Advantage Program Provider Operating Guide The Blue Cross Blue Shield of Arizona

Transcription

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

Advantage Program Provider Operating Guide The Blue Cross Blue Shield of Arizona

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