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Provider and Facility Reference Manual

Appendix 1: Medicare Advantage

Senior Blue (HMO), BlueSaver (HMO), Senior Blue Group (HMO-POS), and Forever Blue (PPO)


About This Section of the Manual

For your convenience, we have organized information pertaining exclusively to our Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) products in this separate section of the Provider Manual.

General Overview

HealthNow New York Inc. is the parent company of Buffalo-based Highmark Blue Cross Blue Shield of Western New York, and Albany-based Highmark Blue Shield of Northeastern New York.

Senior Blue (HMO) and BlueSaver (HMO) are considered Medicare health maintenance organization (HMO) plans. Forever Blue (PPO) is the preferred provider organization product offered to Medicare eligible consumers.

These products provide quality, comprehensive health care services to people who are eligible for Medicare benefits either through disability or for those who are 65 years of age or older. As a Medicare HMO, Senior Blue (HMO) and BlueSaver (HMO) emphasize prevention, health maintenance and early diagnosis and treatment. Forever Blue (PPO) offers comprehensive benefits while also giving members the flexibility of choosing a provider from our network, obtaining specialist services without a referral, and the option to seek out-of-network care.

Provider Network

Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) have contracted with hospitals and practitioners in Allegheny, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, and Wyoming counties. These providers are individually licensed or certified by the State to engage in the delivery of health care services, as well as entities engaged in the delivery of health care services. The providers were selected from our Blue Cross Blue Shield provider panel. All of our providers are credentialed when they enroll with Blue Cross Blue Shield and are re-credentialed every three years.

Senior Blue (HMO) and BlueSaver (HMO) members are required to select a primary care physician (PCP) from our directory of participating physicians. The PCP monitors his/her patients and coordinates the delivery of all health services, including preventive and routine medical care, hospitalization and specialized care.

Members are instructed to contact their PCP before seeking medical treatment, except in the case of a medical emergency, or when seeking out-of-area urgent care. This gives the PCP the opportunity to provide the member with the care he or she needs in the most appropriate manner.

The service area for Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) includes Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming counties in New York State.

The service area for Forever Blue 799 (PPO) includes all 50 states.

Referrals and Preauthorization

Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) have a no-referral policy. However, if the member has or chooses to list a primary physician, it is important that the primary physician be responsible for monitoring and coordinating the delivery of all health care services, including preventive and routine medical care, hospitalization and specialized care for their patients.

Preauthorization must be obtained for all inpatient admissions and select outpatient procedures with a plan provider. These outpatient procedures are listed in current preauthorization guidelines found in our Stat Bulletins.

Government Programs Provider Service

Blue Cross Blue Shield Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) products are serviced by a dedicated unit located in Buffalo, New York. Service Representatives are trained to assist you with claim questions. If you have a question regarding the status of a Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) claim or need an adjustment, please call 1-877-327-1395 or our TTY line for the hearing impaired at 711. Hours of operation are Monday to Friday, 8 a.m. to 5 p.m.

Blue Cross Blue Shield maintains the right to inspect, audit and evaluate all aspects of medical services furnished to Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) members. Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) providers must maintain all patient related records for at least ten years for audit purposes.

Statement of Cultural Diversity

Blue Cross Blue Shield recognizes the cultural diversity of our Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) members. If you need assistance to meet the cultural needs of a member, the following are available:

  • Toll-free TTY line for the hearing impaired 711
  • The member may call the Government Programs Service Department for:
    • Assistance in contacting language or sign language interpreters through community services.
    • Assistance in identifying practitioners that speak a specific language (i.e., specialist that speaks Spanish).
    • Upon request, Blue Cross Blue Shield will make an interpreter available through the TransPerfect translator line for non-English speaking members free of charge. The member should direct his/her request to the Government Programs Customer Service Department at 1-800-329-2792. An interpreter will be located and connected to the call within minutes, free of charge.

Hours are 8 a.m. to 8 p.m. seven days a week, October 1 to March 31 and 8 a.m. to 8 p.m. Monday through Friday, April 1 to September 30.           

Anti-Discrimination Policy

Blue Cross Blue Shield is committed to non-discriminatory behavior in conducting business with all of its members. All providers should have policies which demonstrate that they treat any member in need of health care services.

Product Overview

Senior Blue (HMO), BlueSaver (HMO), and Senior Blue Group (HMO-POS) are Medicare Advantage HMO plans. Senior Blue (HMO), BlueSaver (HMO), and Senior Blue Group (HMO-POS) plan options provide quality, comprehensive health care services to people who are eligible for Medicare, with an emphasis on prevention, health maintenance and early diagnosis and treatment. Senior Blue (HMO), BlueSaver (HMO) and Senior Blue Group (HMO-POS) are available to members who reside in Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming counties in New York State.

Senior Blue (HMO), BlueSaver (HMO) and Senior Blue Group (HMO-POS) are Medicare Advantage health plans with a Medicare contract offered by Highmark Blue Cross Blue Shield of Western New York. Applicants must be entitled to Part A, enrolled in Part B, and continue to pay any required Medicare premiums. All Medicare beneficiaries residing in the Senior Blue (HMO), BlueSaver (HMO), and Senior Blue Group (HMOPOS) service area may apply. Members must receive all routine and scheduled medical care from plan providers.

Senior Blue Group (HMO-POS) members also have the option to obtain care outside of the service area (out-of-network), through their POS benefit, for an additional cost. This excludes emergency or urgent care situations or for out-of-area rental dialysis, for which 2020 Provider and Facility Reference Manual 200 Updated April 2020 additional out-of-network cost does not apply. There is a limit to what our plan will cover under the Point-of-service (POS) benefit. Not all services are available under the POS benefit. Please reference the Evidence of Coverage (EOC) for more details.

Beneficiaries who meet the eligibility requirements cannot be denied membership into the plan. Senior Blue (HMO), BlueSaver (HMO), and Senior Blue Group (HMO-POS) do not discriminate among Medicare beneficiaries based on health-related factors.

Please refer to the Senior Blue (HMO), BlueSaver (HMO), and Senior Blue Group (HMO-POS) Evidence of Coverage (EOC) for detailed information on covered services and copays.

Forever Blue (PPO) is our Medicare Advantage PPO plan option. Forever Blue (PPO) offers comprehensive benefits while also giving members the flexibility of choosing a provider from our network, obtaining specialist services without a referral, and the option to seek out-of-network care.

Forever Blue (PPO) is a Medicare Advantage health plan with a Medicare contract offered by Highmark Blue Cross Blue Shield of Western New York. Applicants must be entitled to Part A, enrolled in Part B, and continue to pay any required Medicare premiums. All Medicare beneficiaries residing in the Forever Blue (PPO) service area may apply. Forever Blue (PPO) plans are available to members who reside in Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming counties in New York State.

Beneficiaries who meet the Forever Blue (PPO) eligibility requirements cannot be denied membership in Forever Blue (PPO). Forever Blue (PPO) does not discriminate among Medicare beneficiaries based on health-related factors.

Please refer to the Forever Blue (PPO) Evidence of Coverage (EOC) for detailed information on covered services and copays

Opting-Out of Medicare

Federal regulations prohibit Medicare Advantage (MA) organizations, including Highmark Blue Cross Blue Shield of Western New York, from paying for services rendered by physicians or practitioners who have chosen to opt out of the Medicare program, except in limited circumstances.

A MA organization may contract only with physicians or practitioners who are approved for  participation in the Medicare program and who have not opted out of providing services to Medicare beneficiaries (See Social Security Act§ 42 CFR § 422.220). Opting out is not the same as "non-participating." Physicians or practitioners who opt out of Medicare cannot participate in our MA HMO and PPO networks.

Blue Cross Blue Shield will not cover any services provided by physicians/practitioners on or after the effective opt-out date, unless it is demonstrated that the service was eligible for payment as an emergency, or urgently needed under applicable Medicare standards.

Physicians and practitioners must follow the Centers for Medicare and Medicaid Services (CMS) rules regarding opting out of Medicare. Some of the rules could affect your business financially, such as the requirements under Social Security Act §1848 (g)(l) and/or 1848(g)(3).

CMS regulations for opt-out physicians or practitioners also require a "private contract" between the Medicare beneficiary and the physician or practitioner who opted out of Medicare. The private contract must include language such as, but not limited to, agreement that the Medicare beneficiary gives up Medicare payment - including payment from MA plans - for services furnished by the opt-out physician or practitioner, as well as to pay the physician/practitioner for services directly.

A physician or practitioner may cancel opt out by submitting written notice to the Medicare Administrative Contractor not later than 30 days before the end of the current two-year opt-out period. If a physician or practitioner wants an early termination of their opt-out status, there are specific Medicare requirements that must be met timely and the physician or practitioner must not have previously opted out. The requirements and possible exceptions concerning opting out are outlined in the CMS Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services. Chapter 15 can be accessed online at cms.gov/Regulations-and-Guidance/Guidance/Manuals/lnternet-Only-Manuals-lOMs.html

If your status with Medicare changes, you must notify your Provider Network Management and Operations Specialist promptly at 1-800-666-4627.

More information regarding New York state physicians or practitioners who opt out of Medicare is available from the local Medicare Administrative Contractor, National Government Services, at ngsmedicare.comStatement of Cultural Diversity

Blue Cross Blue Shield recognizes the cultural diversity of our Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) members. If you need assistance to meet the cultural needs of a member, the following are available:

  • Toll-free TTY line for the hearing impaired 711
  • The member may call the Government Programs Service Department for:
    • Assistance in contacting language or sign language interpreters through community services.
    • Assistance in identifying practitioners that speak a specific language (i.e., specialist that speaks Spanish).
    • Upon request, Blue Cross Blue Shield will make an interpreter available through the TransPerfect translator line for non-English speaking members free of charge. The member should direct his/her request to the Government Programs Customer Service Department at 1-800-329-2792. An interpreter will be located and connected to the call within minutes, free of charge.

Hours are 8 a.m. to 8 p.m. seven days a week, October 1 to March 31 and 8 a.m. to 8 p.m. Monday through Friday, April 1 to September 30

Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) Plan Exclusions

Any service not provided or arranged by a contracting medical provider, or prior authorized, (except for emergency or urgent care situations or for out-of-area renal dialysis) are not covered by Senior Blue (HMO) or BlueSaver (HMO).

Senior Blue Group (HMO-POS) members have the option to obtain care outside of the service area (out-of-network), through their POS benefit, for an additional cost. This excludes emergency or urgent care situations or for out-of-area renal dialysis, for which additional out-of-network cost does not apply. There is a limit to what our plan will cover under the Point-of-service (POS) benefit. Not all services are available under the POS benefit. Please reference the Evidence of Coverage (EOC) for more details. Forever Blue (PPO) members may see medical providers that are not part of the network, but they will pay a higher cost-share.

In addition to any exclusions or limitations described in this manual, Chapter 4 of the member Evidence of Coverage (EOC) outlines additional plan level exclusions. This section is titled “What services are not covered by the plan”. These documents can be requested as needed by calling the plan.

Medical Protocols

Medical Protocols are available on our website. Unless separate Medicare Advantage criteria are listed in the protocol, the criteria indicated are applicable to services provided in the local Medicare Advantage operating area for Medicare Advantage members.  This information in our protocols is designed to give you a concise, quick overview of the medical criteria we use to determine if a service is considered medically necessary under our Medicare Advantage contracts.

Outpatient Pharmacy Benefits

Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) offer plans with a Medicare Part D Prescription Drug Benefit. Drugs administered or dispensed while the member is a patient in a hospital, nursing home, doctor's office, outpatient clinic, or other institution are not covered under this benefit. The member, however, may be entitled to benefits under his or her basic medical contract.

With the Medicare Part D Prescription Drug benefit, physicians may prescribe drugs included on the Blue Cross Blue Shield Drug Formulary. The Drug Formulary promotes the safe and effective use of drug therapies by helping physicians select the drug product(s) considered most beneficial to their patient populations. The Formulary promotes rational, scientific prescribing based upon consideration of published clinical studies, data from the Food and Drug Administration (FDA), community standards, and cost/benefit evaluation.

The Formulary contains a listing of approved or preferred medications. It was developed and is maintained by our Pharmacy and Therapeutics (P&T) Committee. This committee consists of physicians, pharmacists, and other appropriate professional staff.

The goal of the Formulary is to improve the value of pharmaceutical care delivered through proper consideration of both quality-of-care and economic issues.

The P&T Committee evaluates and appraises the numerous pharmaceutical products available and makes recommendations to the Plan on those drugs considered to have the highest contribution to patient care. Through a continuous improvement process, the P&T Committee performs therapeutic drug class and product specific evaluations to maintain a clinically appropriate, cost-effective Formulary. Criteria such as efficacy, safety, risk/benefit ratio, therapeutic outcome, and cost are all included in the assessment process. Participating Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) providers are strongly encouraged to reference the Formulary before authorizing prescriptions for Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) members. For the latest pharmacy information, providers and members may visit our website at bcbswny.com/medicare. Here you can click on “Rx drug information”, where you will find materials such as our drug formulary, monthly formulary changes, drug preauthorization requirements, step therapy guidelines, and our pharmacy quantity limits.

At the point of dispensing, the pharmacy will receive a message each time a non-Formulary medication is being filled. If you are the prescriber, the pharmacist may contact you prior to dispensing to discuss Formulary alternatives. Please consider the

Appropriateness of Formulary treatment options for each patient. Many times a therapeutic switch can be made that will offer the patient the same outcomes to which they are accustomed.

Utilization Management Program Overview

The Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) Utilization Management Program is a dynamic process whose goal is to facilitate member health management throughout the continuum of care. The Program is tailored to meet the individual needs of our members. Our Care Management, Case Management, and Operations and Regulatory Compliance Units use an integrated process to help assure access to medical care for both members and providers.

For complete information regarding Blue Cross Blue Shield's Utilization Management Policies and Procedures please review Section 5 - Utilization Management.

Health Care and Service Quality Improvement Program

Highmark Blue Cross Blue Shield of Western New York recognizes the need for a comprehensive Health Care and Service Quality Improvement Program for our Medicare Advantage HMO and PPO products. We have initiated and carried out such a program in a manner designed to meet the goals and objectives of our Corporation.

The focus of the Health Care and Service Quality Improvement program is to assess and improve, on a continuous basis:

  1. Care delivered by providers to members
  2. Services delivered by Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) staff to members and
  3. Health care and services rendered to Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) members in Western New York.


Program Objectives
 

  • Assist in the Corporate Mission and Vision.
  • Integrate quality improvement activities into corporate strategic plans and goals.
  • Initiate and monitor activities and to correct quality/safety of care, access and service issues.
  • Identify best practices through review of structure, process, and outcomes.
  • Report quality assessment information and make recommendations regarding participation and continued participation of providers according to the approved credentialing process.
  • Develop, implement and evaluate for effectiveness the opportunities to improve quality of care and services.
  • Distribute quality improvement activity findings as part of a Quality Improvement Process (QIP) or Problem Solving Process (PSP).
  • Sponsor and support interdepartmental quality improvement activities.
  • Promote a high standard of care through analysis of clinical and service practices.
  • Adopt national (or regional if more stringent) standards, criteria and benchmarks for health care quality improvement activities
  • Serve as a resource to providers, supplying consultation and education related to implementation of the Quality Improvement programs.
  • Provide a leadership role in health improvement programs, utilizing preventive care guidelines, best practice and clinical quality measures.
  • Educate providers and members toward improving their health and health care meet and exceed all requirements for regulatory and accreditation oversight (CMS, NYS DOH/DFS, NCQA, and BCBSA)
  • Identify areas of the health care provided to our members that require improvement and take corrective action


Scope

The scope of the Health Care Quality Improvement Program is comprehensive. It includes all Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) members, as well as providers and practitioners who participate on these provider panels. Expansion areas will be included in all Quality Improvement initiatives.

The Health Care Quality Improvement Program includes organizational-wide activities, a focus on trend analysis, and development of interventions that improve the quality of care and service provided to our members.

The Health Care Quality Improvement Program monitors and evaluates a wide variety of clinical and service topics for Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) members that include, but are not limited to, those listed below.


Clinical Topics
 

  • Health Promotion
  • Preventive Care
  • Disease Management
  • Case Management-coordination of care
    • 24-hour health information line
    • Utilization Management (including appropriate utilization of services)
    • Patient Safety
    • Behavioral Health Management
    • Culturally and Linguistically Appropriate Services 
    • Complaint management for access to care or quality of care issues
    • Medical policy
    • Pharmacy Management
    • Continuity and Coordination of Care


Service Topics

  • Accurate and timely phone responses
  • Access to practitioners and providers
  • Satisfaction/dissatisfaction issues identified through satisfaction surveys, complaints, PCP change requests
  • Information regarding managed care processes, such as competence of staff, attitude of representatives, times of operation and efficiency of Public Health Goals Integration


Public Health Goals Integration

The Health Care Quality Improvement Program for our Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) products include, whenever possible, integration of Public Health goals. In particular:

  • Healthy People 2020 goals are used in planning and evaluating progress on clinical issues.
  • HEDIS®, QARR, and Quality Rating System (QRS) results, etc. where appropriate
  • Staff interacts with local and state Public Health Department staff to address issues of local special populations such as Medicaid recipients, children and the elderly
  • Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) utilize reports and data from Public Health Sources in evaluating the needs of the membership, the population in general and service areas covered.
  • Staff actively participates in collaborations with community task forces and initiatives to improve the health status of the Western New York community (such as smoking cessation coalitions, physical activity task forces, health risk appraisals for Western New York counties, etc.)

Claims Submission

See Section 13 for electronic claim submission information.

All adjustments and/or correspondence for Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) should be submitted to the following address:

Highmark Blue Cross Blue Shield of Western New York
PO Box 80
Buffalo, NY 14240

The following abbreviation will appear on your payment voucher to indicate the contract type:
SB – Senior Blue (HMO) and BlueSaver (HMO)
MPPO – Forever Blue (PPO)

This abbreviation will appear in the Line of Business (LOB) code field. Claims will be processed and paid in accordance with CMS Prompt Pay guidelines.

For further information regarding billing and/or claims submission, please refer to the Claims/Billing Information Section of your Physician Manual.

Reimbursement

Senior Blue (HMO) and BlueSaver (HMO) reimbursement for covered services will be made according to the Senior Blue (HMO) and BlueSaver (HMO) fee schedule. For authorized services provided by a non-participating Senior Blue (HMO) or BlueSaver (HMO) physician, payment will be made according to Medicare reimbursement policies.

Forever Blue (PPO)

Reimbursement for covered services will be made according to the Forever Blue (PPO) fee schedule. For authorized services provided by a non-participating Forever Blue (PPO) physician, payment will be made according to Medicare reimbursement policies.

Concierge or Boutique Medicine

Participating physicians, suppliers, and providers who consider charging Medicare patients additional fees should be mindful that they are subject to civil money penalties if they request any payment for already covered services from Medicare patients other than the applicable deductible and coinsurance.

If you have additional questions regarding payment for services rendered to Senior Blue (HMO), BlueSaver (HMO), or Forever Blue (PPO) members, please refer to your Participating Provider Agreement.

Member ID Card

Members may not receive an identification card prior to their effective date of coverage. A proposed effective date letter and a copy of the enrollment application are mailed to the member while Blue Cross Blue Shield is processing the member's application. The enrollment application and/or effective date letter should be used by providers as proof of enrollment in lieu of an ID card.

To verify a member's eligibility, please call our Government Programs Member Service Department at 1-800-329-2792 (TTY 711). Hours of operation are 8 a.m. to 8 p.m. seven days a week, October 1 to March 31 and 8 a.m. to 8 p.m. Monday through Friday, April 1 to September 30.

Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) members will receive a member ID card. Patients should be asked to present their ID card at the time of service to assist in:

  • checking eligibility
  • obtaining copayment information
  • coordinating admissions
  • delivering service
  • filing claims

Possession of a member ID card does not guarantee eligibility for benefits, coverage or payment. Please verify eligibility status at the time of delivery of service or admission to a hospital or other facility.

Members enrolled in Senior Blue (HMO), BlueSaver (HMO), or Forever Blue (PPO) will have both a Blue Cross Blue Shield ID card and their Medicare card. A Medicare ID card alone is not proof of eligibility.

Medicare Outpatient Observation Notice (MOON)

Blue Cross Blue Shield requires all hospitals to provide the Medicare Outpatient Observation Notice (MOON) form to Blue Cross Blue Shield Medicare Advantage members, as required by the Centers for Medicare & Medicaid Services (CMS).

According to the CMS Claims Processing Manual (chapter 30, section 400), the MOON form must be given to all Medicare beneficiaries receiving observation services for more than 24 hours who are not an inpatient of your facility.

CMS requires the MOON form to be delivered within 36 hours of initiating observational services, or sooner, if the patient is transferred, discharged or admitted. This information must also be available in alternative forms (e.g., braille, large print, audio) upon request. For more information regarding this requirement, please visit the CMS Claims Processing Manual at cms.gov.

Member Rights and Responsibilities

Blue Cross Blue Shield members that have selected our Senior Blue (HMO), BlueSaver (HMO), or Forever Blue (PPO) health plan options have certain rights to help protect them and responsibilities that we ask they assume. We have included an abridged version of the Member Rights and Responsibilities document below. Also included is a copy of our policy regarding Perceived Denials. We encourage all of our participating Medicare Advantage providers to review these policies and become familiar with them.

Perceived Denials

We recognize, appreciate, and support your efforts to manage the care of your Medicare Advantage patients in a prudent, cost-effective manner. However, the Centers for Medicare and Medicaid Services (CMS) require that when a member perceives a denial of treatment or care, he/she is entitled to certain appeal rights under Federal Law. This includes situations in which the member's request is made directly to the provider and one of the following conditions exists:

  • The member disagrees with your prescribed course and/or type of treatment.
  • You decline to provide a course of treatment and/or type of treatment that the member is requesting.
  • You discontinue a course of treatment or reduce a course of treatment.

Examples of Denial

Some examples of a perceived denial are:

  • A patient asks to be referred to a radiologist for a MRI but you feel that a MRI is not necessary.
  • A new prescription drug comes out on the market and one of your patients would like you to prescribe it for him/her. You decline to write the prescription at the present time because the American Medical Association and the Food and Drug Administration have not yet approved the drug for use in the senior population.
  • A patient asks to be referred to a dermatologist for the treatment of a rash. You decline to refer the patient because you can effectively treat him/her yourself.
  • A patient is receiving physical therapy services and you determine that physical therapy is no longer necessary.

Your Responsibility

When a perceived denial occurs, the following must take place:

  • You must contact the Utilization Management Department, the day that the denial occurs, at 1-800-677-3086 to apprise Blue Cross Blue Shield of the situation. It is your responsibility to ensure that our members are informed of their right to appeal.
  • We will then issue a letter stating the details of the denial, including a description and reason for the denial. The letter will inform the member of the clinical rationale, as well as the right to obtain reconsideration and the procedure for requesting reconsideration. You will receive a copy of this letter, at the same time the letter is sent to the member.
  • The member will be advised that he/she can appeal if they do not agree with our decision about their health care.

If you have any questions about perceived denials, contact Utilization Management at 1-800-677-3086.

Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) Appeals Process

The member is entitled to certain appeal rights under Federal Law pertaining to disputes involving an initial organization determination, denial of services, or payment.

All disputes involving initial adverse organization determinations are handled through the Medicare Appeals process. There is a Standard Appeals Process and an Expedited Appeals Process. The Expedited Appeals Process addresses adverse initial organization determinations, which could seriously jeopardize the life or health of the member or the member's ability to regain maximum function.

There are five levels of appeal:

  1. Level I Reconsideration Request Determination
  2. Level II IRE Reconsideration
  3. Level III Administrative Appeal (Administrative Law Judge)
  4. Level IV Appeals Council
  5. Level V Federal Court

Level I appeal
A Level I appeal is a reconsideration request of the adverse initial organization determination, whether standard or expedited. A clinical peer reviewer who has not made the initial determination makes a Level I appeal decision. In the context of adverse determination appeals, a clinical peer reviewer is a licensed physician who is in the same or similar specialty as the health care provider who typically manages the medical condition, procedure, or treatment under review.

Level II appeal
If a Level I denial is upheld, whether payment or services, the entire case is forwarded to the Independent Review Entity (IRE) Reconsideration for a Level II Appeal review.

Level III appeal
Any party to the reconsideration (except Blue Cross Blue Shield) dissatisfied with the reconsideration decision has a right to a hearing before an Administrative Law Judge (ALJ) of the Social Security Administration.

Level IV appeal
Any party dissatisfied with the decision of the ALJ (including Blue Cross Blue Shield) may request the Medicare Appeals Council (MAC) to review the ALJ's decision or dismissal.

Level V appeal
A right to a Judicial Review of an ALJ decision may be requested only if the MAC has acted on the case. A party to the hearing (including Blue Cross Blue Shield) may request judicial review of an ALJ or MAC decision.

Standard appeal

Deadline for requesting an appeal: A member may request an appeal of an adverse determination in writing within 30 days for pre service and 60 days for post service after receiving notification of the adverse determination.

The following may file a request for reconsideration:

  • Member
  • Legal representative of a deceased member's estate
  • The authorized representative of a member (representative form must be completed).

Procedure for conducting a standard appeal:

  1.  Blue Cross Blue Shield requests pertinent medical records from the provider if they have not already been submitted.
  2. If the member's health could be in jeopardy, the expedited review process is implemented. Blue Cross Blue Shield also may extend the time frame by up to 14 calendar days if the organization justifies a need for additional information and documents how the delay is in the interest of the enrollee.
  3. Blue Cross Blue Shield is responsible for processing standard appeals within 30 days for pre service and 60 days for post service from the date request is received. The determination of an appeal on a clinical matter will be made by personnel qualified to review the appeal, including licensed, certified or registered health care professionals who did not make the initial determination.
  4. If the decision is to uphold the original denial, the entire case must be sent to the Independent Review Entity (IRE). The IRE will make a reconsideration decision on clean cases within 30 days and claim reconsiderations within 60 days and will advise the member of that decision in writing. If the decision is not wholly favorable to the member, the notice will include the member's right to a hearing before an Administrative Law Judge of the Social Security Administration.

Expedited appeal

Eligibility for expedited appeal:

Request for an expedited appeal may be made by telephone or in writing. There is an established process for making reconsideration determinations when the life or health of a member or a member's ability to regain maximum function could be seriously jeopardized by waiting 30 days for a standard reconsideration determination.

A request for an Expedited Appeal may come from a physician, if the physician has been designated as the member's representative (The "Appointment of Representative Form" must be completed), or a member. Any request from a member must first be reviewed to ensure that it meets the criteria for an Expedited Appeal. The member or physician may state that they want an "Expedited Appeal", a "fast appeal" or a "72-hour appeal." These terms are all synonymous and imply an expedited review other than the standard 30 day appeal process.

Procedure for conducting an expedited appeal:

  • Blue Cross Blue Shield requests pertinent medical records from the provider if they have not already been submitted.
  • Blue Cross Blue Shield makes a determination with regard to the expedited appeal within 72 hours of receipt of the appeal. The determination of an appeal on a clinical matter is made by personnel qualified to review the appeal, including licensed, certified, or registered health care professionals who did not make the initial determination.
  • If the decision is to uphold the original denial, the entire case must be sent to the Independent Review Entity (IRE). The IRE will make a reconsideration decision within 72 hours and will advise the member of that decision in writing. If the decision is not wholly favorable to the member, the notice will include the member's right to a hearing before an Administrative Law Judge of the Social Security Administration.
  • Failure to comply with timeframes for an internal appeal of a utilization review determination is deemed a reversal of the initial determination.

Advance Directives

Blue Cross Blue Shield is required by law to inform our members of their right to make health care decisions and to execute advance directives regarding their care. An advance directive is a formal document, written by the member in advance of an incapacitating illness or injury. As long as the Blue Cross Blue Shield member can speak for him/her self, contracting Blue Cross Blue Shield medical providers must honor the member's wishes. In the event that an incapacitating illness prevents the member from being able to make his or her own health care decisions, then the advance directive will guide the Blue Cross Blue Shield provider to provide treatment according to the member's wishes. Members who complete the advance directive will spare caregivers the task of making difficult treatment decisions without prior knowledge of what the member would have wanted.

All participating Blue Cross Blue Shield providers should obtain, and keep on file, advance directives that clearly outline a member's wishes in the event that a serious illness or injury should occur. Advance directives may be obtained by having the member complete a Health Care Proxy, Do Not Resuscitate Order (DNR) or Living Will. Many providers have found it helpful to add advanced directives to the preventive health checklist and to the initial/annual visit routines.

Health Education and Preventive Care

Health Education and Preventive Care are important in keeping your patients healthy. That is why we offer the Community Wellness Program, with more than 250 health education programs to choose from. The Community Wellness Program offers your patients a wide variety of health resources, free of charge. Patients do not require a referral or written approval for most approved classes.

At the present time, classes are primarily offered in the following categories:

  • Asthma
  • Arthritis 
  • Children and adolescent health
  • Diabetes education
  • Heart health
  • Injury prevention and self-care
  • Maternal and infant health
  • Nutrition
  • Physical activity
  • Senior health
  • Smoking cessation
  • Stress management
  • Weight management

You or your patients may view a current list of programs by visiting the Health & Wellness section of our website.

Preventive Health Guidelines

Prevention and Screening programs are important. Senior Blue (HMO), BlueSaver (HMO), and Forever Blue (PPO) practitioners will receive notice in the provider newsletter when the Preventive Health Guidelines are updated. Physicians serving on our Quality Management Committee approve these guidelines.  We urge you to encourage your patients to receive these important screening tests. To assist you in this effort, we have developed several programs targeted to our senior population, e.g., breast and colorectal cancer screening reminders and flu shot and pneumonia vaccine awareness campaigns.

Health Management Programs

The goal of health management programs is to improve the quality of life for patients. Health management employs a team effort to assist the primary care physician with patient management, particularly those patients with serious or chronic medical problems. Instead of the traditional component management system, health management incorporates a systems approach to improving patient outcomes by effectively coordinating all elements of health care delivery.

Through health management programs, we can examine physician practice patterns and patient compliance with treatment recommendations. By documenting these variables, we can determine how well current treatments are working for patients in every day practice. The relationship between treatment and patient outcomes is usually studied through controlled clinical trials that randomly assign patients to different treatments, thereby assuring similarity of patients across treatments when comparing outcomes.

However, in Health Management Programs, we measure what happens to patients in everyday practice. Patients receiving different treatments are generally not comparable -- those who are sicker receive more intensive treatment. The goal of each health management program is to answer the question: "How do we provide the best treatment to every patient with this condition, thus assuring the best possible health outcomes?"

To assist physicians in caring for patients with serious chronic medical problems, Blue Cross Blue Shield has implemented planned health management programs for the following:

  • Asthma Program
  • Attention Deficit Hyperactivity Disorder (ADHD) Program
  • Behavioral Health Case Management
  • Cardiovascular Management Program (includes CAD and CHF)
  • Case Management Program (includes oncology, chronic kidney disease)
  • COPD Management Program
  • Depression Management Program
  • Diabetes Management Program
  • Hip and Knee Program
  • Obstructive Sleep Apnea Program
  • Palliative Care Program
  • Right Start High-Risk Prenatal Program
  • Spine Health Management Program
  • Substance Use Disorder Program