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Provider and Facility Reference Manual

Section 12 - Product Information

 

General Information


Blue Cross Blue Shield offers a wide variety of health coverage options, including managed care, preferred provider organization (PPO), point of service (POS) and traditional contracts to employer groups throughout western New York.
Blue Cross Blue Shield has removed the referral requirement from most of our managed care lines of business. This no-referral policy applies to all specialty services provided in-network. Please note the following:

  • Blue Cross Blue Shield continues to encourage members to consult with their primary care physician (PCP) regarding their choice of specialty provider prior to visiting a specialist.
  • For continuity of care, specialists must continue to communicate with the PCP about any treatment that is provided.
  • Any services that currently require preauthorization will still require preauthorization.
  • Benefit coverage and limitations have not changed. For example, if only 20 physical therapy visits were covered with a referral, only 20 visits will continue to be covered.
  • This change is for In-Network referrals only. The current referral process will continue to apply for Out-of-Network situations, including out-of-plan referrals. The only exception is for emergencies.


Note: Some products may require a referral, for example Government programs. Please verify eligibility and benefits at wnyhealthenet.com

HMO and POS

Our managed care contracts provide coverage for preventive and health maintenance care, early diagnosis and treatment, as well as coverage for illness and injury.

In a managed care environment, the PCP manages the member's care. The PCP is responsible for coordinating care and must contact Blue Cross Blue Shield to obtain referrals and preauthorization when required by the member's benefit package.

HMO and POS Features


Copayments/Coinsurance

The provider may not bill the member for services covered except for any applicable co-pays, co-insurance, or permitted deductibles. A copayment, or copay, is a set amount paid to the provider by the member at the time of service. This amount is deducted from the reimbursement we make to you. Some of the services that require copayments are office visits, emergency room visits, diagnostic services, hospital admissions and therapies. Copayments vary depending on the type of contract, provider (PCP or specialist) and service involved. Office visit copayments appear on most member identification cards.

In some cases, members are responsible for a coinsurance for covered services. Providers should submit the claim to Blue Cross Blue Shield for processing and then collect from the member their responsibility. Some products also have deductible amounts prior to copayments or coinsurance being applicable. Providers should submit the claim to Blue Cross Blue Shield to determine the member responsibility.

Please note if you are a Blue Cross Blue Shield specialist covering for a PCP, you should collect the specialist copay. OB-GYNs should collect the PCP copayment.

Out-of-Network Benefit

The Out-of-Network benefit gives our members the flexibility to see any doctor without a referral. This benefit provides traditional-style coverage if a member chooses to go outside the network of participating providers to seek care. The member is responsible for a deductible and coinsurance on Out-of-Network services.

This benefit applies to POS products, PPO products and most HMO 200 Series products and is offered as an option to groups who have HMO100 Series products.

Administrative Services Only (ASO)

This coverage is designed for employers who choose to self-fund their employee health benefit programs. Self-funding allows businesses to design their own benefit plans and pay their own claims. Blue Cross Blue Shield handles the administrative services such as processing claims and developing provider networks. Payment is made according to the fee schedule and all protocols apply. The copayment will vary depending on the group. There is no withhold deducted from the allowance for physicians who provide services to a Blue Cross Blue Shield member who has an ASO contract. For more detailed information on benefits and claims processing, please call the Provider Service Department at 1-800-950-0052

Preferred Provider Organization (PPO) or Exclusive Provider Organization (EPO) Contracts

PPO and EPO contracts are designed for consumers with indemnity insurance who are looking for an option that does not include the gatekeeper and who want a national provider network.

The PPO concept offers a preferred provider network for members' use. Selection and use of a network physician provides a richer benefit for the member than use of an Out-of-Network provider. The member decides which physician or facility to use. EPO contracts only provide coverage through the exclusive provider network. If a member utilizes a non-network provider, there is no coverage for those services, unless it is an emergency.

The PPO and EPO provider network is based upon the HMO 200 Series panel of physicians. Services are reimbursed at the Blue Cross Blue Shield fee schedule; however, there will be no withhold, no referrals required and the member is not required to choose a PCP. The patients covered under this product are not included in risk or incentive programs.

The managed care features of this product consist of the Blue Cross Blue Shield Protocols, inpatient and certain outpatient preauthorization requirements and copayments.

If a PPO member chooses to receive care from a physician who is not participating with the PPO network, the services are considered Out-of-Network. Payment will be made at a percentage of the traditional fee schedule. The member is responsible for the remaining percentage of the traditional fee schedule and the deductible. Participating traditional providers can only bill the member up to the traditional allowance and the amount that is applied to the deductible. EPO members are responsible for the full cost of services when receiving care outside of the EPO network.

Medicaid Managed Care

As a participating provider it is your responsibility to verify at the time of service if the member is eligible for Medicaid Managed Care by accessing the Electronic Medicaid Eligibility Verification System (EMEVS). If you provide services to an ineligible person you may not receive payment for these services.

Below is a list (not complete) of Services that are covered and non-covered for Medicaid Managed Care (MMC). Certain non-covered services for MMC may be covered through the Medicaid Fee for Service Program.

The provider should advise the enrollee, prior to initiating a service, that the service is not covered by the MCO, and to state the cost of the service.

Medicaid Managed Care members have no Out of Area benefits except for ER, inpatient admissions through the ER and authorizations through Utilization Management due to inability or lack of network providers to deliver care.

Medicaid Managed Care: Covered Services

The following services are covered by Blue Cross Blue Shield when provided by the PCP or arranged by the PCP:

  •  Assertive Community Treatment (ACT)
  • Comprehensive Psychiatric Emergency Program (CPEP)
  • Consumer-directed personal care services
  • Continuing Day Treatment (CDT)
  • Crisis Intervention
  • Crisis Intervention
  • Dental, including medically necessary orthodontia
  • Detox Services
  • Durable medical equipment
  • Emergency services
  • Eye care
  • Family planning
  • Home health services
  • Hospice services
  • Inpatient hospital services
  • Inpatient Substance Use Disorder Treatment
  • Laboratory services
  • Medical supplies
  • Mental Health Clinic
  • Mental Health Inpatient Rehabilitation
  • Mental health services
  • Opioid Treatment (including Medically Assisted Treatment - MAT)
  • Outpatient Clinic
  • Partial Hospitalization
  • Personal care services
  • Personal Recovery Oriented Services (PROS)
  • Physician services – primary and specialty
  • Prescription drugs
  • Preventive health services
  • Private duty nursing
  • Residential Services
  • Substance use disorder services

Medicaid Managed Care: Non-Covered Services

The following services are covered through Medicaid fee for service and not Blue Cross Blue Shield:

Emergent and non-emergent transportation (NYS Medicaid contracts with Medical Answering Services for Non-Emergent Transportation Services.)

Medical Answering Services Contact Numbers
Allegany County 1-866-271-0564
Cattaraugus County 1-866-371-4751
Chautauqua County 1-855-733- 9405
Erie County 1-800-651-7040
Genesee County 1-866-753-4430
Niagara County 1-866-260-2305
Wyoming County 1-855-733-9403
Important Phone Numbers  
Blue Cross Blue Shield Member Services 1-866 231-0847 (TTY 711)
New York State Health Department Complaints 1-800-206-8125
Allegany County Department of Social Services (585) 268-9300
Cattaraugus County Department of Social Services (716) 373-8077
Chautauqua County Department of Social Services 1-877 653-0216
Erie County Department of Social Services (716) 858-6105
Genesee County Department of Social Services (585) 344-8502
Niagara County Department of Social Services (716) 278-8400
Orleans County Department of Social Services (585) 589-3209
Wyoming County Department of Social Services (585) 786-8900

Traditional Contracts

Our traditional contracts provide comprehensive hospital and medical coverage. These contracts cover inpatient medical care, outpatient services such as emergency room visits, outpatient surgical care and pre-admission testing. Covered medical services include hospital visits, most surgery and surgical assistance, maternity care, non-routine lab and radiology procedures.

Members can choose to receive care from any doctor in Western New York. However, members who select a non-participating provider have to pay a higher out-of-pocket cost. Providers who participate in our traditional programs are required to bill us directly and accept our allowances as payment in full for covered benefits after the deductible and coinsurance has been met.

High-Deductible Health Plans

We offer a number of high-deductible health plans (HDHPs) that can be purchased and utilized with a health savings account (HSA) or health reimbursement arrangement (HRA). Deductible, contribution, and out-of-pocket limits are defined by the IRS for HSA accounts. Providers must bill for services rendered and Blue Cross Blue Shield will calculate the member responsibility (deductible, copay, coinsurance).

Chiropractic Services

Chiropractic care is managed by Blue Cross Blue Shield. Many traditional and managed care members receive chiropractic benefits due to a New York State chiropractic mandate. This mandate requires contracts that cover services provided in a physician's office to also cover medically necessary chiropractic care received from a licensed physician or doctor of chiropractic. Coverage includes spinal manipulation or adjustment of the spinal column and x-rays that relate to chiropractic treatment. Routine wellness and maintenance care visits are not considered to be medically necessary and are not covered.

The mandated chiropractic services do not apply to the following contracts:

  • Medicare Supplemental Plans
  • Medicaid MCO 501
  • Federal Contracts
  • Child Health Plus 201
  • Self-insured Plans, unless employer group arranges for coverage (Administrative Services Only - ASO)
  • Senior Blue HMO - the mandate does not apply


How the Mandated Chiropractic Benefit Works
For Managed Care contracts

Members may seek care from any participating network chiropractor without a referral from their primary physician. For each visit, members are responsible for the applicable copay and/or coinsurance.


For PPO, EPO, and Traditional Contracts

Members may seek care from any chiropractor. We will reimburse these chiropractic services at our schedule of allowances, subject to any applicable copay, deductible and/or coinsurance. Chiropractors who do not participate with Blue Cross Blue Shield may balance bill members.

Participating Blue Cross Blue Shield providers will receive direct payment. For members who seek treatment from a non-participating provider, the member will receive direct payment
 

For ASO Self-funded contracts:

Preauthorization is required for members with contractual chiropractic visit limitations.  For these members, providers need to submit a completed Chiropractic Treatment Request (CTR) form to our Utilization Management Department. After the medical necessity determination has been made, the provider and member are notified within three days. If additional chiropractic visits are required, the provider must submit additional CTR forms.


Chiropractic Claims:

Submit claims electronically through your vendor or directly to ASK EDI. If unable to submit electronically, send paper claims to:

Highmark Blue Cross Blue Shield of Western New York
PO Box 80
Buffalo, NY 14240-0080

If you have any questions about covered chiropractic services, preauthorization, or claims submission, please call Blue Cross Blue Shield at the number identified on the back of the identification card.

Please see the Chiropractic Section of our provider website for additional information including a Chiropractic Reference Manual, and necessary forms.

Laboratory Services

Referred laboratory services provided to our members must be performed by a provider participating with our laboratory network. Please refer to the most recent participating laboratory location guide on our website.

If your patients have coverage under the following Highmark Blue Cross Blue Shield of Western New York plans, laboratory tests must be performed at a Quest Diagnostics Lab in order for services to be covered at the in-network benefit.

  • HMO
  • POS
  • HMO/POS
  • Medicare Advantage HMO
  • Essential Plan
  • Medicaid Managed Care

If the test is not performed at a Quest Diagnostics lab, claims for members in the above plans will be processed under their out-of-network benefit and the member will have higher out-of-pocket costs. Claims for HMO members without POS benefits will be denied. 

Out-of-Network Preauthorization Requests
 

  • For testing that cannot be performed by Quest Diagnostics, the ordering physician must request an out-of-network preauthorization by calling Quest Diagnostics at (716) 568-5253.
  • Quest Diagnostics will confirm that the testing cannot be performed by their laboratory and is FDA approved; Quest will forward the request to our Utilization Management Department for review.
  • Utilization Management staff will determine if the services are medically necessary and, when applicable, approve the out-of-network preauthorization to a non-participating lab so that claims will process at the in-network benefit.
  • Highmark Blue Cross Blue Shield of Western New York members in the above plans do not have to use a Quest Diagnostics Lab for the following:
  • Testing performed during an inpatient admission.
  • Pre-admission or pre-surgical testing performed prior to an inpatient stay or outpatient surgery.
  • Test associated with an emergency room visit.
  • Certain testing that physicians/hospitals may perform. (See Laboratory Exempt Lists on our website.)

Highmark Blue Cross Blue Shield of Western New York policy for continued referrals of laboratory specimens by participating providers to a non-preferred laboratory for the plans above, or to a non-participating laboratory for all plans include the following measures:

First Occurrence: Blue Cross Blue Shield (BCBSWNY) will contact the provider/group office via email or phone and educate on the requirement to refer specimens to a participating laboratory or the preferred laboratory (Quest Diagnostics) as applicable for the member’s plan or product.  Then BCBSWNY will send a 1st notice letter via Certified Mail to the provider/group as a follow-up to the original e-mail or phone conversation (reference contract section 2.3.1 and 2.10.4).

Second Occurrence: BCBSWNY will send a 2nd notice letter via Certified Mail to the provider/group (contract references 2.3.1 and 2.10.4). Financial consequences are noted in the letter.

Third Occurrence (final notice): BCBSWNY will send a 3rd and final notice letter via Certified Mail to the provider/group (contract references 2.3.1 and 2.10.4). The letter needs to include the date that the previous letter was sent. Financial consequences that would be applicable are noted in the final notice letter, if the third occurrence is within the 12-month time from the first occurrence.

Vendors

To better meet the health needs of our members, Blue Cross Blue Shield contracts with vendors who have expertise in certain specialties. Working with outside organizations helps Blue Cross Blue Shield more effectively manage health care costs, while continuing to provide members with high quality care.


MRI, PET, CT Scans, Nuclear Cardiology, and Radiation Oncology Program

National Imaging Associates (NIA) manages the preauthorization process for MRI/MRA, PET Scans and Radiation Oncology Program for all Blue Cross Blue Shield lines of business (unless specified per the member’s contract).

To obtain a preauthorization for these services, you can submit your requests

24 hours a day, seven days a week at radmd.com or contact their dedicated provider call center at 1-800-642-7820. This center is staffed with physicians, on call from 8 a.m. - 8 p.m. EST, Monday through Friday.

 

eviCore healthcare Post-Acute Care Program

Beginning November 1, 2020, eviCore healthcare will provide post-acute care preauthorization for select Medicare Advantage members with complex medical conditions.

Services requiring preauthorization:

  • Skilled nursing facility (SNF) admissions
  • Inpatient rehabilitation facility (IRF) admissions
  • Long-term acute care (LTAC) admissions


Preauthorization for all other members is managed by the BCBSWNY utilization management department.

Preauthorization can be submitted online or by phone or fax:
Registering Online:
https://www.evicore.com/provider
Click “Register Now” under the Log In button

Phone and Fax Number

  • Provider call center: 866-525-5027
  • Fax Number: 877-256-6892

eviCore Hours of operation:

  • Monday through Friday: 8 a.m. - 7 p.m. EST
  • Saturday: 9 a.m. - 5 p.m. EST
  • Sundays and Holidays: 9 a.m. - 2 p.m. EST
  • 24/7 on call coverage for urgent needs


Identification Cards

It is important to check your patient's insurance card to identify changes since their last visit to keep your records current and to ensure that you submit claims to the correct insurance carrier.

Members will have a prefix on their identification card. The first two letters "YJ" indicates that the member is enrolled with Blue Cross Blue Shield. The third letter of the prefix will vary to indicate the member's type of coverage.


ASO (Administrative Services Only) Accounts

Prefixes for ASO accounts may be different. To verify benefits and eligibility, go to wnyhealthenet.com or call the telephone number on the member’s card.


National Accounts

Prefixes for national accounts may be different. The corporate name may appear on the member's identification card. For questions on benefits, eligibility, payment method, and claim inquiries for national accounts call the National Accounts telephone number at 1-877-576-6440.

Vision Services


Davis Vision is our Routine Vision Partner

Davis Vision is our partner for routine vision exams, glasses and contacts beginning January 1, 2021 for Highmark New York members. As part of our affiliation with Highmark, we will begin gradually moving your Highmark Blue Cross Blue Shield of Western New York patients onto Highmark’s system starting January 1, 2022. Subsequently, these patients’ routine vision claims will need to be processed by Davis Vision as they move onto Highmark’s system. 

Routine vision benefits may vary by plan for your Blue Cross Blue Shield patients. Coverage for problem eye services is considered a medical benefit and will not be managed by Davis Vision. Medical claims (for care including but not limited to infection, macular degeneration, glaucoma, detached retina) will continue to be submitted electronically through Administrative Services of Kansas, Inc. (ASK) for all patients. However, there may be some different requirements or processes for patients who have moved onto Highmark’s system.  


Pediatric Exchange Vision Coverage

Effective January 1, 2021 pediatric (up to age 19) Affordable Care Act (ACA) patients who are covered by our Individual and Small Group (Bronze, Silver, Gold and Platinum) plans must see Blue Cross Blue Shield network vision providers for routine eye exams, and eye care accessories (frames, lenses, contact lenses) as these benefits are embedded in the medical benefit.

If you are not currently credentialed with us, please visit the provider website for credentialing instructions, or call us at 1-800-666-4627 with questions.

Beginning January 1, 2022, pediatric ACA routine vision claims as described above will begin to be processed through Davis Vision for patients who have moved onto Highmark’s system. If you care for pediatric ACA patients, you will need to be in the Davis Vision network. If you are already contracted with Davis Vision, you will be able to send claims to Davis Vision directly for routine eye exams and eye care accessories for these Highmark pediatric patients who have moved onto Highmark’s system.

If you are not in the Davis Vision network, you may continue to see these pediatric patients still on our legacy system throughout 2022 until they move onto Highmark’s system; claims for these patients will continue to be submitted directly to us.


Medicare Advantage Vision Coverage

Effective January 1, 2021, all covered Medicare Advantage vision services and products claims must be processed through Davis Vision. This includes routine vision exams, glasses, contacts, and post cataract benefits for glasses or contacts.

Patients with Medicare Advantage HMO plans must use a Davis Vision participating provider to receive benefits for vision services. Patients with Medicare Advantage PPO plans can see a non-participating Davis Vision provider; however the claims must be submitted to Davis Vision using the Davis Vision’s out of Network Claim form.


Filing Vision Claims

If you are contracted with Davis Vision, you will be able to provide and bill Davis Vision directly for covered routine vision services to Blue Cross Blue Shield Commercial and Medicare Advantage patients beginning on January 1.

  • Non Participating Davis Vision providers should not submit claims directly to Blue Cross Blue Shield using Administrative Services of Kansas, Inc. (ASK) for routine vision services including routine exam, glasses, contacts or Medicare Advantage required post cataract benefits. 

The following services should be billed directly to Blue Cross Blue Shield, as they are considered medical benefits:

  • Routine vision services and accessories to pediatric patients under age 19 who are part of Blue Cross Blue Shield Bronze, Silver, Gold and Platinum plans until the patient moves onto the Highmark system.
  • Any problem or diagnosis-focused eye services Medical claims (for care including but not limited to infection, macular degeneration, glaucoma, detached retina) will continue to be submitted electronically through Administrative Services of Kansas, Inc. (ASK) for all patients. However, there may be some different requirements or processes for patients who have moved onto Highmark’s system. 

Please follow the links below to join the Davis Vision and or Blue Cross Blue Shield networks.

If you are already a part of the Davis Vision network and have a general inquiry, you can reach them at 1 (800) 773-2847. Call center hours of operation are Monday – Friday: 8 a.m. to 8 p.m. (Eastern time), Saturday: 9 a.m. to 4 p.m.)