chiropractic services included
in their benefits. If the member has chiropractic benefits, he or she can self-refer directly to any
contracting chiropractor. No referral from the primary care physician or prior authorization from
BlueChoice is necessary. At the time of the first visit, however, we recommend contacting our Member
Services department at 800-868-2528 or visiting our website to verify individual coverage. Chiropractic
benefits may vary, depending upon what coverage the member’s employer group has chosen. Once the
member’s benefits have been exhausted, services will no longer be covered by BlueChoice, with the
exception of MyChoice Advantage Exchange members. For precertification requirements, verify benefits
and eligibility through My Insurance Manager. Please note: State HMO members do require a referral for
these services.
Page 23
Physical therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) — PT, OT and ST do
not require prior authorization for up to the yearly benefit limits, unless they are provided at home. At the
member’s first visit, we recommend contacting our Member Services department at 800-868-2528 or
visiting our website to review the member’s benefits and to make sure his or her benefits have not been
exhausted. Once benefits have been exhausted, we will no longer cover services, with the exception of
MyChoice Advantage Exchange members. For precertification requirements, verify benefits and eligibility
through My Insurance Manager. Please note: State HMO members do require a referral for these
services.
Ask Health Care Services
If you have a question about services available on the Web or any other question you would like to ask
Health Care Services, you can go through My Insurance Manager by clicking on the “Ask Health Care
Services” button located at the bottom of the page.
This button takes you to a screen where you are able to ask a question or opt out to STATchat for a live
person.
If the question is asked via the Web, we will provide a response within one business day via the “Your
Mailbox” feature. Enter the question in the box indicated and note the ID number and date of birth of the
patient you are referencing. Also include the authorization number if applicable. Be sure you hit “submit”
after entering your information.
To retrieve your response, go to “Your Mailbox” on the My Insurance Manager toolbar. Choose
BlueChoice HealthPlan, type in the member ID number and click “continue.” You will see the response.
Click on “response” to get the answer to your question.
Page 24
Section 4
Page 25
Prior Authorization for Services and Procedures
This section applies to all BlueChoice HealthPlan members (Primary Choice, MyChoice and Open
Access) with the exception of MyChoice Advantage Exchange members. For precertification
requirements, verify benefits and eligibility through My Insurance Manager.
Prior authorization for services is the responsibility of the rendering (or ordering) primary care physician or
specialist physician. Once the primary care physician has referred a member to a specialist, it becomes
the specialist’s responsibility to get prior authorization for services or procedures that require a separate
authorization.
You can get prior authorizations by calling Health Care Services at 800-950-5387 (option #6) or by faxing
the Request for Prior Authorization for Services and Procedures Form found on our website to 800-6105685. Please note the special contact information for radiology, DME and mental health prior
authorizations.
These services/procedures require prior authorization:
Inpatient Hospital Services
• All inpatient hospital admissions (prior authorization for most direct emergency admissions is
available online)
Outpatient Facility Services
• Infusions/transfusions
• Surgical procedures (many available online)
• Lab services not provided through LabCorp
Advanced Radiology Imaging Services (any place of service) – Call National Imaging Associates
(NIA) directly at 888-642-9181 or go to www.RadMD.com for prior authorization. NIA is an
independent company that provides utilization management services of certain radiological procedures on
behalf of BlueChoice.
•
•
•
•
•
•
•
•
•
CT and CTA scans
CT colonography (CPT 74261 & 74263)
Coronary CTA (available at approved pilot program locations only)
MRCP
MRI and MRA scans
Nuclear cardiology studies (including stress thallium and Lexiscan stress tests)
Outpatient interventional radiology services
PET scans
Stress echocardiology
Page 26
RadMD – Get Your Radiology Services Prior Authorizations Online! You can contact National
Imaging Associates (NIA) online for prior authorizations at its website www.RadMD.com or by choosing
the RadMD link on the BlueChoice HealthPlan website under “Providers” and then “Resources.” To get
started, simply go to www.RadMD.com and click the “New User” button on the right side of the home
page. Fill out the application and click the “Submit” button. The NIA webmaster will respond with your
NIA-approved username and password. On subsequent visits to the site, just click the “Login” button to
proceed. RadMD is designed to make things easy for you, allowing you to quickly access the
authorization information you need.
Office-Based Services (performed in physician’s office)
• Colonoscopy (not required if at ASC or facility)
• Complex pulmonary function tests listed on page 39 (except when rendered by pulmonologist or
allergist)
• EGD (not required if at ASC or facility) lab services not provided through LabCorp or Genzyme
Genetics and not on the in-office approved lab list.
• Nerve conduction studies/EMGs (except when rendered by neurologist, neurosurgeon or physiatrist)
• Thyroid ultrasounds - CPT 76536 (except when rendered by general surgeon or endocrinologist)
Other Services (any place of service)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Aquatic therapy
Biofeedback
Capsule endoscopy (CPT 91110)
Cardiac rehabilitation
Cholesterol subparticle testing (e. g., Berkeley
HeartLab, Health Diagnostics Lab)
Cosmetic procedures (those without a
functional impairment)
Diabetic teaching programs (except at approved
facilities – call 800-327-3183, ext. 25450 for list,
see page 40)
Erectile dysfunction or infertility treatment
Extracorporeal shock wave lithotripsy of the foot
(ESWL)
Genetic lab testing (except when rendered by
LabCorp or Genzyme Genetics, see page 39)
Guided imagery – except when rendered by
neurosurgeon
Specialty drugs – certain injectable and infusion
drugs require prior authorization (see list on
pages 31)
Injectable/infusible chemotherapy
Investigational procedures/services
Neurostimulators (bone, muscle, TENS)
Pain management services and/or
multidisciplinary programs
• Pediatric developmental testing (CPT 96110 &
96111) only available for developmental
pediatricians
• Pharmacy drugs – certain pharmacy drugs
require prior authorization (see list on pages 26,
27 & 31)
• Pregen
• Pulmonary rehabilitation
• Radiation therapy (including IMRT)
• Referrals to non-contracting providers
• Refractive surgeries/services
• Routine foot care (CPT 11055-11057 and
11719-11721) and corrective shoes
• Sleep studies
• Therapeutic blood therapies, including
transfusions and dialysis
• Tilt table testing
• 24-hour ambulatory blood pressure monitors
• UPPP/LAUP
• Ultrasound, CT or radiographic bone mineral
density studies (CPT 76977, 77078 & 77079
only)
• Varicose vein procedures including endovenous
radiofrequency and laser ablation, ligation and
sclerotherapy
• Other possible contract exclusions (e. g., skin
tags - CPT 11200 & 11201)
Page 27
Laboratory Services
There are many approved in-office labs listed on page 32 that can be performed in your office without
prior authorization. All other labs, including stat labs, should be sent to LabCorp. Stat labs available
through LabCorp are also listed on page 32. If LabCorp is unable to provide a necessary stat lab, please
contact Health Care Services for prior authorization at 800-950-5387.
DME, Home Health, Hospice, Orthotics, Prosthetics and Other Medical Supplies
BlueChoice HealthPlan directly manages prior authorizations, claims and network management.
•
•
•
•
•
•
DME
Hemophilia management
Home health services
Home infusion therapy
Orthotics and prosthetics
Oxygen and respiratory equipment
•
•
•
•
•
Home physical therapy
Home occupational therapy
Home speech therapy
Private duty nursing
Hospice care
Most services do not require prior authorization. Simply order the product or service from a network
provider. Please review the current Ancillary Services Prior Authorization Required list of services that
require prior authorization. You can find the current list at www.BlueChoiceSC.com by selecting
“Providers,” then “Resources,” then “Ancillary Services.”
Please use the Request for Preauthorization of Benefits for Ancillary Services form to request all services
requiring prior authorization. Print, complete and fax the form as indicated. You can find this form in the
Providers’ area of our website. You can also request this form by contacting Member Services at 800868-2528. Ancillary services can only be authorized via fax.
Mental Health and Substance Abuse Services
Please contact CBA for prior authorization by calling 800-868-1032 or by using the CBA Initial Outpatient
Mental Health Treatment Request Form available at CBA’s online Form Resource Center
(https://forms.companionbenefitalternatives.com).
Primary Care Physician Services
These services/procedures do not require prior authorization when performed by a primary care
physician:
•
•
•
•
•
•
•
•
•
Colonoscopy (45378-45392)
Continuous overnight pulse oximetry (94762)
Iron injection (J1750)
Nails (11720-11755)
Paring or cutting of benign lesions (11055-11057)
Removal of skin tags (11200-11201)
Sigmoidoscopy (45300-45341)
Simple pulmonary stress test
U/S bone density measurement (peripheral 76977)
Page 28
Online Prior Authorization
We are always looking for ways to streamline our prior authorization procedures. Physicians can request
prior authorizations online for many inpatient and outpatient services and procedures. We are continually
adding more services and procedures, so check the website for the most current list of online prior
authorizations available.
Getting prior authorization online is easy. Just follow these simple instructions:
•
•
•
•
Go to “My Insurance Manager.”
Click on “Authorization/Precertification/Referral.”
You can currently get online authorization for these procedures (these lists are not inclusive). We add
services and procedures to these lists periodically. Please refer to the online guide, "What You Need to
Know About Precertifications and Referrals," at www.BlueChoiceSC.com, for updates and additions.
Inpatient Hospital Surgical Procedures:
Abdominal aortic aneurysm repair
Aortic valve replacement
Appendectomy/not perforated
Appendectomy/ruptured
Carotid endarterectomy
Colectomy
Coronary angioplasty (PTCA)
Coronary bypass procedure
Craniotomy
Diskectomy
Ectopic pregnancy
Femoral-popliteal artery bypass
Fusion, cervical spine
Fusion, lumbar spine
Hip arthroplasty, total
Knee arthroplasty, total
Laminectomy
Mastectomy, radical (neoplasm)
Mastectomy, simple (neoplasm)
Mitral valve replacement
Myomectomy
Nephrectomy
ORIF lower limb
ORIF upper limb
Parathyroidectomy, complete
Parathyroidectomy, partial
Prostatectomy, radical
Splenectomy
Thoracotomy
Thyroidectomy, subtotal
Thyroidectomy, total
Inpatient Hospital Medical:
Abdominal pain, emergency
Acute pancreatitis
Acute pericarditis
Acute pyelonephritis
Adult acute febrile illness
Ascites (intractable)
Asthma
Cardiac arrhythmia
Cellulitis
Chest pain
CHF
CNS bleed
Com acquired pneumonia
Coma
COPD
CVA
DKA
Ectopic pregnancy
Hypertensive crisis
Intract renal colic
Meningitis
MI
MVA
Neonatal jaundice
Obstruction-intestine
ORIF
Overdose
Ped apnea
Ped asthma
Ped bone fracture
Ped brain abscess
Ped bronchiolitis
Ped burn major
Ped cellulitis
Ped croup
Ped DKA
Page 29
Inpatient Hospital Medical (continued):
Ped drug ingestion
Ped dysentery-bacterial
Ped epiglottitis
Ped fever unknown origin
Ped gastroenteritis
Ped head injury
Ped hemophilia
Ped idiopath thrombocytopenia
Ped intussusception
Ped lye ingestion
Ped orbit abscess
Ped osteomyelitis
Ped pneumonia
Ped renal colic
Ped RSV pneumonia
Ped seizure
Ped sepsis
Ped septic arthritis
Ped sickle cell crisis
Ped skull fracture
Ped stat epilepticus
Ped syncope
Ped venom exposure
Pelvic bone fracture (open)
Pneumothorax
Pulmonary embolism
Relapsing pancreatitis
Renal failure, acute
Renal failure, chronic
Retropharyngeal abscess
SAH
Seizure
Septicemia
Sickle cell crisis
Subacute endocarditis
Syncope
TBI
TIA
Esophageal manometry
HSG
Maternity D&
Nasal endoscopy
PH probe, esophagus
Outpatient Medical:
ABGs
Cardiac rehabilitation facility
Ectopic pregnancy
Outpatient Surgical Procedures:
Anal fistulotomy
Arthros/rotator cuff, shoulder
Arthroscopy, knee
Arthroscopy, shoulder
Arthroscopy/chrondroplasty, knee
AV fistula-dialysis create/revise
Biopsy of anal/rectal wall
Bone marrow biopsy
Breast biopsy
needle core/incision
needle aspiration
stereotactic
ultrasound guided
Bronchoscopy - no navigational
bronch
Bunionectomy
Cardiac catheterization
Cardiac pacemaker insertion
Carpal tunnel release
Cataract extraction
Cataract membranous, laser
Cerclage
Cholecystectomy lap
Circumcision over age 28 days
Colposcopy
Conization of cervix
Cystoscopy
Cystoscopy w/biopsy
Cystoscopy w/insertion of
urethral stent
Cystoscopy w/removal of stent/
calculus
Cystoscopy w/renal lithotripsy
Diagnostic laparoscopy
Discectomy
Dilation and curettage (D&C)
Ectopic pregnancy
Endometrial Biopsy
EPS study/cardiac ablation
ERCP
Fissurectomy
Ganglion cyst – wrist, excision
Hammertoe correction
Hemorrhoidectomy
Hernia repair, all types
Hydrocele, excision of
Hysteroscopy
Hysteroscopy w/D&C
Hysteroscopy/endometrial ablation
Knee arthroscopy w/menisectomy
Laminectomy
Laparoscopic ovarian cystectomy
Laryngoscopy
Lithotripsy – renal (ESWL)
Liver biopsy
Lumpectomy
Maternity D&C
Mediastinoscopy
Myringotomy w/tubes
Orchiectomy
Page 30
Outpatient Surgical Procedures (continued):
ORIF, lower limb
ORIF, upper limb
Peritoneal dialysis catheter
Pilinidal cyst excision
Plantar fasciotomy
Prostate biopsy
Prostatectomy, trans-uretheral
Removal of external fixation
SI joint injection
Skin biopsy
Sphincterotomy - anal
Tendon sheath incision
Trigger finger release
Ureteral stent
Urethral stent
Venous access insert/revise
Vitrectomy
If you have any questions about how to get prior authorization online, please contact Provider Education
at 803-264-4730 or [email protected].
Pharmacy Drug Prior Authorization
BlueChoice requires that physicians get prior authorization before prescribing certain medications to
members. All of our PA criteria are developed and based on the most current FDA prescriber labeling and
clinical recommendations from the BlueChoice HealthPlan and BlueCross BlueShield of South Carolina
Pharmacy and Therapeutics Committee (P & T Committee).
Certain PA drugs are subject to medical necessity review and may require the submission of additional
details or medical records for approval. To initiate the PA process, please contact the CVS Caremark PA
center toll free at 800-294-5979 before giving the member the prescription. You will be asked to provide
member specific information via phone or fax, including the diagnosis and the member’s previous
medication use. You can also print off a copy of each individual prior authorization request form from our
website at www.BlueChoiceSC.com by selecting “Providers,” then clicking on “Forms,” then selecting
“Oral Drug Prior Authorization (PA) Forms” on the right side. Simply fill out the appropriate prior
authorization request form and fax it to CVS Caremark toll free at 888-836-0730.
This list of medications and their generics, if available, require prior authorization. Here is a brief summary
of the criteria for each:
Abstral, Lazanda, Onsolis, Subsys
Coverage provided for members 18 years and older for the management of breakthrough cancer pain
who are already receiving opioid therapy.
Aciphex, Dexilant, Nexium, Prevacid, Prilosec, Protonix, Zegerid
(Please Note: This PA does not apply to prescriptions for OTC versions of these medications.)
• After satisfying initial step criteria, prior authorization is required to continue therapy after eight
weeks of initial therapy
• Coverage provided after failure of step-down therapy of a separate trial of a prescription or OTC
version of lansoprazole, omeprazole or pantoprazole when treating reflux (GERD)
• Coverage provided for twice-daily dosing for treatment of reflux (GERD) only after failure of fullstrength once-daily dosing
• Coverage for other disorders such as Barrett’s esophagus, erosive esophagitis and Zollinger-Ellison
syndrome has less restrictive treatment and dosing guidelines
Page 31
Actiq, Fentora
Coverage provided for members 16 years and older for the management of breakthrough cancer pain
who are already receiving opioid therapy.
Adoxa, Doryx, Monodox
Coverage allows up to 14 days of therapy in 365 days. Requests for additional days of therapy for acne
diagnoses require medical review.
Anti-emetic Agents (Anzemet, granisetron, Granisol, Sancuso, Zofran, Zuplenz)
Coverage provided for treatment of nausea and vomiting associated with moderately emetogenic
chemotherapy or hyperemesis gravidarum (granisetron, Granisol, Sancuso, Zofran only).
Buprenorphine, Suboxone
Coverage provided for members who are confirmed to be receiving treatment for opioid dependence in a
valid opioid-addiction treatment program.
Celebrex
After satisfying initial step criteria, coverage provided for members at doses greater than 200 mg total per
day only for treatment of acute pain, ankylosing spondylitis, dysmenorrhea or rheumatoid arthritis.
Exalgo
Coverage provided for treatment of opioid-tolerant patients who require continuous, around-the-clock
analgesia for an extended time frame.
Lovaza
Coverage provided to members 18 years and older who have elevated triglycerides above 500 mg/dl and
have failed on previous FDA-approved therapy to lower triglycerides along with diet.
Nuvigil
Coverage provided for members with a diagnosis of narcolepsy, multiple sclerosis-related fatigue,
persistent sleepiness due to obstructive sleep apnea refractory to traditional treatments (i. e. CPAP etc. )
and sleepiness associated with diagnosed shift work sleep disorder.
Pradaxa
Coverage requires that members have a diagnosis of non-valvular atrial fibrillation and risk factors for
thromboembolism. It is requested that the physician not use in patients over 75 years of age.
Proscar
Coverage provided for the treatment of symptomatic benign prostatic hypertrophy in males over 40.
Page 32
Provigil
Coverage provided for members with a diagnosis of multiple sclerosis-related fatigue or an FDA-approved
indication that have tried and failed at least a 30-day trial of Nuvigil in the last 365 days.
Soriatane
Coverage provided for the treatment of keratization disorder, lichen planus, pityriasis rubra pilaris or
severe psoriasis in adults.
Symlin Pen
Coverage provided for patients with Type 1 or Type 2 diabetes who have failed to achieve adequate
glycemic control despite optimal insulin therapy.
Testosterone
Coverage provided for males who require replacement therapy in conditions associated with deficiency or
absence of endogenous testosterone and for females with advancing inoperable metastatic (skeletal)
mammary cancer who are one to five years postmenopausal as secondary treatment.
In general, prior authorization medications are assigned the highest Tier 3 copayment, with the exception
of Nexium (assigned the Tier 2 copayment); and prescription generic or OTC (brand or generic) versions
of lansoprazole, omeprazole or pantoprazole (assigned the Tier 1 copayment). Please note that
medications requiring PA may be added or removed from this list at any time with or without notice to
providers or members. Go to the Providers’ section of our website at www.BlueChoiceSC.com for the
most current list of medications requiring prior authorization.
Certain drugs in a variety of categories are subject to medical necessity review and may require the
submission of additional detail and/or medical records for approval. Please see the appropriate prior
authorization forms on our website, www.BlueChoiceSC.com. This list is subject to change at any time
without prior notice to members or physicians.
Page 33
DRUGS REQUIRING PRIOR
AUTHORIZATION FOR MEDICAL
NECESSITY
ALTERNATIVES THAT DO NOT
REQUIRE PRIOR AUTHORIZATION
FOR MEDICAL NECESSITY
ALLERGIES – NASAL STEROIDS
BECONASE AQ, DYMISTA, FLONASE, OMNARIS,
QNASL, RHINOCORT AQUA, VERAMYST, ZETONNA
flunisolide spray, fluticasone spray, triamcinolone spray,
NASONEX
DEPRESSION – ANTIDEPRESSANTS
OLEPTRO
trazodone
DERMATOLOGY – CORTICOSTEROIDS
OLUX-E FOAM
clobetasol propionate foam 0.05%
DIABETES
FORTAMET, GLUMETZA, RIOMET, JENTADUETO,
TRADJENTA
FREESTYLE TEST STRIPS
HUMALOG, HUMALOG MIX 50/50, HUMALOG MIX
75/25, HUMULIN 70/30, HUMULIN N, HUMULIN R
JANUMET, JANUMET XR, JANUVIA, KOMBIGLYZE
XR, ONGLYZA
ACCU-CHEK STRIPS, ONETOUCH STRIPS
NOVOLIN 70/30, NOVOLIN N, NOVOLIN R,
NOVOLOG, NOVOLOG MIX 70/30
(NOTE: HUMULIN U-500 concentrate will not be subject to
prior authorization and will continue to be covered.)
GLAUCOMA
LUMIGAN
latanoprost, TRAVATAN Z, ZIOPTAN
HIGH BLOOD PRESSURE
ATACAND, ATACAND HCT, AVALIDE, AVAPRO,
COZAAR, EDARBI, EDARBYCLOR, HYZAAR,
TEVETEN, TEVETEN HCT, TEKTURNA, TEKTURNA
HCT
Eprosartan, irbesartan, irbesartan/hydrochlorothiazide,
losartan, losartan/hydrochlorothiazide,
valsartan/hydrochlorothiazide, BENICAR, BENICAR
HCT, DIOVAN
HIGH CHOLESTEROL
ADVICOR
ALTOPREV, LIVALO
OVERACTIVE BLADDER/INCONTINENCE
DETROL, DETROL LA, DETROL XL, MYRBETRIQ,
OXYTROL, SANCTURA XR, TOVIAZ
SLEEP HYPNOTICS
AMBIEN, AMBIEN CR, EDLUAR, INTERMEZZO,
LUNESTA, SILENOR, SONATA, ZOLPIMIST
TESTOSTERONE REPLACEMENT
ANDROGEL, TESTIM
atorvastatin, fluvastatin, lovastatin, pravastatin,
simvastatin, SIMCOR
atorvastatin, fluvastatin, lovastatin, pravastatin,
simvastatin, CRESTOR, VYTORIN
oxybutynin ext-rel, tolterodine, trospium, GELNIQUE,
VESICARE
zolpidem, zolpidem ext-rel, zaleplon
ANDRODERM, AXIRON, FORTESTA
Page 34
Step Therapy
BlueChoice requires that certain medications covered under the prescription benefit satisfy specific step
therapy criteria. Medications that currently require step therapy are identified by the notation “ST”
throughout the text of the Prescription Drug List. Step therapy criteria simply means that before
BlueChoice members can fill medications on the Step Therapy Drug List, they must first have tried one or
more prerequisite medications to treat their conditions before other medications are covered through their
benefits. All step therapy criteria are based on current FDA prescriber labeling and clinical decisions
made by the BlueChoice P& T Committee.
Most step therapy requests are handled by our pharmacy benefits manager, CVS Caremark, by calling
800-294-5979. For other step therapy requests, please call Health Care Services toll free at 800-9505387 (option #6) to determine if the medication is approved based on the step therapy criteria.
Quantity Management
Some drugs on the Prescription Drug List have quantity limits, typically for a one-month supply. These
limits have been approved by the P & T Committee and are based on FDA prescriber labeling and
treatment/prescribing guidelines developed by nationally accepted medical organizations. Medications
that currently have a quantity limit are identified by the notation “QL” throughout the text of the
Prescription Drug List.
If you deem it necessary for your patient to have more than the quantity limit allows, you can request an
exception. Some quantity limit requests are handled by our pharmacy benefit manager, CVS Caremark,
by calling 800-294-5979. For other quantity limit requests, please call Health Care Services toll free at
800-950-5387 (option #6).
Specialty Drug Prior Authorization
The specialty pharmaceuticals benefit covers medications that treat complex clinical conditions, often with
complex drug delivery systems and routes of administration. Specialty pharmaceuticals are covered
according to each member’s group health plan. These medications include, but are not limited to,
infusible medications for chronic disease, injectable and self-injectable medications for acute and chronic
diseases, and other oral specialty medications.
BlueChoice provides coverage for specialty drugs under both the pharmacy and medical benefit.
Specialty oral and self-injectable medications are covered under the pharmacy benefit and must be filled
through our preferred specialty pharmacy, Accredo Specialty Pharmacy. Accredo is an independent
company that provides specialty pharmacy management on behalf of BlueChoice.
Drugs you administer in your office should be billed under the medical benefit. You are not
required to buy these drugs from Accredo.
Page 35
Several specialty drugs require prior authorization. If you administer a drug in your office that needs prior
authorization (and you bill for it under your tax ID number), contact BlueChoice at 800-950-5387 or fax us
at 800-610-5685. For self- administered (injectable or oral specialty) drugs, you can fax a prescription to
Accredo or call Accredo at 877-283-2829. For drugs that require prior authorization, Accredo will collect
the necessary information to pass along to Care Continuum. Care Continuum is an independent company
that provides specialty pharmacy utilization management on behalf of BlueChoice. You can also call Care
Continuum directly at 866-544-0857.
The member has a specialty pharmacy copayment for every dose you administer in your office. The
member has a monthly specialty pharmacy copayment for oral or self-injectable drugs. This copayment
ranges from $80 to $175. Please contact our Member Services department at 800-868-2528 or visit our
website at www.BlueChoiceSC.com to determine specific benefits and copayments for your patient. If you
supply these drugs in your office, please collect the copayment directly from the member. If Accredo is
dispensing the drug directly to the member, Accredo will collect the copayment.
For the most updated version of the Specialty Drug list, please see the Provider section of our website at
www.BlueChoiceSC.com. Go to Resources on the right side of the page, then Prescription Drug
Information, then Specialty Drugs.
In-Office Approved Labs
You can perform these labs in your office without prior authorization and bill them to BlueChoice
HealthPlan, or you can send them to LabCorp. All other labs must be sent to LabCorp. Any requests for
labs not sent to LabCorp or Genzyme Genetics (e. g., genetic tests, cholesterol subparticle testing, etc.)
must be preauthorized by Health Care Services at 800-950-5387.
81000 - Urinalysis
81001 - Urinalysis
81002 - Urinalysis
81003 - Urinalysis
81005 - Urinalysis
81015 - Urinalysis
81025 - Urine pregnancy
82042 - Urine
82043 - Urine, microalbumin,
quantitative
82044 - Urine, microalbumin,
semiquantitative
82120 - Amines, vaginal fluid,
qualitative
82247 - Bilirubin, total
82248 - Bilirubin, direct
82270 - 82272 - Fecal occult
blood
82274 - Fecal occult blood
82465 - Cholesterol
82947 - Glucose
82948 - Glucose
82950 - Post glucose dose
82951 - Glucose tolerance test (OB
office only)
83518 - Amnisure (OB office only)
83986 - pH, body fluid, except
blood
84702 - hCG, quantitative
84703 - hCG, qualitative
85013 - Hct
85014 - Hct
85018 - Hg
85025 - CBC with differential
85027 - CBC without differential
85048 - WBC
85610 - Prothrombin time (PT)
86308 - Mono
86403 - Rapid strep test
86580 - PPD
87070 - Culture, nose or throat
87081 - Culture, bacterial
87210 - Wet prep
87220 - KOH pre
87430 - Strep, group A,
immunoassay, multistep
87449 - Antigen immunoassay,
multistep
87480 - Candida, direct probe
87510 - Gardnerella vaginalis,
direct probe
87797 - Direct probe, NOS
87804 - Influenza, direct optical
observation
87807 - RSV (respiratory
syncytial virus)
87880 - Strep, group A, direct
optical observation
Page 36
LabCorp Stat Labs Menu
These stat labs must be sent to LabCorp only and do not require prior authorization. After verifying that
LabCorp is unable to provide a necessary stat lab, please contact Health Care Services for prior
authorization at 800-950-5387.
80048 - Basic Metabolic Panel, Serum
80051 - Electrolytes (Sodium, Potassium,
Chloride, C02), Serum
80053 - Comprehensive Metabolic Panel, Serum
80076 - Hepatic Function Panel, Serum
80156 - Carbamazepine, Serum
80162 - Digoxin, Serum
80178 - Lithium, Serum
80184 - Phenobarbitol, Serum
80186 - Dilantin, Serum
80198 - Theophylline, Serum
81001 - Urinalysis with microscopic
81003 - Urinalysis (without microscopic)
82040 - Albumin, Serum
82150 - Amylase, Serum
82247 - Total Bilirubin, Serum
82248 - Direct Bilirubin, Serum
82310 - Calcium, Serum
82374 - C02, Serum
82435 - Chloride, Serum
82552, 82550 - CPK
82553, 82550 - CKMB/Total
82565 - Creatinine, Serum
82947 – Glucose, Serum or Plasma
83690 - Lipase, Serum
83735 - Magnesium, Serum
84075 - Alkaline Phosphatase, Serum
84132 - Potassium, Serum
84155 - Total Protein, Serum
84295 - Sodium, Serum
84450 - SGOT, Serum
84460 - SGPT, Serum
84484 - Troponin
84520 - BUN, Serum
84702 - Beta HCG, Quantitative, Serum
84703, 81025 - Beta HcG, Qualitative, Serum or
Urine
85014, 85018, 85041, 85048 - CBC (only)
85025 - CBC with Platelets and Differential
85048, 85004 - Differential (only)
85049 - Platelets (only)
85060 - Pathology Review of Differential
85610 - Prothrombin Time
85651 - Sedimentation Rate
85730 - Partial Thromboplastin Time
86308 - Mononucleosis
87205 - Gram Stain
Genetic Lab Testing Services
Please direct genetic testing services for BlueChoice members to LabCorp or Genzyme Genetics.
Services rendered by LabCorp or Genzyme Genetics do not require preauthorization. To receive test
requisitions, patient brochures, supplies or to arrange for pick-up of a specimen, you can contact
Genzyme Genetics at 800-848-4436 or contact your local LabCorp office. If the specific genetic test is not
available through Genzyme or LabCorp, then prior authorization for that test is required.
Pathology
You have the option of sending cytopathology and surgical pathology specimens to LabCorp or a local,
contracting pathology group. For a listing of the pathology groups contracting with BlueChoice, please
refer to the Network Directory on the website or call Member Services at 800-868-2528.
Page 37
DME and Home Care Services
BlueChoice HealthPlan directly manages prior authorizations, claims and network management processes
for DME and home care services. BlueChoice will coordinate the delivery and authorization for home care
services.
Most services do not require prior authorization. Simply order the product or service from a network
provider. Please use the Request for Preauthorization of Benefits for Ancillary Services form to request all
other services requiring prior authorization. This form can be found on our website. Go to
www.BlueChoiceSC.com and select “Providers” then “Resources.” Print, complete and fax the form as
indicated.
DME under $100 may be supplied in the physician’s office and filed under the physician’s tax ID number
without prior authorization.
Pulmonary Function Tests
These complex pulmonary function tests require prior authorization except when rendered in a contracting
pulmonology/allergy office or a contracting outpatient facility:
94011 – 94016
94070
94150
94200
94240
94250
94260
94350
94360
94370
94375
94400 – 94621
94640
94642
94660
94662
94667 – 94750
94760 – 94779
Diabetes Education, Insulin Pumps, and Supplies
Diabetes education does not require prior authorization when provided at an approved center. Members
with diabetes and pre-diabetes can attend an education program at one of our contracting centers with no
copayment, deductible or coinsurance. If you would like a listing of the diabetic education program centers
in your area, please call 800-327-3183, ext. 25450 or visit our website at www.BlueChoiceSC.com. Click
“Health and Wellness.” Click on “Great Expectations for Health programs” and then click “Diabetes.” You’ll
find a link in this section to “Approved Education Centers.”
Glucose monitors are provided free of charge to our members with diabetes. Our preferred monitors are
AccuCheck (product of Roche Diagnostics*) and OneTouch (product of Lifescan, Inc. *). We send either
the AccuCheck Compact or OneTouch Ultra, but other models are available. Using a preferred model
reduces the member’s copayment for testing strips.
To order a glucose monitor, the patient or physician’s office can call our Diabetes Hotline at 800-3273183, ext. 25450. We will send the patient a free monitor in three to five business days.
* Please do not give the member a prescription for the monitor. The member’s pharmacy benefit does not
cover monitors. We do, however, cover strips under the pharmacy benefit, so the member will need a
prescription for the strips indicating how often you want him or her to test. Requests for more than 200
test strips per month require prior authorization.
Page 38
Insulin pumps and continuous glucose monitor systems are covered after meeting medical necessity
criteria up to the limits of the member’s DME benefit maximum. The physician’s office that is managing
the pump therapy must complete the Precertification for Medical Necessity External Insulin Infusion Pump
form found on our website. Continuous glucose monitoring systems can only be requested by completion
of the Precertification for Medical Necessity Continuous Glucose Monitoring System form found on our
website. Please call the Great Expectations Diabetes program at 800-327-3183, ext. 25224 with any
questions about this procedure.
Diabetic shoes (one pair per year) and inserts (two pairs per year) are covered if medically
necessary. Please be prepared to provide clinical information. The member’s financial responsibility will
depend on his or her individual coverage.
Diabetic care vouchers are sent to all members with diabetes. The purpose of the voucher is to
encourage the member to schedule a visit with his or her physician to get recommended screening tests
and review his or her diabetes care plan.
BlueChoice members who present this voucher are entitled to a maximum of up to one 30-minute
physician visit at no charge to the member in a calendar year. Additional visits during the calendar year
are subject to applicable copayments, deductibles and coinsurance.
When you submit a claim using either of the codes and diagnoses below, we will reimburse you at 100
percent of allowable charges by BlueChoice. You can submit evaluation and management codes with
your claim. The additional codes will be subject to deductible and coinsurance. You should not charge
members a copayment for this visit. As this voucher is for a diabetes care visit to review the member’s
diabetes care plan and make appropriate adjustments, we ask that you consider these tests as supported
by the American Diabetes Association during the visit:
•
•
•
•
•
HbA1c test (send to LabCorp or other preapproved laboratory)
LDL cholesterol (send to LabCorp or other preapproved laboratory)
Urine microalbumin test (performed in office or send to LabCorp or other preapproved laboratory)
Blood pressure measurement
Encourage your patient to get an eye exam
The American Diabetes Association is an independent organization that provides diabetes education
information on behalf of BlueChoice HealthPlan.
Submit your claim using one of these CPT codes for this benefit:
• 99401 - Preventive Medicine Counseling, Individual, 15 minutes
• 99402 - Preventive Medicine Counseling, Individual, 30 minutes
• Allowable primary diagnosis codes: 250.00 - 250.90
Microalbumin tests (CPT codes 82043 and 82044) are recommended by the American Diabetes
Association at least once a year for patients with diabetes. These tests can be performed in the
physician’s office or sent to LabCorp without authorization.
We cover diabetic eye exams for all our members with diabetes at no cost. If the member has routine
vision benefits, he or she can self-refer directly to any Physicians Eyecare Network (PEN) participating
provider. If the member does not have routine vision benefits, he or she can still receive a free exam by
contacting the Great Expectations Diabetes program at 800-327-3183, ext. 25450 for details.
Page 39
Asthma Supplies
Peak flow meters are provided free of charge to BlueChoice members with asthma, upon request, if
supplies are available. The member or physician can call 800-327-3183, ext. 25295 to order.
Spacers are covered under the member's pharmacy benefit. They are available at the middle tier,
preferred copayment. Only Aerochamber spacers, with or without a mask, are covered. This benefit is
limited to one per year. To get a spacer, the member must take a prescription for the Aerochamber to a
contracting pharmacy.
Nebulizers are a 10-month rent-to-purchase item for our members with asthma, reactive airway disease
or COPD.
Mental Health and Substance Abuse Prior
Authorization
Mental health and substance abuse services require prior authorization. Your office can get prior
authorization for these services by calling CBA at 800-868-1032 or any alternate number listed on the
back of the member’s identification card. You can also use CBA’s online Form Resource Center
(https://forms.companionbenefitalternatives.com).
It is during the initial evaluation of the member that the type of treatment and number of visits is
determined. CBA will encourage the behavioral health specialist to communicate the treatment plan to the
member’s primary care physician. Member benefits and medical necessity are considered during the
approval process.
Inpatient Care Prior Authorization
All inpatient hospital admissions require prior authorization. The admitting physician is responsible for
getting prior authorization for all elective procedures prior to admission by contacting our Health Care
Services department at 800-950-5387 (option #6). For emergency admissions that occur after hours or on
weekends, including antepartum maternity and all deliveries, the facility must notify us on the first
business day following the admission or delivery.
We approve benefits for the initial length of stay based on the member’s eligibility, admitting diagnosis
and medical necessity. One of our RN care management coordinators conducts a concurrent review.
Many of our contracting facilities are set up for on-site inpatient review. At facilities where on-site reviews
are not available, the RN care management coordinators receive clinical information directly from the
facility by phone, fax or the ProviderLink System. We use Milliman Care Guidelines to assist in medical
necessity determinations. These reviews are also evaluated by a BlueChoice HealthPlan medical director.
If we need additional clinical information to determine medical necessity, the RN care management
coordinator will contact the facility and/or the physician. During the concurrent review process, the RN
care management coordinators will also facilitate discharge planning.
Inpatient hospital prior authorizations include coverage for services of the attending physicians and
surgeons, including anesthesiology, pathology and radiology services. The authorization will also cover
labs for pre-admission testing.
Page 40
BlueChoice Care CallsSM
BlueChoice HealthPlan has an after-discharge call program to support the physician’s plan of care for
members following discharge from an inpatient facility. This program is called Care Calls. Our objective is
to provide a resource following discharge that extends the continuum of care for members who are
identified as at-risk for complications.
Criteria for selection for Care Calls include patients:
•
•
•
•
•
•
With complications and/or hospital stays greater than seven days
With identified home care needs
Discharged from a skilled nursing facility (SNF) or rehabilitation hospital
Discharged home on Coumadin therapy
With more than two admissions within the last six months
With co-morbid or chronic conditions that put them at increased risk for readmission (CHF, COPD,
etc.)
• With new diagnoses of diabetes or members admitted with DKA
We now also have a pre-service Care Call program for scheduled knee and hip replacement surgery.
Nurses placing these calls to members will identify potential gaps in care and intervene immediately to
help ensure a positive outcome postprocedure.
If the physician feels the member would benefit from a call, we would appreciate the opportunity to
support the plan of care. Please contact us at 800-327-3183, ext. 25417.
Emergency Medical Care
BlueChoice members are instructed to contact their treating physicians, if possible, before seeking
medical services in an emergency department (ED). If the treating physician sends the member to the
ED, the physician should contact us the next business day so we can provide an authorization. This will
eliminate the need for the claim to meet medical necessity criteria. If the member goes to the ED without
a referral from his or her physician, we will process the claim according to “prudent layperson” criteria. If
the member self-refers to the ED and the claim does not meet prudent layperson criteria, payment of the
claim will be the member’s responsibility.
Definition of “Prudent Layperson Criteria” — a medical condition manifesting itself by acute symptoms of
sufficient severity, including severe pain, such that a prudent layperson who possesses an average
knowledge of health and medicine could reasonably expect the absence of immediate medical attention
to result in:
• Placing the health of the individual, or with respect to a pregnant woman, the health of the woman or
her unborn child, in serious jeopardy
• Serious impairment to bodily functions
• Serious dysfunction of any bodily organ or part
Page 41
Prior Authorization Not Required
BlueChoice does not require you to get prior authorization for certain services when they are
provided in a contracting office. Members with an HMO or point-of-service (POS) plan must have
a valid referral for office visits on file for high benefits.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Arthrocentesis
Barium Enema
Barium Swallow
Bone Density Scans
Bone Scans
Breast Biopsies
Cardiac Event/Holter Monitor
Cardiovascular Stress Test (does not
include Nuclear Echo ie., Sestamibi,
Thallium etc.)
Colposcopy
CT/MR Guidance
Cystoscopy
Dilation of Anal Spincter
EEG (Neurologist office only)
EMG (Neurologist and Physiatrist only)
Endometrial Biopsy
Endometrial Ablation w/o Hysteroscopic
Guidance
EKG
Electroretinography w/Interpretation &
Report
Fluoroscopic Guidance for Needle
Placement
Fluoroscopic Guidance and Localization
Fundus Photography
Gastric Emptying Study
Hemorrhoid Ligation
Hemorrhoidectomy
Hemorrhoidopexy
Hida Scan (Hepatobiliary Scan)
Hysterosalpingogram (HSG)
Injection(s): Single Tendon Sheath or
Ligament, Aponeurosis (eg., Plantar
"fascia")
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Ingestion Challenge Test
KUB
Laser Treatment for Inflammatory Skin
Disease (Psoriasis)
Mammograms (Screening or Diagnostic)
Methylprednisolone Acetate, Injection
Plain Film X-rays
Plantar Fascia Injection
PT/OT/ST
Pulmonary Function Tests-Simple (see
URG under Pulmonary Function Test for
specific providers)
PUVA (does not require authorization if a
valid dermatology referral is on file)
Retinopathy, Treatment or Extensive or
Progressive Retinopathy
Routine Stress Test (Non-Nuclear)
Scanning Laser
Sigmoidoscopy
Surgical Tray
Trigger Point Injections
Ultrasounds (Abdominal, Pelvic, Renal,
Carotid,Transcranial Doppler,Opthalmic)
Urodynamics
UVA and UVB (does not require
authorization if a valid dermatology
referral is on file)
Vasectomy in a Urologist Office (check
exclusions)
VCUG (if Urinalysis is requested an
authorization will need to be loaded to the
facility for the UA)
Visual Field Examination
Page 42
Primary Care Physician Services
These services/procedures do not require prior authorization when performed by a primary
care physician:
•
•
•
•
•
•
•
•
•
Colonoscopy (45378-45392)
Continuous overnight pulse oximetry (94762)
Excision of nail (11720-11755)
Flexible sigmoidoscopy (45300, 45330-45335, 45338- 45340)
Iron injection (J1750)
Paring or cutting of benign lesions (11055-11057)
Removal of skin tags (11200-11201)
Spirometry (94010, 94014-94016, 94060, 94070, 94375, 94620)
U/S bone density measurement (76977), peripheral
Page 43
Section 5
Page 44
Obstetrical Authorization Procedures
Great Expectations Maternity
BlueChoice enrolls all pregnant members in our maternity program, Great Expectations Maternity,
which provides educational materials and ongoing support and monitoring by our nurses and health
educators. If you would like to talk with someone about this program, please call us at 800-327-3183, ext.
25293.
Global Maternity Authorization
Once a member discovers or suspects she is pregnant, she can go to either her primary care physician or
self-refer to her obstetrician. The physician who verifies the member is pregnant should immediately
initiate the maternity authorization
by completing the Maternity Authorization Form found on our website in the Providers’ section and faxing
it to BlueChoice. We developed this form as a mechanism for the physician and BlueChoice to monitor
members who are at risk for delivering low birth weight or otherwise high-risk infants.
Once we receive the form, our Maternity Services department will authorize global maternity care. We will
send a confirmation letter to the obstetrician, primary care physician and member.
Services Included in the Maternity Authorization
The global fee (which is to be billed after delivery) includes all prenatal visits (routine or non-routine),
delivery and postpartum care. Once you get the initial maternity authorization, these services can be
performed in the obstetrician’s office and billed separately without additional authorization:
•
•
•
•
•
•
Ultrasounds
Amniocentesis
Non-stress tests
Biophysical profiles
Approved in-house labs (see list on page 33)
Rhogam injections
Please note: BlueChoice will pay for these services without a separate authorization, as long as they are
medically necessary. We may request medical records to confirm medical necessity (e. g., ultrasounds
performed solely to determine sex are not considered medically necessary). Should we identify a service
as not medically necessary, we will deny coverage of the service or request a refund from your office. In
these circumstances, the member is not liable for the charges.
Services Provided In the OB Office That Require Prior
Authorization
BlueChoice only needs to separately authorize services that are not related to maternity care. We will not
cover non- maternity services provided without authorization.
Page 45
Services Provided Outside the OB Office That Require Prior
Authorization
Several maternity services rendered outside the obstetrician’s office require prior authorization. These
services can be preauthorized by calling BlueChoice at 800-950-5387 (option #3) or by faxing the
Maternity Referral Form found on our website to 800-610-5685. You may be held responsible for these
services if received by the member without prior authorization.
Examples of services that require prior authorization:
• Referrals for outpatient services including amniocentesis, non-stress tests and biophysical profiles
[No separate authorization for outpatient fetal non-stress test (59025) is required, if filed with one of
these diagnostic codes: 643.91-645.20, 648.84-648.94.]
• Referrals to other specialists (maternity or non-maternity related)
• Labs, pathology and genetic testing sent to a non-contracting facility
• External Cephalic Version
• Referrals for inpatient services, including all deliveries (notification process found on page 42,
Inpatient Care Prior Authorizations). In accordance with federal guidelines, a minimum two-day
inpatient length of stay will be authorized for a vaginal delivery and a minimum three-day inpatient
length of stay will be authorized for a Cesarean section delivery. Hospital-affiliated birthing centers
(or birthing centers owned by a hospital) are a covered benefit for some groups. A maternity
authorization must be on file for the hospital-affiliated birthing center.
• Hydroxyprogesterone (17-P) Injections
Referrals to Specialists
While the member is pregnant, her obstetrician can serve as her primary care physician and refer her to
other specialists when necessary. These referrals can be maternity or non-maternity related. Once it is
determined that the member needs to be referred to a specialist, it is the obstetrician’s responsibility to get
authorization from BlueChoice. If the member has been treated for the condition by her primary care
physician, or if it is something that the primary care physician can treat, we may request that you send the
member to her primary care physician. You can get authorization for referrals by calling BlueChoice at
800-950-5387 or by faxing the Maternity Referral Form found on our website to 800-610-5685.
Laboratory
You can perform the in-office approved labs listed on page 33 without authorization. You should send all
labs not on the list of approved in-office labs to LabCorp and they do not require prior authorization.
Also, refer to page 33 for a list of labs that can be performed stat by LabCorp. These stat labs must be
sent to LabCorp only and do not require prior authorization. After verifying that LabCorp is unable to
provide a necessary stat lab, please contact Health Care Services for prior authorization at 800-950-5387.
Any lab work performed at a location other than the obstetrician’s office, LabCorp or a contracting
pathology group must have prior authorization.
Page 46
Pathology
You can send anatomical pathology (histology) and cytology specimens to LabCorp or to one of the local
contracting pathology groups. For a listing of the local pathology groups contracting with BlueChoice,
please refer to the Network Directory on the website or call Member Services at 800-868-2528.
Anatomical pathology specimens you send to a contracting laboratory do not require prior authorization.
Genetic Lab Testing Services
You can send genetic lab testing to LabCorp or Genzyme Genetics. Services rendered by LabCorp or
Genzyme Genetics do not require prior authorization. To receive test requisitions, patient brochures and
supplies, or to arrange for pick-up of a specimen, please contact Genzyme Genetics at 800-848-4436 or
your local LabCorp office. If the specific genetic test is not available through Genzyme or LabCorp, then
prior authorization for the test is required.
Greenwood Genetics is now in the network. As long as a valid referral is on file, no authorization is
required for labs done in the office. You can get authorization for referrals by calling BlueChoice at 800950-5387 or by faxing the Maternity Referral Form found on our website to 800-610-5685.
Filing Claims for Maternity Services
BlueChoice pays claims for prenatal office visits (routine and non-routine), delivery and postpartum visits
under a global reimbursement arrangement. You should file these claims after the member delivers. Use
these CPT codes for global maternity charges:
59400 — Routine OB care, including antepartum care, vaginal delivery (with or without episiotomy,
and/or forceps) and postpartum care
59510 — Routine OB care, including antepartum care, Cesarean delivery and postpartum care
59610 — Routine OB care, including antepartum care, vaginal delivery (with or without episiotomy
and/or forceps) and postpartum care, after previous Cesarean delivery
59618 — Routine obstetric care, including antepartum care, Cesarean delivery and postpartum care
following attempted vaginal delivery after previous Cesarean delivery
Page 47
You can file claims individually for prenatal visits, delivery and postpartum visits only when the member
miscarries, changes physicians, disenrolls, delivers before her 26th week, or if the member is received by
her obstetrician or enrolls with BlueChoice after her 34th week. You should use these CPT codes when
filing individually for maternity services:
59409 — Vaginal delivery only (with or without episiotomy and/or forceps)
59410 — Vaginal delivery, including postpartum care
59514 — Cesarean delivery only
59515 — Cesarean delivery, including postpartum care
59612 — Vaginal delivery only, after previous Cesarean delivery (with or without episiotomy and/or
forceps)
59614 — Vaginal delivery including postpartum care, after previous Cesarean (with or without
episiotomy and/or forceps)
59620 — Cesarean delivery only, following attempted vaginal delivery after previous Cesarean delivery
59622 — Cesarean delivery only, following attempted vaginal delivery after previous Cesarean delivery,
including postpartum care
99201 to 99215 — Prenatal office visits
59425 — Antepartum care only; four to six visits
59426 — Antepartum care only; seven or more visits
If a member miscarries, changes physicians, disenrolls or delivers before her 26th week, the obstetrician
should notify BlueChoice as soon as possible so that the maternity authorization can be updated to pay
the above services individually. If BlueChoice HealthPlan does not receive notification, claims for
individual services will not process separately.
Copayments for maternity members are one-time only since the charge for obstetrical care is global.
Special Considerations
• Fetal non-stress test for multi-fetal gestation is not eligible for additional reimbursement.
• Delivery of multiple babies is not eligible for additional delivery reimbursement through the same
opening (vaginal or C-section).
• Prenatal or childbirth education classes are non-covered services.
• Some drugs require prior authorization to override the approved quantity of medications. For
assistance with Zofran (odanestron) overrides, please call BlueChoice at 800-950-5387 (option #3).
Members can get an initial quantity of six per month from their pharmacies without prior
authorization.
• Lovenox must be filled by the preferred specialty pharmacy. Members are allowed, however, to get
an initial 30-day supply at a retail pharmacy. Prior authorization is required after 30 days of therapy.
• Based on the member’s benefits, we may cover the purchase of ONE breast pump per 12-month
period. Please call with questions or to review benefits.
Page 48
Section 6
Page 49
Claims and Billing Information
Filing Claims
Electronic Claims Filing — BlueChoice encourages you to file your claims electronically. Electronic
claims are processed significantly faster than hard copy claims. Please check with your computer system
vendor for more information on the benefits of filing electronically. If you are already filing your claims
electronically and need help with a technical problem, please contact your computer system vendor or our
Technology Support Center at 800-868-2505.
Web Claims — You can also file your primary and corrected claims through our website at
www.BlueChoiceSC.com. Claims you file through our website are immediately entered into our system
which allows for a much faster processing time. The “Your Patient Directory” feature allows providers to
create a directory of their patients’ names, ID numbers, dates of birth, addresses, etc. This information will
then be auto-populated into their Web claims, eliminating the need to re-enter this information each time
you file a new claim. If you are interested in filing your claims through our website, please contact
Provider Education at 803-264-4730 or [email protected] for a demonstration.
Hard Copy Claims — Please file hard copy professional claims on a CMS-1500 (formerly HCFA-1500)
claim form or institutional claims on a UB04 claim form. Mail claims to:
ATTN: Claims Department
P. O. Box 6170 (AX-415) Columbia, SC 29260-6170
Electronic Funds Transfer (eft) and Electronic Remittance Advice (ERA) — EFT and ERA are
required for all providers in the BlueChoice provider network. Payments received through EFT are several
days quicker than paper checks and remits. You can view your remits on our website at
www.BlueChoiceSC.com through My Insurance Manager or My Remit Manager. You can also choose to
set up Electronic Remittance Advice (ERA) through your vendor. If you are not currently set up for EFT or
ERA, please contact our EFT department at [email protected].
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Superbill
Superbill is a convenient way for providers to expedite submission of primary claims for one date of
service only. You can create and store your Superbill online, then use it to submit a professional Web
claim with a minimum number of keystrokes. All you do is click on the procedure codes and diagnosis
codes on your Superbill and hit “Submit.” You can use the Superbill with “Your Patient Directory” for the
fastest possible Web claim submission.
Superbill is available to all contracting providers FREE of charge. Just visit our website and follow these
easy steps:
•
•
•
•
•
Go to “My Insurance Manager.”
Click on “Professional Claim Entry.”
Look under “Superbill” and click on “customize” to set up one or more Superbills with your most
frequently used procedures and diagnosis codes.
You can also contact Provider Education at 803-264-4730 or [email protected] if you’d like
someone to come by your office to help you get set up on Superbill.
My Remit Manager
My Remit Manager allows you to sort remits by:
•
•
•
•
•
•
•
•
Patient’s name
Patient’s account number
Check number
Provider’s location
Payor’s name
Date of service
Place of service (inpatient or outpatient)
Paid status (primary, secondary, denied, etc.)
It is very user friendly! Remits and EOBs are downloaded into easy-to-read PDF files. Files can also be
exported into Microsoft Excel spreadsheets. To sign up:
• Go to www.SouthCarolinaBlues.com.
• Click on “Providers” and look under “Resources.”
• Click on “My Remit Manager.”
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Checking Claim Status
BlueChoice Website — The best way to check the status of a claim is by visiting our website at
www.BlueChoiceSC.com and using “My Insurance Manager.” If you would like a demonstration of our
website, please contact Provider Education at 803-264-4730 or [email protected].
Voice Response Unit — You can also check the status of a claim by accessing the BlueChoice Voice
Response Unit at 800-868-2528. Once the automated operator answers, press 1. Then press 2 for
providers and enter your nine- or 12-digit Tax Identification Number followed by the pound (#) key.
Member Services Department — You can always check the status of a claim by speaking directly to a
BlueChoice Member Services representative by calling 800-868-2528. Select option 1 for English, then
option 2 for providers.
Assistant Surgeon and Co-Surgeon Claim Filing
You should file claims for assistant surgeon services with modifier 80 to indicate a surgical assistant was
used. We only recognize physicians, physician assistants, nurse practitioners and clinical nurse
specialists as assistant surgeons. We pay benefits for assistant surgeons according to BlueChoice
policies and base them on the surgical procedure and Milliman Care Guidelines criteria.
You should file claims for co-surgeon services with modifier 62. These claims will be reviewed postprocedure to ensure appropriate reimbursement. Requests for assistant surgeons and co-surgeons
should be preauthorized whenever possible.
Bilateral Procedure Claim Filing
You should file claims for bilateral procedures on one line with the 50-modifier and one unit.
Multiple Procedure Claim Filing
You should file claims for multiple procedures filed on the same date of service on the same line with the
appropriate number of units.
Unlisted J-Code Claim Filing
When a new drug is released and has not yet been assigned its own unique J-code, you can file for the
drug using an unlisted J-code, if so indicated by the manufacturer. It is, however, very important to
include the drug name, dosage and National Drug Code (NDC) on the claim so we can properly identify
the drug and process your claim without delay.
Anesthesia Claim Filing
Time Units — You should file anesthesia claims with the number of minutes in the quantity field. We
reimburse all physician and Certified Registered Nurse Anesthetist (CRNA) services in 15-minute
increments (1 time unit = 15 minutes). We will round units to the nearest tenth.
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Modifiers — You should file anesthesia claims with CPT codes 00100-01999 and they must have one of
these modifiers:
Anesthesiologist Modifiers
AA - Anesthesia services personally performed by the anesthesiologist
Pricing Formula = (RVU + Time Units) x Conversion Factor
AD - Supervision of five or more concurrent anesthesia services – not paid by BlueChoice HealthPlan.
QK -Medical direction by anesthesiologist – two, three or four concurrent procedures
Pricing Formula = (RVU + Time Units) x Conversion Factor x 65%
QS - Monitored Anesthesia Care – must be billed with modifier AA
Pricing Formula = (RVU + Time Units) x Conversion Factor
QY - Supervision of one procedure
CRNA Modifiers
QX - Medically directed anesthesia services
QZ - Anesthetist services not medically directed
No additional benefits are allowed for other anesthesia services on the same day as services with
modifier QZ.
Please note: BlueChoice uses Medicare RVUs to price anesthesia claims.
Risk Factor Modifiers — Risk factor modifiers for anesthesia services are only allowed when the
services are filed with the“AA” modifier. Here are the valid risk modifiers:
P3 - A patient with severe systemic disease (add one RVU)
P4 - A patient with severe systemic disease that is a constant threat to life (add two RVUs)
P5 - A moribund patient who is not expected to survive without the operation (add three RVUs)
Anesthesia Procedures reimbursed by fee schedule — These procedure codes are reimbursed by fee
schedule:
01967 - Anesthesia for planned vaginal delivery
01968 - Anesthesia for Cesarean delivery
01969 - Anesthesia for Cesarean hysterectomy following neuraxial labor anesthesia
CRNAs may be reimbursed for epidurals. The CRNA should file with the “QX” modifier, and the physician
should file with the “QK” modifier. If the epidural is performed solely by the physician, then the “AA”
modifier should be used.
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Member Responsibility Guidelines
Members are liable for your charges when:
• A member does not reveal to your office that he or she has BlueChoice coverage and the claim is
denied because your office renders a service that requires prior authorization from BlueChoice. In
this instance, members are responsible for all denied charges. Note: You will need to provide
documentation to request reconsideration.
• A member receives services after his or her disenrollment date. In this case, members are
responsible for all denied charges.
• A member receives services his or her benefit plan does not cover. In this instance, members are
responsible for all non-covered charges.
• A Primary Choice or MyChoice HMO plan member self-refers to a participating specialist and
refuses to get a referral from his or her primary care physician. In this case, your office staff should
require that the member sign a statement specific to the date of service that verifies the member
understands BlueChoice will not cover charges without a referral from his or her primary care
physician and that he or she will be responsible for your charges. Please collect the payment directly
from the member and do not file your claim to BlueChoice HealthPlan. If the claim is filed to
BlueChoice and denied, you will need to submit the signed statement from the member along with
an appeal letter for payment reconsideration.
• A Primary Choice plan member self-refers to a non-participating physician. In this instance,
members are responsible for all denied charges. If a contracting physician refers a member to a noncontracting provider, however, the member is not responsible for those charges. Note: Members can
appeal claims denied for this reason, and the referring office may become responsible for the nonparticipating office’s charges.
Member Financial Responsibility
Copayments
The copayment is a “threshold” amount that you should collect each time the member visits your office.
The only exception is for obstetrical care, which has a one-time only copayment, considered a “global”
fee. It is your responsibility to collect copayments from members. The best time to do this is at the time of
service.
Coinsurance and Deductibles
Some BlueChoice members have benefit plans with coinsurance and deductibles. The coinsurance is the
percentage of the allowed amount that the member, not BlueChoice, is responsible for (e. g., we pay 80
percent and the member pays 20 percent). Members may also have to meet a deductible before we will
begin making payments.
Balance Billing
We base physician reimbursement on our “allowed amount.” By signing the Professional Agreement and
Hold Harmless Agreement, you have agreed not to bill members for any balance between the BlueChoice
allowed amount and your charge for covered services.
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Refunds
If you receive a payment that needs to be returned to BlueChoice, you can use the Refund Form found on
our website. This form ensures that your check is routed to the appropriate department and is properly
processed.
Coordination of Benefits (COB)
Some members elect to have more than one health insurance policy in order to help eliminate or reduce
the amount of out-of-pocket expenses the member has to pay. Members can now complete the Other
Health Coverage Questionnaire online by logging into My Health Toolkit®. If you want to provide hard
copies to your members, you can view and print the form from our website under “Providers” and then
“Forms.”
Regarding COB claims, we often refer to the insurance carriers as either primary or secondary. Primary is
the policy that pays first. Secondary is the policy that pays second.
Filing COB Claims — Please file your secondary claims along with a copy of the primary carrier’s
Explanation of Benefits (EOB).
Determining Primary vs. Secondary — To determine which policy is primary, we apply these COB rules
in this order:
1. Non-Dependent/Dependent — The group plan provided where an employee works is primary for
the employee.
If the same employee is also covered as a dependent under a spouse’s plan, the spouse’s plan is
secondary.
2. Dependent Child: Parents Not Separated or Divorced — When the same child is covered as a
dependent of different persons, called “parents”:
a. The plan of the parent whose birthday falls earlier in a year is primary to the plan of the parent
whose birthday falls later in that year.
b. If both parents have the same birth date, the plan that has been in effect longer is primary.
The reference to “birth date” means only the month and day. It does not refer to the year of birth.
3. Dependent Child: Parents Separated or Divorced — When a child is covered as a dependent
under two or more plans of divorced or separated parents, coverage responsibility is determined in
this order:
a. First, the plan of the parent with custody of the child
b. Then, the plan of the spouse of the parent with custody of the child
c. Then, the plan of the parent not having custody of the child
If the court has determined that one of the parents is responsible for the health care expenses of the
child, and the entity obligated to pay or provide the benefits of the plan of the parent has actual
knowledge of those terms, however, the benefits of that plan are primary. The plan of the other
parent is considered secondary.
4. Joint Custody — If a court has determined that the parents shall share joint custody, without stating
that one of the parents is responsible for the health care expenses of the child, the primary plan will
be determined according to Rule 2 above.
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5. Active/Inactive Employee — The plan that covers a person as an employee who is neither laid off
nor retired (or that employee’s dependent) is primary to the plan that covers that person as a laid off
or retired employee (or that employee’s dependent).
6. Longer/Shorter Length of Coverage — If none of the rules above apply, the plan the member has
been covered under the longest is primary.
7. Medicare — BlueChoice is secondary to Medicare except when federal law mandates BlueChoice
to be the primary plan. NOTE: The laws governing Medicare are very complex and change
frequently. The two most common examples of our plan paying primary are listed below. If you have
more questions, please contact our Member Services department.
a. This plan is primary to Medicare for employer group health plans of 20 or more employees for
working members over age 65 and their spouses.
b. This plan is primary to Medicare for employer group health plans for employees, retirees and
dependents who are entitled to Medicare solely on the basis of End Stage Renal Disease (ESRD)
for up to 30 months.
Methods for Calculating COB — Each employer group decides what type of COB it would like to
purchase for its employees. Each method calculates payments differently, and may not provide for
payment of the entire remaining balance after the primary carrier has paid. Here are three methods for
calculating COB payment:
• Standard COB — The secondary policy subtracts the primary policy’s payment from the total
charges to calculate the remaining liability. The secondary policy will either pay the remaining
liability or the secondary policy’s “primary liability,” whichever is less.
• Maintenance of Benefits — The secondary policy subtracts the primary policy’s payment from its
allowed amount to calculate the remaining liability. The secondary policy will either pay the
remaining liability up to its allowed amount or the secondary policy’s “primary liability,” whichever is
less.
• Non-Duplication of Benefits — The secondary policy subtracts the primary policy’s payment from
the secondary policy’s primary liability to calculate the remaining liability. The secondary policy will
pay either its “primary liability,” or its “primary liability” minus the primary policy’s payment, whichever
is less.
NOTE: The secondary “primary liability” is the amount that the secondary policy would have paid if it had
been the primary policy.
Medicare and COB
These guidelines will assist you in handling Medicare beneficiaries who also have BlueChoice coverage:
When Medicare is primary and the provider has accepted assignment:
•
•
•
•
Do not charge the patient.
File the claim to Medicare.
Receive the Medicare Summary Notice (MSN).
File the claim to BlueChoice and include a copy of the MSN. Indicate in the “other coverage” field
that Medicare is primary.
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When Medicare is primary and the provider has not accepted assignment:
• Charge the member in full, up to the Medicare-allowed amount.
• File the claim to Medicare.
• File the claim to BlueChoice indicating in the “other coverage” field that the member has Medicare
and has “paid in full.”
• After Medicare has processed the claim, have the member file a copy of the MSN to BlueChoice.
When Medicare is secondary:
• Collect the BlueChoice copayment from the member.
• File the claim to BlueChoice and indicate in the “other coverage” field that Medicare is secondary.
• BlueChoice will pay the claim according to our current fee schedule.
• The member can then file to Medicare for reimbursement for the BlueChoice copayment.
Subrogation
Subrogation is the method BlueChoice uses to collect compensation from the appropriate insurance
carrier or responsible third party when a member receives treatment for an injury. We will exercise all
rights to subrogation procedures where they apply. When a BlueChoice member is involved in a
subrogation case, you should treat the patient as any other BlueChoice member. We will pay benefits
directly to your office. If the court deposes you, or requests that you file certain forms or render care over
and above what is considered medically necessary, you should collect any related fees from the other
insurance carrier or the attorney representing the carrier.
Workers’ Compensation
BlueChoice does not cover treatment of an occupational illness or injury covered by workers’
compensation. You should treat the member and follow the normal procedures for filing workers’
compensation claims. If there is any question whether workers’ compensation covers the treatment,
please follow all normal BlueChoice referral and authorization procedures.
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Section 7
Page 58
Network Status and Credentialing
Change In Status
Please notify BlueChoice any time your practice experiences a status change by completing the
appropriate form on our website in the Providers’ section under Forms or other appropriate
documentation.
All status changes need to be emailed or faxed to:
[email protected]
Fax: 803-264-4795
Examples of changes that we need to know about:
•
•
•
•
•
•
Change of name, address, telephone, TIN number or NPI number
New satellite office locations
New physician joining a practice
Physician leaving a practice
Change of office manager or other contact person
Change of ownership (practice purchased by a hospital, MSO, IPA, etc.)
When a primary care physician leaves a practice, BlueChoice will send notification letters to all members
assigned to that physician. When a specialist physician terminates his or her contract with BlueChoice,
the specialist is responsible for notifying his or her members.
Provider Credentialing
BlueChoice credentials all physicians before adding them to the network according to the National
Committee for Quality Assurance (NCQA) standards. This applies even when a new physician joins an
established practice. New physicians must complete the SC Uniform Managed Care Application and
the additional forms and information included in the BlueChoice Provider Credentialing Packet.
Please contact Provider Education at 803-264-4730 or [email protected] for a copy of the
full BlueChoice credentialing packet, including the SC Uniform Managed Care Provider Credentialing
Application, or you can access the information on our website, www.BlueChoiceSC.com. You can also get
a disk copy of the SC Uniform Managed Care Application from the South Carolina Medical Association.
Please email or fax your completed application and forms to:
[email protected]
Fax: 803-264-4795
Once our Credentialing department receives a fully completed application, it takes approximately 30 to 60
days before the process is complete. Your Provider Education representative will contact your office to let
you know the effective date and to set up a time for a new office educational session.
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Until a physician has successfully completed the credentialing process, we cannot publish his or her
name in the BlueChoice Network Directory, nor will members be able to select him or her as their
physician. The effective date will be the date of approval by the credentialing committee. Effective dates
are not retroactive.
Sleep Studies — BlueChoice has a separate credentialing process for facilities and providers of sleep
study services. Both sleep labs and physicians interpreting sleep studies have to meet specific criteria
every three years to remain current. All sleep studies for BlueChoice members must be preauthorized.
For authorization to be approved, the physician or facility needs to appear on our list of currently
credentialed sleep study providers. Please contact Provider Education at 803-264-4730 or
[email protected] for a copy of the BlueChoice Sleep Lab Facility or Interpreting Physician
credentialing form.
Recredentialing — BlueChoice recredentials all physicians every three years. The SC Uniform Managed
Care Practitioner Credentials Update Form is used for recredentialing. Our Credentialing department will
notify your office and send you a copy of this form when it is time for recredentialing. You can download a
copy of the form found on our website in the Providers’ section under Forms.
Recredentialing is a requirement of your professional agreement and must be completed in order to
maintain active network status.
Credentialing Rights
We want to make sure the information we collect as part of the credentialing process is accurate and
complete. We afford physicians these rights as they relate to their credentialing and recredentialing
information:
• The right to review information submitted to support the credentialing or recredentialing application
• The right to correct erroneous information
• The right to be informed of the status of the credentialing or recredentialing application
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Section 8
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Quality Improvement
Quality Improvement Program and Report
BlueChoice maintains an active quality improvement program. This program oversees various monitoring
functions, such as Quality Assurance (QA) studies, member satisfaction surveys and a review of patient
grievances. BlueChoice continuously monitors clinical and service quality issues. We document this
process in our annual Quality Improvement Evaluation and Action Plan. If you would like to receive
information about our quality improvement program or the annual evaluation, please call our Quality
Improvement department at 803-786-8466. You can also find selected results of our annual Healthcare
Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and
Systems (CAHPS) surveys on our website under About Us/Performance.
Practitioner/Provider Performance Data
Practitioner/provider performance data refers to compliance rates, reports and other information related to
the appropriateness, cost, efficiency and/or quality of care delivered by an individual health care
practitioner, such as a physician, or a health care organization, such as a hospital. Common examples of
performance data would include the HEDIS quality of care measures maintained by the National
Committee for Quality Assurance (NCQA) and the comprehensive set of measures maintained by the
National Quality Forum (NQF). We can use practitioner/provider performance data for multiple plan
programs and initiatives, including, but not limited to:
• Reward Programs – Pay for performance (P4P), pay for value (PFV) and other results-based
reimbursement programs that tie provider or facility reimbursement to performance against a defined
set of compliance metrics. Reimbursement models include, but are not limited to, shared savings
programs, enhanced fee schedules and bundled payment arrangements.
• Recognition Programs – Programs designed to transparently identify high-value providers and
facilities and make that information available to consumers, employers, peer practitioners and other
health care stakeholders.
Primary Care Physician Office Access Goals
For primary care services, the standards, found in the appendix, reflect the BlueChoice Clinical Quality
Improvement Committee’s recommendations for accessibility to the primary care physician office. The
Clinical Quality Improvement Committee consists of contracting primary and specialty care physicians
and internal BlueChoice staff. We measure physician compliance with the access standards through
member satisfaction surveys, on-site office assessments and monitoring of member complaints.
Improving Patient Satisfaction by Decreasing Wait Time
Results of previous member satisfaction surveys indicate that wait time in BlueChoice network offices
continues to be longer than wait times in other parts of the country. We always strive to provide
information to our physicians that can improve office efficiencies. If you would like suggestions on
decreasing wait time and improving your patients’ satisfaction, we have a resource for you. We have
researched the literature related to improving satisfaction by decreasing wait time in the office, and have
summarized our findings in an article in the appendix.
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Preventive Health Services
BlueChoice and its Clinical Quality Improvement Committee have adopted preventive health guidelines
for adults and children. We select national preventive guidelines and receive local input from the
Committee. The objective of the Health Management department is to provide ongoing education to
members and physicians to ensure they are aware of these guidelines. We take steps to develop
appropriate programs to assist our members and physicians in following the preventive health guidelines.
You can find a description of these guidelines and associated websites in the appendix or you can find
them on our website at www.BlueChoiceSC.com.
Practice Guidelines
BlueChoice and its Clinical Quality Improvement Committee have adopted best practice guidelines for
several areas of clinical care. We select national practice guidelines and receive local input from the
committee. We then monitor compliance with these standards through medical chart review and claims
analysis. Please refer to the appendix for a listing of the Web addresses for the national guidelines we
have adopted. Or, you can visit our website at www.BlueChoiceSC.com for direct links to these practice
guidelines. If you would prefer to receive a hard copy of these guidelines, please call the Quality
Improvement department at 803-786-8466.
Medical Office Site and Records Review
We conduct the general office review for all physician offices that have received a member complaint in
one of these categories: physical accessibility, physical appearance and adequacy of waiting and
examining room space. BlueChoice has 60 days after a complaint to conduct an office review. Multiple
complaints about the same provider within the same complaint category does not generate the need for
additional office reviews. If a provider receives a complaint in a different category, however, we must
conduct an additional office review whether or not we have already conducted a prior office review. The
purpose of this review is to verify that care is being provided in an appropriate environment that can
adequately meet the needs of our members.
BlueChoice will continue to conduct pre-contracting general office reviews for Medicare and Medicaid.
Providers who perform outside our standard are reviewed every six months until achieving a passing
score. The purpose of this review is to verify that care is being provided in an appropriate environment
that can adequately meet the needs of our members. The review covers areas including medical record
keeping practices, office physical environment, medical emergency preparedness,
appointments/scheduling, laboratory facilities and radiology services.
It is the primary care physician’s responsibility to ensure the continuity and coordination of care. The
medical records should include documentation of all services provided, including ancillary and diagnostic
tests the primary care physician ordered, and all diagnostic, consultation and therapeutic services for
which the primary care physician referred the member.
We have established standards for medical record documentation and on-site medical office reviews.
Please refer to the appendix for a copy of our medical record documentation criteria and our medical
office review criteria. For copy-ready model chart forms, you can contact the Quality Management
department or visit our website at www.BlueChoiceSC.com.
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Member Satisfaction Surveys
BlueChoice conducts a survey to assess members’ satisfaction with the care and services they receive.
We share the results of these surveys with physicians annually. For information on the results of the most
recent survey, please visit our website at www.BlueChoiceSC.com or contact Provider Education at 803264-4730 or [email protected].
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Appeals
Member Appeals — Members can appeal the denial of coverage of a service. Members should contact
the Member Services department to request an appeal.
Physician Appeals — Contracting physician offices can request an appeal of a claim denial or other
adverse determination. You must submit the appeal request on the Physician Appeal/Reconsideration
Request Form found on our website and file it within 90 calendar days of the earliest adverse
determination notification. You must include pertinent clinical or other documentation necessary to
support the appeal. Physicians have one level of appeal only. Physician offices that provide a fax number
on the appeal form will receive fax confirmation from the Appeals department.
Mail appeals to:
ATTN: Provider Appeals/Reconsiderations
P. O. Box 6170 (AX-325) Columbia, SC 29260-6170
Or, fax to: 800-610-5685
Physicians can request appeals for:
• Denials for payment only when there are extenuating circumstances (For example, if a member
does not reveal to you that he or she is covered by BlueChoice or if a Primary Choice member
refuses to get a referral from his or her primary care physician before seeking the services of a
contracting specialist.)
Physicians can request reconsiderations for:
• Payments for surgical procedures only when there is added complexity that may warrant
additional payment (You should include medical records and operating room time with your
request.)
Expedited Appeals — If you or a member believes that a denial of coverage of pending medical services
warrants immediate appeal due to the medical urgency of requested services, you or the member can
request an expedited appeal. An expedited appeal related to pre-service medical necessity must indicate
that a delay in decision making might seriously jeopardize the life or health of the member; or if a
member’s physician certifies that the member has a serious condition that requires immediate medical
attention to avoid serious impairment to bodily functions, serious harm to an organ or body part, that
would place the member’s health in serious jeopardy; or if in the opinion of a provider with knowledge of
the member’s medical condition, would subject the member to severe pain that cannot be adequately
managed without the care or treatment that is the subject of the request. If BlueChoice determines that
the appeal qualifies for expedited status, we will process the appeal and notify all involved of our decision
within 24 to 72 hours of the receipt of all information necessary to complete the appeal, dependent upon
the plan’s non-grandfathered versus grandfathered status.
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Pre-service Appeals — Physicians can request internal appeals of adverse determinations related to
medical necessity or the experimental or investigational nature of any proposed health care service or
supply. Physicians shall have the right to file an appeal of an adverse determination prior to rendering the
service (“Pre-Service Appeal”), if they are appealing on behalf of the BlueChoice member. For urgent
Pre-Service Appeals, we will automatically deem the physician to be the authorized representative of the
member. For all other Pre-Service Appeals, you must get authorization from the member in writing. If you
file a Pre-Service Appeal on behalf of the member, we will handle it under the appeal process available to
its plan member based on the terms of that plan member’s plan and the applicable state and federal laws
and regulations.
Independent Review Organization Requests — Certain medical necessity appeals may qualify for
review by an Independent Review Organization (IRO). These requests must be in writing, initiated by the
member (or legally authorized member representative) and must meet this criteria in accordance with the
SC Department of Insurance (SCDOI) Guide to External Review, Bulletin Number 2001-4(A):
• The service or payment for service was denied, reduced or terminated because:
 The service does not meet our requirements for medical necessity, appropriateness, health care
setting, level of care, or effectiveness; or
 The service was experimental or investigational and involves a life-threatening or seriously
disabling condition; and
• The amount payable for covered benefits is at least $500 for grandfathered plans (nongrandfathered plans do not have a required minimum dollar amount); and
• The BlueChoice internal appeals process has been completed.
To qualify for this type of appeal, you must exhaust the internal BlueChoice appeal process and you must
request the external appeal process within 90 days of the original appeal. Additionally, the disputed
service amount must be more than $500 for grandfathered plans (non-grandfathered plans do not have a
required minimum dollar amount).
Medical Director Access — If a physician disagrees with a clinical decision BlueChoice makes about the
denial of coverage of services, the physician can discuss the case with our medical director. Please dial
800-950-5387 and select option 5 to leave a message for the medical director. Include the member’s
name and identification number along with the clinical service in question. The medical director will then
return your call, generally within one business day.
Medical Necessity Criteria
BlueChoice uses Milliman Care Guidelines criteria for determining appropriateness of benefit application.
In situations where Milliman does not have criteria, we use the Blue Cross and Blue Shield Association
Uniform Medical Policy Manual, Technology Evaluation Center assessments, or criteria developed by our
Policy and Procedure Committee. For information on how to receive a copy of any criteria we use in our
decision making, please call Health Care Services at 800-950-5387. Many of our medical policies are
also available on our website at www.BlueChoiceSC.com.
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Coverage for Appropriate Services
BlueChoice is committed to providing a comprehensive plan of services and benefits to our members. As
a part of this commitment, BlueChoice:
• Makes decisions regarding the coverage of services based on appropriateness of care and services,
and whether they are provided in accordance with the member’s plan of benefits
• Does not compensate any decision-makers for denying coverage of care or services
• Does not offer any incentives to encourage denials
• Monitors utilization of services to identify any potential problems of under-utilization
The current statement on ensuring appropriate coverage and treatment is located on our website at
www.BlueChoiceSC.com.
Our Privacy Practices
BlueChoice knows it is important to protect the privacy of our members’ confidential medical information.
Here are some of the steps we have taken to protect the privacy of confidential information:
• We require all staff, consultants and business associates to keep confidential any personal health
information they learn in performing their jobs. We require all physicians and other health care
providers to maintain the confidentiality of this information. They must guard against unauthorized or
inadvertent disclosure of confidential information. Practice staff must receive periodic training in
member information confidentiality. BlueChoice will review this as part of our general medical record
review process.
• We require any entity with which we contract for clinical or administrative services to maintain such
confidentiality and to have a privacy policy in place that protects against unauthorized use or
disclosure of confidential information. All such entities must sign an agreement attesting that they
are compliant with federal privacy regulations.
• We have advanced security systems to limit unauthorized access to information in our computer
files.
• We keep any medical information we get from physicians and other health care providers in a
secure area, and we limit access to authorized staff. We also require physicians and other health
care providers to keep medical records in a secure area, and we monitor this through on-site visits to
their offices.
Please go to our website to review our Notice of Privacy Practices, or you can contact our Member
Services department to request a copy.
Disclosure of Protected Health Information (PHI) for HEDIS
Purposes
According to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), a health care
provider is permitted to disclose a patient’s protected health information (PHI) to a health plan for
purposes of the plan’s health care operations, which include quality assessment and improvement
activities. Therefore, HIPAA allows providers to disclose a patient’s PHI to a health plan for HEDIS data
collection purposes without authorization when both the provider and health plan have (or had) a
relationship with the patient, and the information disclosed pertains to that relationship [45 CFR 164. 501
and 506(c)(4)].
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Communication Between Physicians
Communication between primary care physicians and specialists is very important for the continuity and
coordination of care. BlueChoice has evaluated physicians’ satisfaction with the communication they
receive and have found that both primary care physicians and specialists have some level of
dissatisfaction. Our Clinical Quality Improvement Committee recommended that we provide physicians
with forms that can be used for communication with each other. The Physician Communication Summary
Visit Report can be used for any communication between primary care physicians and specialists
regarding a patient. Using this form can minimize the need to send dictated letters, and thus minimize the
administrative burden of communication with other physicians. We encourage you to consider using this
form which can be found on our website in the Providers’ section under Forms. Using these forms can
minimize the need to send dictated letters, and thus minimize the administrative burden of communicating
with other physicians.
Health Care Services
Illness or injury can impact anyone. The complexity of the health care system is often confusing to
patients. Our Health Care Services team is available to help you ensure that patients receive the services
they need.
Case Management — A physician can contact Health Care Services to request evaluation for case
management services or to discuss a member’s treatment. A registered nurse case manager will then
review information from the physician, member and other appropriate sources to determine if the member
is a candidate for case management. Once we have reviewed a referral, we either accept or decline the
case. If we accept the case, the case manager will contact the member, identify problems, develop a care
plan, develop primary goals and establish interventions, all in coordination with the physician's treatment
plan for the member.
Medical Management — BlueChoice’s clinical staff represents multiple specialties. Our goal is to help
patients move through the health care system and assist them in receiving needed care.
To contact an RN care management coordinator on the Inpatient Team, please call 800-327-3183, ext.
25553.
Solicited Records
We may request records in order to determine medical necessity or apply benefits to a claim, or
we may request records for risk adjustment or HEDIS review. When you receive a request for
records, please respond to the appropriate mailing address or fax number provided with the
request.
You or any entity designated for such responsibilities should not charge BlueChoice for the
creation or submission of medical records. As a participating provider, your contract states you
agree to permit BlueCross, BlueChoice® or one of our business partners to inspect, review and
acquire copies of records upon request at no charge. We appreciate you working with your
vendors to ensure they understand this contractual arrangement to submit the requested records
(on your behalf) without delay or request for payment.
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Section 9
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Great Expections® Health and
Disease Management Programs
As a managed care organization, BlueChoice understands the importance of integrating disease
management and preventive services with other components of the health care delivery system to support
the health of our members. As a result, we offer Great expectations for Health, a set of health
management programs that addresses a variety of health issues. Unless otherwise noted, we offer these
programs free of charge to our members. Enrollment in these programs occurs when we identify
members internally through claims or clinical data, or when physicians refer them. Physicians should call
the phone numbers listed with each program described here to refer a member to the respective program.
Members can also self-refer to these programs by telephone or via Web enrollment. Membership is
voluntary and in no way affects a member’s benefit plan. Any benefit design incentives for participating in
programs are established by individual employer groups and not the health plan.
Alcohol
The Health Coaching for Substance Use Disorder program is offered by CBA. The program helps
members prevent relapses and maintain sobriety through personalized coaching. The program helps
members prevent relapses and maintain sobriety through personalized coaching. This support program
can be used along with other forms of treatment to help the member coordinate their steps to recovery.
Services offered include guidance and support during scheduled phone calls, assistance with developing
a plan of care, help with setting long-term and short-term goals as well as supplying the member and their
family with educational and community resources. For more information, please contact CBA at 800-8681032, ext. 25835.
Asthma
The Great Expectations Asthma program helps members learn how to manage their asthma and
improve their quality of life. Through mailings and phone calls, our experienced respiratory therapists
provide education about asthma and support for complying with each member’s doctor’s plan of care.
Members can request a free peak flow meter, and we will also provide a free home health educational
visit to interested higher risk members, with physician consent. For more information, please contact us at
800-327-3183, ext. 25295.
Back Care
The Great Expectations Back Care program helps members learn to take care of their backs.
Participants get a Back Care resource guide with a lot of helpful information, including strengthening and
stretching exercises to prevent future problems. Members with severe, chronic back pain will be
considered for case management. For more information, please contact us at 800-327-3183, ext. 25541.
Case Management
The Great Expectations Case Management program is for members with extraordinary health needs.
Experienced nurse case managers work with members, their families and caregivers and the member’s
medical team to help coordinate services to meet the physician’s treatment plan. Physicians may refer
members for case management evaluation by calling 800-327-3183, ext. 25370.
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Childhood Obesity
The Great Expectations Healthy and Active Kids program identifies children who are overweight or
obese and offers their families education and interactive tools and incentives for adopting healthy habits.
Eligible children can also visit a registered dietitian at their regular office visit copayment. For more
information, please contact us at 800-327-3183, ext. 25541.
Children’s Health
The Great Expectations Children’s Health program reminds parents of the importance of immunizations
and well checkups. Children ages 2 and under and adolescents are automatically enrolled. The program
includes educational materials and immunization reminder cards. For more information, please contact us
at 800-327-3183, ext. 25541.
Chronic Kidney Disease
Great Expectations Chronic Kidney Disease is an individualized program for members with ESRD, as
well as stage four and five chronic kidney disease. Nurses provide one-on-one counseling, education,
home visits, social service coordination and other case management services. We automatically enroll all
ESRD patients at no charge. For more information, please contact us at 800-327-3183, ext. 25241.
Chronic Obstructive Pulmonary Disease (COPD)
Great Expectations COPD is a program that helps members with chronic obstructive pulmonary disease
learn how to manage their disease. Our goal is to support members in practicing recommended self-care
behaviors and following their physicians’ plan of care. Members receive educational materials,
newsletters, coaching calls and case management services, when needed. We will also provide a free
home health educational visit to interested high-risk members, with physician consent. For more
Depression
The Health Coaching for Depression program is offered by CBA. The program educates members
about depression, antidepressant medications and the importance of following their physicians’
recommendations for care. Members receive educational materials and phone calls from registered
nurses and social workers who offer an initial assessment and follow-up coaching sessions. Members can
also enroll in Beating the BluesTM, online cognitive therapy for depression, anxiety and stress. For more
information, please contact CBA at 800-868-1032, ext. 25835.
Diabetes
The Great Expectations Diabetes program helps members learn how to manage their diabetes and
reduce the risk of developing complications from their disease. The program consists of educational
materials, coaching, lab work reminders, free glucose monitors and a free yearly diabetes office visit. We
also help members take advantage of their benefits for eye exams and diabetes education, both at no
additional charge to the member. For more information, please contact us at 800-327-3183, ext. 25450.
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Heart Disease
Great Expectations Heart Disease is a program for members with coronary artery or ischemic heart
disease. The program educates members about lifestyle modifications and evidence-based guidelines for
the monitoring and control of cardiac risk factors, such as hyperlipidemia and hypertension. Members may
receive educational mailings, newsletters, coaching and case management services, as appropriate. For
more information, please contact us at 800-327-3183, ext. 25576.
Heart Failure
The Great Expectations Heart Failure program educates members with heart failure about appropriate
self-care strategies to minimize exacerbation of their condition. Members receive educational materials,
including a heart education manual and newsletters, and may receive coaching phone calls or case
management services, as appropriate. For more information, please contact us at 800-327-3183, ext.
25576.
High Blood Pressure
The Great Expectations High Blood Pressure program helps members learn about and manage
hypertension. Members are sent educational materials and may receive coaching calls from a cardiac
nurse to encourage them to take an active role in their blood pressure management. For more
High Cholesterol
The Great Expectations High Cholesterol program is for members who want to lower their cholesterol
and manage risk factors for heart disease. Members are sent educational material and may be called by
a cardiac health coach to work with them on healthy lifestyle behaviors to reduce cholesterol. The
program also sends reminders for needed care, such as annual cholesterol checks. For more information,
please call us at 800-327-3183, ext. 25576.
Irritable Bowel Syndrome (IBS)
The Great Expectations Irritable Bowel Syndrome program educates members about IBS and the
importance of working with their doctors to learn how to manage symptoms. Members identified for the
program are sent educational materials and a Food and Symptom Tracker to complete and bring to their
next doctor’s appointment. For more information, please contact us at 800-327-3183, ext. 25541.
Maternity
The Great Expectations Maternity program educates members about taking steps toward having a
healthy baby. We provide educational materials, support and monitoring throughout a member’s
pregnancy and postpartum period. We automatically enroll women in the program at no charge when a
primary care physician or obstetrician sends in a maternity authorization form or notification of pregnancy.
For more information, please contact us at 800-327-3183, ext. 25293.
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Men’s Health
Great Expectations Men’s Health is BlueChoice’s program for male members ages 20 and above. The
program educates men about the early detection of cancer, the prevention of heart disease and related
risk factors, and other vital men’s health issues. Members receive educational materials and reminders
for annual preventive screenings. For more information, please contact us at 800-327-3183, ext. 25541.
Migraine
The Great Expectations Migraine program is for members who suffer from severe, recurrent
headaches. We provide information about the importance of having a personal physician to guide
headache management. The member receives educational materials about pertinent migraine-related
topics. His or her personal physician receives information on emergency room visits and medications
prescribed by other physicians to improve the continuity of care in treating the member. For more
Pre-conception
The Great Expectations Before Baby program educates members about the importance of preconception planning and being healthy not only during, but before pregnancy. Members have to enroll in
this program proactively to participate. For more information, please contact us a 800-327-3183, ext.
25293.
Pre-Diabetes
The Great Expectations Pre-Diabetes program helps members learn how to manage their pre-diabetes
and reduce the risk of developing Type 2 diabetes. The program consists of educational materials to
encourage lifestyle changes, coaching when needed, free glucose monitors, and information to help
members take advantage of their benefits for free diabetes education. For more information, please
contact us at 800-327-3183, ext. 25450.
Quit Smoking
Great Expectations Quit Smoking is a four-month quit smoking program that is tailored to individuals. The
program consists of two outbound calls by a health coach trained in motivational interviewing and unlimited
inbound calls for members. The program also consists of a monthly mailing to assist members through each
stage of the quitting process. Members can self-refer or be referred through their physicians. The program is
available at no cost for active members. For more information, please contact us at 800-327-3183 ext. 25541.
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Administrative Manual ǀ Appendix
Weight Management
Great Expectations Weight Management is a 10-week program to educate members about healthy eating
and exercise behaviors, as well as behavior modification strategies to maximize weight loss and
maintenance. We are teaming up with the American Institute of Preventive Medicine (AIPM) to offer members
the self-paced weight management program. AIPM is an independent organization that provides weight
management programs on behalf of BlueChoice HealthCare. The program consists of unlimited telephone
access to a weight management coach and a comprehensive educational kit. The kit includes: a workbook
that guides members through the 10-week program; healthy menus and recipes; a record book; a resistance
exercise band; guidebook and a CD of relaxation exercises. There is a $15 fee for the program. The fee,
however, is only $5 for members participating in another Great Expectations program for pregnancy,
asthma, COPD, diabetes, heart disease or heart failure. For more information, please contact us at 800-3273183, ext. 25541.
Women’s Health
Great Expectations Women’s Health is a program for female members ages 20 and above. The program
educates women about the early detection of breast and cervical cancer, the management of menopause,
the prevention of osteoporosis and heart disease, and other important women’s health issues. Members
receive educational materials and reminders for annual preventive screenings. For more information, please
contact us at 800-327-3183, ext. 25541.
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Appendix
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Physician Office Accessibility Standards
1. Wait time for health maintenance/preventive care
To meet criteria, routine complete physical exam appointments should be scheduled within eight weeks
of request.
2. Wait time for routine care appointments
To meet criteria, routine care appointments should be scheduled within four weeks.
3. Wait time for episodic care appointments
To meet criteria, episodic care appointments should be scheduled within three days, with 24-hour,
seven days a week triage availability.
4. Wait time for urgent care
To meet criteria, urgent care appointments should be scheduled within 24 hours.
5. Wait time for emergency
To meet criteria, emergency care patients should be seen immediately or referred to an emergency
room or urgent care center.
6. Appointment scheduling per hour
To meet criteria, each physician should schedule no more than five to six appointments per hour.
7. Waiting time in waiting room
To meet criteria, patients should be seen by the provider within 15 minutes of arrival.
8. After-hours access
To meet criteria, physicians should have an after-hours answering mechanism in place 24 hours a day,
seven days a week.
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Preventive Health Guidelines for Children and
Adults
We have adopted the recommendations of the U.S. Department of Health and Human Services through the
Public Health Service, the Office of Public Health and Science, and the Office of Disease Prevention and
Health Promotion as our preventive health guidelines for children and adults. With permission from these
organizations, BlueChoice has created a direct link from our website to these guidelines.
While we review the guidelines annually, you should not construe them as a legal or required standard of
care, or as an indication they will always apply in every medical situation. These are recommendations only,
and do not guarantee any medical results or indicate coverage for such services by any given plan or policy.
We hope these guidelines will be a convenient resource in helping you care for your patients. This Web
address will take you to these guidelines listed in the Guide to Clinical Preventive Services, 2010-2011:
http://www.ahrq.gov/clinic/pocketgd.htm
The Clinicians Handbook is part of Put Prevention into Practice, an Agency for Healthcare Research and
Quality (AHRQ) national program to improve delivery of appropriate clinical preventive services. You can
order a copy of the book from the AHRQ Publications Clearinghouse at P.O. Box 8547, Silver Spring, MD
20907, or by calling 800-358-9295. You can also request a free information packet of Put Prevention Into
Practice materials.
You can also reference the Recommended Immunization Schedules for Adults and Children at
www.immunize.org.
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BlueChoice
2014 Clinical Practice Guidelines
BlueChoice’s Clinical Quality Improvement Committee (CQIC) reviews and adopts all guidelines at least
annually and more frequently if necessary to review new scientific evidence or national standards published
before time for CQIC’s annual clinical guideline adoption.
These are independent companies that offer clinical guideline information on behalf of BlueChoice
HealthPlan.
Asthma
• National Heart, Lung and Blood Institute
 Guidelines for the Diagnosis and Management of Asthma (EPR 3 Summary Report 2007)
Behavioral Health
Attention Deficit Hyperactivity Disorder
• American Academy of Child and Adolescent Psychiatry
 Practice Parameter for the Assessment of Children and Adolescents with AttentionDeficit/Hyperactivity Disorder (J.AM.ACAD.CHILD ADOLESC.PSYCHIATRY.46:7.JULY 2007)
• American Psychiatric Association (APA)
 APA Practice Guidelines for the Treatment of Psychiatric Disorders (Compendium 2006)
• American Academy of Pediatrics (AAP)
 Bright Futures in Practice: Mental Health
 Clinical Practice Guideline: Diagnosis and Evaluation of the Child with AttentionDeficit/Hyperactivity Disorder (PEDIATRICS Vol. 105 No. 5 May 2000, pp. 1158-1170)
 Clinical Practice Guideline: Treatment of the School-Aged Child with Attention-Deficit/Hyperactivity
Disorder (PEDIATRICS Vol. 108 No. 4 October 2001, pp. 1033-1044)
Depression
• American Psychiatric Association
 Practice Guideline for the Treatment of Patients with Major Depressive Disorder: A Quick
Reference Guide (Including Guideline Watch “Practice Guideline for the Treatment of Patients with
Major Depressive Disorder, 2nd Edition”)
(http://www.psychiatryonline.com/pracGuide/pracGuideTopic_7.aspx)
Cancer (Supportive Care in Oncology)
• National Comprehensive Cancer Network (NCCN)
 National Comprehensive Cancer Network Clinical Practice Guidelines
Chlamydia
• Centers for Disease Control and Prevention (CDC)
 Sexually Transmitted Diseases – Treatment Guidelines 2006 (Chlamydial Infections)
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Chronic Heart Failure (CHF) (in the Adult)
• American College of Cardiology/American Heart Association (Updated)
 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure
in Adults (Journal of the American College of Cardiology 2009; 53:1343-1382,
doi:10.1016/j.jaac.2008.11.009), published online 26 March 2009
(http://content.onlinejacc.org/cgi/content/full/53/15/1343)
• Heart Failure Society of America 2010 Comprehensive Heart Failure practice Guideline
 The 2010 Heart Failure Society of America Comprehensive Heart Failure Practice Guideline
(http://www.heartfailureguideline.org/guideline_sections/41)
Chronic Obstructive Pulmonary Disease (COPD)
• American Thoracic Society/European Respiratory Society Task Force
 Updated 2012 COPD Guidelines Standards for the Diagnosis and Management of Patients with
COPD (http://www.thoracic.org/clinical/copd-guidelines/resources/copddoc.pdf)
• The Global Initiative for Chronic Obstructive Pulmonary Disease (Updated)
 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for
Chronic Obstructive Lung Disease (GOLD) 2013
(http://www.goldcopd.org/uploads/users/files/GOLD_Report_2013_Feb20.pdf)
Coronary Artery Disease (CAD)
• American College of Cardiology/American Heart Association (Updated)
 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic
Cardiovascular Risk in Adults
(http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.full.pdf+html)
• American College of Cardiology/American Heart Association
 2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable
Angina/ Non -ST-Elevation Myocardial Infarction
(http://circ.ahajournals.org/content/early/2012/07/16/CIR.0b013e318256f1e0.full.pdf)
• American Heart Association (AHA)
 Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women 2011
Update: A Guideline From the American Heart Association
(http://circ.ahajournals.org/content/123/11/1243.full.pdf)
• American Heart Association/American College of Cardiology
 AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and
Other Atherosclerotic Vascular Disease: 2011
Update(http://circ.ahajournals.org/content/124/22/2458)
Diabetes
• American Diabetes Association (ADA) (Updated)
 Standards of Medical Care in Diabetes 2013
(http://care.diabetesjournals.org/content/36/Supplement_1/S11.full.pdf)
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High Blood Cholesterol
• National Institutes of Health (NIH)
 Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel
III)
 Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult
Treatment Panel III Guidelines (2004)
Human Papillomavirus (HPV)
• Centers for Disease Control and Prevention (CDC)
 Human Papillomavirus (HPV) Infection Treatment Guidelines 2006
 HPV Information for Clinicians – Brochure on transmission, prevention, detection and clinical
management of HPV (April 2007)
Hypertension (High Blood Pressure)
• National Heart, Lung and Blood Institute
 High Blood Pressure Guidelines (JNC 7)
• American Heart Association
 Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease: A
Scientific Statement from the American Heart Association Council for High Blood Pressure
Research and the Councils on Clinical Cardiology and Epidemiology and Prevention (2007)
Kidney Disease
• National Kidney Foundation (NKF)
 Kidney Disease Quality Outcomes Initiative (KDQOI) Clinical Practice Guidelines
Obesity and Overweight: Adults
• National Institutes of Health: National Heart, Lung and Blood Institute
 Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in
Adults
(Adobe PDF document)
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Obesity and Overweight: Children
 AAP Publications Retired or Reaffirmed, October 2006 (PEDIATRICS Vol. 119 No. 2 February
2007, pp.405)
 Active Healthy Living: Prevention of Childhood Obesity Through Increased Physical Activity (AAP
Policy Statement. Pediatrics, Vol. 117 No. 5 May 2006, pp. 1834-1842)
 Dietary Recommendations for Children and Adolescents: A Guide for Practitioners (AAP Policy
Statement. Pediatrics, Vol. 117 No. 2 February 2006, pp. 544-559)
 Obesity Evaluation and Treatment: Expert Committee Recommendations (PEDIATRICS, 1998;
102, Adobe PDF document)
 Prevention of Pediatric Overweight and Obesity (AAP Policy Statement. PEDIATRICS, Vol. 112
No. 2 August 2003, pp. 424-430) A Statement of Reaffirmation for this policy was published on
February 1, 2007.
• National Initiative for Children’s Healthcare Quality (NICHQ)
 Expert Recommendations on the Assessment, Prevention and Treatment of Child and Adolescent
Overweight and Obesity (http://www.ama-assn.org/ama1/pub/upload/mm/433/ped_obesityrecs.pdf)
 Journal of Clinical Endocrinology and Metabolism – Guidelines for the Prevention and Treatment of
Pediatric Obesity
 Themed Review – Clinical Interventions to Promote Physical Activity in Youth
Perinatal Care
• American Congress of Obstetricians and Gynecologists
 ACOG Guidelines for Perinatal Care, Sixth Edition (2007)
(http://www.acog.org/bookstore/Guidelines_for_Perinatal_Care_P262.cfm)
• March of Dimes (Added)
 March of Dimes 2010
(http://www.marchofdimes.com/professionals/professionals.html)
Tobacco Use
 Tobacco, Alcohol and Other Drugs: The Role of the Pediatrician in Prevention and Management of
Substance Abuse (AAP Policy Statement. PEDIATRICS Vol. 101 No. 1 January 1998, pp. 125128)
• National Guideline Clearinghouse
 Counseling to Prevent Tobacco Use and Tobacco-Caused Disease: Recommendation Statement
• Washington State Department of Health
 Smoking Cessation During Pregnancy: Guidelines for Intervention; Revised Edition 2008
Preventive Guidelines
• Preventive Health Guidelines for Adults
 Clinician’s Handbook of Preventive Services, 2nd Edition (1998)
• Preventive Health Guidelines for Children and Adolescents
 Clinician’s Handbook of Preventive Services, 2nd Edition (1998)
 American Academy of Pediatrics Immunization Information for Clinicians Centers for Disease
Control and Prevention, Vaccines & Immunizations Information (2007)
Page 83
Medical Record Review Criteria
The performance goal is an overall score of 80 percent. Offices who do not meet this are resurveyed
every two years until they meet the goal.
Each medical record is retrievable for review. The medical record must be available for review to receive
full credit.
Practices should maintain medical records in an organized, uniform manner. Computerized medical
records are acceptable. To receive full credit, each patient should have an individual and organized medical
record. Family charts should maintain an organized and individual record for each member of the family to
receive full credit. Unorganized records receive no credit. Partially organized records receive partial credit.
Each medical record contains a completed patient history, which consists of patient and family
medical history, along with documentation of tobacco, alcohol and substance abuse history. Each
item counts 20 percent of the overall score. All items must be present to receive (100 percent). Histories may
appear in the progress notes, on a printed medical form, or in hospital dictations prepared by the physician.
Transferred records with documentation that the current primary care physician has reviewed and noted the
history are also acceptable. For pediatric patients, patient history consists of patient and family medical
history only, and each part counts 50 percent. Both items must be present to receive full credit (100 percent).
The medical record has documentation of, and prominently displays, allergies or drug reactions.
Documentation of allergy information, including the absence of known allergies (NKA or NKDA), should be
documented in a consistent location for all charts (i.e., chart folder, progress note, medication form,
diagnostic summary, history form, etc.) to receive full credit. Because consistency enables staff to readily
identify allergies, medical records with a consistent location of allergy information are crucial to obtaining full
credit.
Each medical record has a diagnostic summary/problem list, including medical-surgical conditions,
medications and preventive services/risk assessment in a consistent place in the chart. Each item
counts for one-third of the overall score. All items must be present to receive full credit (100 percent).
Medical records with a current problem list in a consistent place that documents acute and chronic problems,
medications and preventive services/risk assessment receive full credit. Medical records that only include a
medication list or only record medical-surgical conditions and/or have no information related to preventive
services/risk assessment receive partial credit. If the problem list is not current or not in a consistent place
within the chart then partial credit is given. Medical records with no diagnostic summary, no problem list and
no preventive services/risk assessment receive no credit. For pediatric patients, diagnostic summary/
problem list is only scored if there is evidence of chronic illness in the patient’s chart. Otherwise this is
recorded as N/A.
Therefore the preventive services/risk assessment would count for 100 percent of this section. An example of
preventive services for pediatrics would be documentation of immunizations, assessing home environment,
car safety, etc.
Progress notes are recorded for each patient encounter and include the following for full credit:
• Working diagnosis(es) consistent with findings. Each encounter should have documentation of an
appropriate diagnosis(es) based on the findings for full credit.
• Treatment plan consistent with diagnosis(es). Encounters should include documentation of an
appropriate treatment plan for the diagnosis(es) (which includes follow-up plans) and the care should be
medically appropriate for full credit. Medical records with diagnosis-specific conditions and no
treatment plan will receive no credit. An incomplete treatment plan will receive partial credit.
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Other items assessed but not calculated into the overall primary care physician’s medical record
review score:
• Communication from facilities and specialists to the primary care physician
(Continuity and Coordination of Care)
• Availability/access and security of patient’s Medical Record
• Annual training on patient’s privacy with staff
• Advance Directives
Medical Office Site Review Criteria
Office Physical Environment
Office is accessible to members, including the handicapped. There is a ramp or other wheelchair or
walker accessible entrance, and a bathroom that is wheelchair accessible. The office receives full credit for
both the ramp and a bathroom.
The office receives no credit for only one of the previously mentioned items.
The waiting room has ample seating to accommodate all patients/guests waiting for an appointment.
Waiting rooms, exam rooms and offices are clean, uncluttered, organized and neat.
Office is free of hazards (electrical shock, fire, poisoning, burns, and items that may cause slips or falls).
Halls and rooms should be free of items that can be of threat to patient or guest safety, corridors or exits
should not be blocked for full credit. The office receives no credit for any hazard identified, i.e., less than 3
feet clearance in corridors or no electrical outlet safety plugs in patient areas for pediatric and family practice
offices.
Exam/dressing rooms and restrooms maintain the patient’s right to privacy. Practices which maintain
privacy through the use of doors or other types of barriers receive full credit. If the dressing rooms or
restrooms do not have doors, the practice receives no credit.
Practices do not store medications in public areas. Practices inventory and lock narcotics. Sample
medications are not stored in patient areas.
Educational materials are available to patients. These materials may be available in the waiting room or
exam room or may be provided to the individual patient based on the diagnosis.
Medical/Emergency Preparedness
The office maintains adequate and proper emergency supplies (IV fluids, ambu bag, airway,
emergency drugs) with scheduled periodic inspections. Medical offices can choose to store supplies on
a cart, shelf or in an emergency case.
The office receives no credit if there are no inspections of the emergency cart supplies, if drugs are expired
or if the emergency supplies are inadequate (i.e., an ambu, an airway and emergency drugs without an
airway, etc.).
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Offices maintain oxygen at all times. Clinical staff should know the location of the oxygen, and oxygen
should be easily accessible within the office for full credit. The office receives no credit if the staff is
unaware of the location of the oxygen or if the oxygen is not easily accessible.
Clinical office staff (nurses, technicians, medical office assistants) has current, certified training in
CPR and is able to respond to other emergencies. Offices receive full credit for current clinical staff
certification. An office will receive no credit if certification is not current for all clinical staff.
Written emergency procedures are available. Written protocols on how to manage emergency situations,
i.e., cardiac arrest, fire evacuation and natural disaster evacuation are easily accessible. Offices receive full
credit for written protocols for both medical emergencies and a fire/natural disaster plan. Offices receive no
credit if they have a fire evacuation map without a written protocol.
Fire extinguishers are available and maintained, or a sprinkler system is present. Offices with either
method receive full credit.
Offices have an Occurrence Reporting System to document all in-office accidents and follow-up
where necessary on all accidents, injuries and safety hazards that occur within the office. Offices with
a handwritten log, an incident report, documentation sent to the insurance company or other emergency care
documentation for the injured person receive full credit.
Offices store and dispose of hazardous wastes in a timely manner and in an acceptable manner to
minimize the risk of infection or contamination (containers for the disposal of needles and other
hazardous wastes). Offices should use standard (HIV) precautions for full credit.
Appointments/Scheduling
Practices schedule appointments and document them in an appointment book or track them on a
computer system, not to exceed six per hour. Each physician, certified physician assistant, or primary
care nurse practitioner should schedule no more than six appointments per hour for full credit.
Schedule allows for same day scheduling of urgent/emergent appointments. Patients should be able to
schedule a same day sick visit for full credit.
An answering mechanism is available 24 hours, seven days a week. Answering services with whom the
physician checks regularly or who can contact the physician directly receive full credit. Physicians who allow
patients to call the doctor directly 24 hours per day receive full credit. An answering machine which instructs
the patient to call the local hospital switchboard to page or beep the doctor receives full credit. An answering
machine which provides instructions for beeping the doctor directly receives full credit. An answering
machine which instructs the patient to go to or call the local emergency room for triage receives no credit.
Medical Record Maintenance
The practice uses a system for the collecting, processing, maintaining, storing, retrieving and
distributing of medical records.
The practice has a policy for retention of active medical records.
Page 86
The practice has a policy for the retirement of inactive medical records. For full credit, medical records
should be purged as frequently as every two years; deceased/inactive files may be routinely purged but
should be purged at least on an every two-year basis. This policy is not required for new practices less than
two years old but new practices are encouraged to begin planning for future purging. Practices without a
purging and storage plan for inactive/deceased records receive no credit.
The practice has a written policy for the release of medical information. This policy may consist of a
medical record release form as acceptable documentation for full credit.
There is a consent form for surgical procedures performed in the office. A surgical form signed by the
patient receives full credit. Any and all invasive procedures require a consent form. Practices who perform
no invasive surgical procedures receive N/A (not applicable). Practices with a generic medical treatment
consent form only receive no credit.
The practice has a written patient confidentiality policy, either in the employee handbook, or as a
separate statement given to each employee. The form does not need the employee’s signature to receive full
credit.
Practices should maintain medical records in an organized, uniform manner. Computerized medical
records are acceptable. To receive full credit, each patient should have an additional and organized medical
record. Family charts should maintain an organized and individual record for each member of the family to
receive full credit. Partially organized records receive no credit.
The medical record has documentation of, and prominently displays, allergies or drug reactions.
Documentation of allergy information, including the absence of known allergies (NKA or NKDA), should be
documented in a consistent location for all charts (i.e., chart folder, progress notes, diagnostic summary,
history form, etc.) to receive full credit.
Each medical record has a diagnostic summary/problem list, including medical-surgical conditions,
medications and preventive services/risk assessment in a consistent place in the chart. Medical
records with a current problem list in a consistent place that documents acute and chronic problems and
medications receive full credit. Medical records that only include a medication list or only record medicalsurgical conditions receive no credit. If the problem list is not current or not in a consistent place within the
chart, then no credit is given. Medical records with no diagnostic summary or problem list receive no credit.
For pediatric patients, a diagnostic summary/problem list is only scored if there is evidence of chronic illness
in the patient’s chart. Otherwise this is recorded as N/A and not included in the overall record review score.
Progress notes are recorded for each patient encounter and include:
•
•
•
•
•
•
All entries are dated.
The record is legible.
There is a date for a return visit or other follow-up plan for each encounter.
Written information is provided to the patient regarding his or her follow-up plan.
Problems from previous visits are addressed.
There is evidence of continuity and coordination of care between primary and specialty physicians.
Page 87
Member Rights and Responsibilities
Member Rights
• Members have the right to be treated with respect and recognition of their dignity and right to privacy.
• Members have the right to choose their own personal doctors from our list of health care professionals.
If members are not happy with their first choice, they have the right to choose another primary care
physician from our network.
• Members have the right to expect their primary care physicians and their teams to coordinate all the
care they need.
• Members have the right to participate with their doctors in decision making to help take charge of their
own health.
• Members have the right to get the information they need to make thoughtful choices before they take
any treatment their doctors suggest. BlueChoice HealthPlan does not direct practitioners to restrict
information regarding treatment options.
• Members have the right to learn about their conditions and treatment in words they understand and to
be a part of decisions about their own care.
• Members have the right to share their opinions, concerns or complaints constructively.
• Members have the right to receive information about BlueChoice HealthPlan, our services, practitioners,
providers and members’ rights and responsibilities.
• Members have the right to complain or make appeals about BlueChoice HealthPlan or the care they
receive.
• Members have the right to make recommendations regarding BlueChoice HealthPlan’s rights and
responsibilities policy.
Member Responsibilities
• Members have the responsibility to treat all medical staff with respect and courtesy as their partners in
good health.
• Members have the responsibility to work with their doctors to form good relationships based on trust and
teamwork.
• Members have the main responsibility of keeping up their good health and preventing illness.
• Members have the responsibility to ask questions and make sure they understand the information they
receive.
• Members have the responsibility to give BlueChoice HealthPlan and their doctors as much information
as they can so it can be used to help them get well.
• Members have the responsibility to work with their primary care physicians to form a treatment plan, and
to follow the directions agreed upon.
• Members have the responsibility to think about what might happen if they don’t follow their doctors’
treatment plan or suggestions.
• Members have the responsibility to keep appointments they schedule. In cases where they may have to
cancel or may be running late, members have the responsibility to call the office and let them know.
• Members have the responsibility to read all our materials carefully as soon as they sign up for
BlueChoice HealthPlan. Members have the responsibility to follow the rules of their membership.
Page 88
Instructions for Requesting an External Insulin
Infusion Pump
Fax these items to the number listed:
• Precertification of Medical Necessity - External Insulin Infusion Pump
 This form must be completed by the physician (or designated staff) who will actually be managing the
insulin pump.
 The managing physician must sign the form.
 All sections of the form must be completed.
• Copies of physician notes for the last two office visits.
• Documentation of the result of the last Hemoglobin A1c test (this test must be within the last six
months).
• Record of the last month’s blood glucose monitoring (either meter download or written records).
• Completed Request for Preauthorization of Benefits for Ancillary Services. You’ll find this form on our
website at www.BlueChoiceSC.com.
Fax the completed forms to:
800-610-5685
If you have questions about this form, call the Great Expectations® Diabetes program at 800-327-3183, ext.
25576 or email [email protected].
Page 89
Instructions for Requesting a Continuous Glucose
Monitoring System
Fax these items to the number listed:
• Precertification of Medical Necessity - Continuous Glucose Monitor
Not for 72-hour request
 This form must be completed by the physician (or designated staff) who will actually be managing the
continuous glucose sensor.
 The managing physician must sign the form.
 All sections of the form must be completed.
• Copies of physician notes for the last two office visits.
• Documentation of the result of the last Hemoglobin A1c test (this test must be within the last six
months).
• Record of the last month’s blood glucose monitoring (either meter download or written records).
• Completed Request for Preauthorization of Benefits for Ancillary Services. You’ll find this form on
our website at www.BlueChoiceSC.com.
• C-peptide level results
Fax the completed forms to:
800-610-5685
If you have questions about this form, call the Great Expectations® Diabetes program at 800-327-3183, ext.
25576 or email [email protected].
Page 90
Page 91

2014 BlueChoice HealthPlan PROVIDER OFFICE ADMINISTRATIVE MANUAL

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