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Provider and Facility Reference Manual

Section 2 - Credentialing Recredentialing Program and Facility Application Protocol and Credentialing Process

Introduction

The Practitioner Credentialing and Recredentialing Programs address the selection and retention of practitioners for participation in Highmark Blue Cross Blue Shield of Western New York. The purpose of using credentialing and recredentialing criteria is to establish consistent, clear objectives for the credentialing and recredentialing of participating practitioners.

The practitioners to whom this program applies include physicians (MD, DO), oral surgeons (DDS, DMD), podiatrists (DPM), and other health care professionals acting within the scope of their licenses, practicing in the outpatient setting. Further, this program applies to the credentialing and recredentialing of individual practitioners, organized medical group practices, and practitioners participating in subcontracted networks.

The procedures established herein are to be implemented for Blue Cross Blue Shield where permitted by state laws and regulatory requirements and by existing contractual arrangements.

The decision to accept or retain a practitioner is based on the information available, including but not limited to the information gathered through a completed practitioner application, the re-evaluation process, and the verification of all collected information. This process takes place every 36 months.

Blue Cross Blue Shield does not discriminate against health care professionals who serve high-risk populations, or who specialize in the treatment of costly conditions, and/or provide certain services (i.e., abortions, HIV care). The provider credentialing and re-credentialing process is conducted in a non-discriminatory manner, without regard for: race, color, religion, sex, national origin, age, marital status, sexual orientation, and veteran status.

Periodic audits of denied credentialing files will be conducted to ensure that practitioners were not discriminated against. A spreadsheet will be maintained for audit purposes. In addition, Blue Cross Blue Shield will conduct periodic audits of practitioner complaints to determine if there are complaints alleging discrimination; ensure that a heterogeneous credentials committee is maintained, and obtain affirmative statements from those responsible for credentialing decisions that all decisions were made in a nondiscriminatory manner.


Medicaid Integrity/Disclosure of Ownership

The Medicaid Managed Care/Family Health Plus Plan Model Contract (18.9 (c) indicates that the Contractor requires all network providers to monitor staff and employees against the stated exclusion list (List of Excluded Individuals and Entities and the Restricted, Terminated or Excluded Individuals or Entities List) and report any exclusions to the Contractor on a monthly basis.

Also, in accordance with federal regulations (Section 42 CFR 455.106) and the Medicaid Managed Care/Family Health Plus Plan Model Contract (18.12 (b)), the managed care health plan/Contractor requires providers to disclose health care related criminal conviction information from all parties affiliated with the provider. Upon entering into an initial agreement or renewal of any agreement between the managed care health plan/contractor and its providers, the managed care health plan/contractor must disclose to the SDOH Division of Health Plan Contracting and Oversight in 20 working days of the disclosure date any conviction of a criminal offense related to that provider or provider's managing employee involvement in any program under Medicare, Medicaid, or Title XX services program (Block grant programs).

As per federal regulation 42 CFR 455.104 and Medicaid Managed Care/Family Health Plus Plan Model Contract 18.6 (b), Blue Cross Blue Shield requires that participating providers disclose complete ownership, control and relationship information upon submitting application, executing the provider agreement, and within 35 days after any change in ownership. In accordance with federal regulation 42 CFR 455.105 and the Medicaid Managed Care/Family Health Plus Plan Model Contract 18.6 (c), and as cited in the Participating Provider Agreement within 35 days of the date of a request by the SDOH, OMIG or DHHS, the managed care organization/contractor will require from any subcontractor disclosure of ownership, with whom an individual network provider has had a business transaction totaling more than $25,000 during the 12-month period ending on the date of request.

Disclosure of Ownership and Controlform must be completed as part of the credentialing process to ensure compliance with the above referenced program requirements. Plan requires that such providers not employ or contract with any employee, subcontractor or agent who has been debarred or suspended by the federal or state government, or otherwise excluded from participation in the Medicare or Medicaid program.

The Disclosure of Ownership and Control form is located on our website under: Provider > Tools & Resources > Forms.

When credentialing and recredentialing criteria for participation, the practitioner:

  • All sections of the CAQH application must be answered, completed and attested to within 180 days of credentialing decision date.
  • Must hold a current valid license to practice in New York State and/or the state where the practitioner practices.
  • Must have completed appropriate training for his/her profession.
  • All physicians are required to be currently board certified in their area of specialty.

Blue Cross Blue Shield recognizes accreditation by the American Osteopathic Association (AOA), the American Board of Medical Specialties (ABMS), the American Board of Oral Surgeons for Oral and Maxillofacial Surgery for DDS and DMD practitioners, the Board of Podiatric Medicine, the American Board of Foot and Ankle Surgery for DPM, or the Royal College of Physicians and Surgeons of Canada (RCPSC) is required. RCPSC certification is not accepted in the following specialties: colorectal surgery, medical genetics, otolaryngology, thoracic surgery, and urology.

General practice is not a recognized specialty by Blue Cross Blue Shield.

Board certification exceptions may be granted to physician practitioners under the following conditions:

  1. Have admitting privileges at one (1) or more in-network hospitals or written agreement with in-network provider/group that will admit on behalf of provider.
  2. Completed an accredited residency program in their area of specialty.

Admitting privilege exceptions may be granted to physician practitioners under the following conditions. If any exceptions are granted, this must be documented in writing and included in the provider's file:

  1. If there is a demonstrated access issue, e.g., rural area, individual consideration may be given by the plan Medical Director or designee.
  2. Practitioner possesses extraordinary credentials and potentially unique abilities worthy of consideration. Circumstances of this nature will be reviewed for consideration by the Medical Director or designee.
  3. Physicians who are currently sitting for their Boards; a written letter from the practitioner will be submitted along with documentation from the Board stating the date when the provider will be sitting.


Primary Care Physician (PCP)

The physician must have completed postgraduate training in Family Practice, Internal Medicine, Geriatric primary care, Adolescent Medicine, or Pediatrics.

All primary care physicians must have a satisfactory on-site attestation and medical record review completed by the appropriate Blue Cross Blue Shield representative, as applicable.


Specialist Physician

The physician must have successfully completed postgraduate training in the specialty the practitioner wishes to practice as a specialist. Providers are required to have unrestricted privileges in the specialty requested at every hospital in which the physician practices, with the exception of Radiology, Dermatology, Pathology, and Anesthesia (at Ambulatory Surgery Centers).


Dual Appointment Physicians

A physician who seeks to be credentialed both as a primary care physician and a specialist physician must demonstrate:

  • The training requirements for both primary care physician and specialty physician have been successfully completed.
  • All dual appointment physicians must have a satisfactory on-site review.
  • All dual appointment physicians must have a satisfactory medical record review.

Credentialing Overview

The purpose of the selection process is to include only those practitioners who meet the established credentialing criteria.

All applications are reviewed by the Chief Medical Officer or designee. The credentials, when complete, are presented to the Credentials Committee that is under the direction of the Blue Cross Blue Shield Medical Director. The committee meets at a minimum of four times per year and is attended by other appropriate personnel to include but not limited to representatives from Quality Management, Special Investigations Unit, and Provider Network, along with physicians from the community.

The Chief Medical Officer or Medical Director\Designee and Credentialing Committee make the final determination for participation.
Credentialing criteria are developed for each type of health care professional who participates with Blue Cross Blue Shield's Managed Care product(s). These criteria are developed and approved by the Credentials Committee. Criteria include specific requirements relative to each specialty.

The goal of the credentialing process is to ensure that the members of Blue Cross Blue Shield will be cared for by qualified practitioners in appropriate settings. The on-site attestation review and medical record review for primary care physicians, obstetricians and gynecologists (OB-GYN), and high-volume behavioral health specialists will be used along with other information compiled in the credentialing process as a tool for improvement of the quality of care and service. An important feature of the credentialing process will be to identify areas that have the potential for improvement and to work with the practitioners to identify ways in which the improvement can be achieved.

Universal Credentialing Electronic Application

Blue Cross Blue Shield now requires providers to enter their credentialing/recredentialing information (free of charge) into a single, uniform online application. This application meets the credentialing needs of health plans, hospitals, and other health care organizations. The CAQH ProView provider data-collection service streamlines the initial application and re-credentialing processes, reduces provider administrative burdens and costs, and offers health plans and networks real-time access to reliable provider information for claims processing, quality assurance and member services, such as directories and referrals.

Providers submit data through CAQH ProView to a secure, state-of-the-art data center. Providers then authorize health plans and other organizations to access the information. Periodic provider updates help ensure that the information is always current.

CAQH ProView is supported by the American Medical Association, the American Academy of Family Physicians, the American College of Physicians, America's Health Insurance Plans, the Medical Group Management Association, the National Association of Medical Staff Services and other provider organizations, and recognized by a number of state legislators and insurance commissioners. The newest version of the CAQH ProView application meets all related URAC, National Committee for Quality Assurance and the Joint Commission standards.

Providers are required to enter their credentialing data with CAQH ProView through the CAQH ProView website: upd.caqh.org. Once this application is complete, providers must allow Blue Cross Blue Shield to view this information by choosing this option at the completion of the application. For more information, or if there are additional questions, you may contact the Provider Enrollment Department at 1-800-666-4627.

Credentialing Process


A. Application for Practitioner Participation

Instructions for enrolling as a participating provider can be found on our website at bcbswny.com.

Initial Credentialing

Providers can enroll into our health plan by filling out the Universal Credentialing Application with CAQH ProView, the Council for Affordable Quality Healthcare.

How it Works

To access the Universal Provider Datasource®, go to upd.caqh.org:

  • Log on with your username and password.
  • Enter your CAQH Provider ID (if unknown, call CAQH at 1-888-599-1771).
  • Enter or update your information.
  • Authorize Highmark Blue Cross Blue Shield of Western New York access to your information electronically.
  • If you do not have a CAQH application, refer to the ’First Time Here’ information and click ‘Register Now’.
  • Complete this form and return it to the fax number on the form.

Once you have completed the CAQH application, please complete the Provider Enrollment Form (PEF) and Disclosure of Ownership and Control form and return both to 716-887-2056.

A Participating Provider Agreement, Disclosure of Ownership and Control form, and instructions will be sent by the Provider Enrollment Department to the practitioner if the panel the practitioner is seeking participation in is open. Should a prospective practitioner request an application for a specialty in which the panel is closed, the practitioner may submit a letter of interest. These letters are kept on file until such time that the panel is reopened to that specialty. All appropriate practitioners operating in the service area are contacted when the panel is reopened in a requested specialty.

The application will be processed if complete information is provided on the CAQH application. If the information supplied on the application is incomplete, the application processor is responsible for contacting the applicant, initially by phone and/or email, to obtain details and documentation, as appropriate. Information will be deemed incomplete if information or documentation requested on the application is not provided, if responses provided require further explanation, if details related to affirmative answers to disclosure questions are not provided, or if any documents have expired prior to making a decision to accept or not to accept an applicant.

Upon receipt of a signed provider agreement, Disclosure of Ownership and Control, and complete CAQH application: 

  1. The Provider Enrollment Specialist reviews the application for completeness. 
  2. The applicant is notified if any additional information is needed. 
  3. Primary source verification of specified credentialing criteria documentation will be initiated by the credentialing specialist. 
  4. The credentialing specialist will also verify if the provider has elected to opt-out of Medicare, as well as verify that the provider is not excluded from participation with Medicaid Managed Care or Medicare.
  5. The completion of an application does not guarantee acceptance into the Blue Cross Blue Shield panel. The prospective practitioner will not be reimbursed as an in-network provider until they have been notified by Blue Cross Blue Shield of their approval. The practitioner will be notified, in writing of our decision. Blue Cross Blue Shield does not back-date any effective date for legal reasons. 
  6. Blue Cross Blue Shield reserves the right to deny participation to any practitioner that is an employee or an independent practitioner of a direct competitor.

If there is a substantial difference between the information provided by the practitioner and primary source verification, the practitioner will be notified and required to provide documentation prior to their credentials being presented to the Credentialing Committee.

Upon receipt of all relevant documents, the credentials are reviewed by the Chief Medical Officer or designee. The Chief Medical Officer or designee will make the final determination regarding participation for level 1 practitioners. All level 2 or level 3 practitioners will be individually presented to the Credentialing Committee. The practitioner is notified in writing of the final decision.

Upon acceptance into Blue Cross Blue Shield the applicant will be provided with materials and appropriate office staff training:

  • Primary Care Physicians - Practice Account Managers
  • Specialist - Provider Network Management and Operations Specialist
  • Behavioral Health - Regional Provider Contract Manager

B. Office Site Review

A review of primary care physicians, obstetricians/gynecologists, opthalmologists, and behavioral health specialist office sites must be completed as a requirement of participation. The physician office site review or office compliance attestation addresses, at a minimum, access to services, waiting area amenities, safety and adequacy of equipment and the treatment area. The physician office site review form and office compliance attestations are used for this purpose. The office compliance attestation will require the office to attest to the requirements by signing the form and returning by email or fax within five (5) business days. The office site review will require a physical visit to the site.

C. Medical Record Review

The medical record components, as described below, must be included within each patient record as a requirement of participation for specific medical specialties. These medical specialties include, without limitation, the primary care specialties (internal medicine, family practice, pediatrics, geriatrics, adolescent medicine, and general practice) obstetrics-gynecology, and high-volume behavioral health specialists.

An office site review or office compliance attestation is completed to verify that the physical components of the medical record (structure, legibility, and completeness) are acceptable and meet Blue Cross Blue Shield quality standards.

The participating physician/provider shall prepare and maintain in accordance with program requirements all appropriate medical and billing records on covered persons receiving covered services. Medical records of covered persons will include, but not be limited to: reports from specialist physicians, medication orders, discharge summaries, records of emergency care received by the covered person, and such other information as the health plan requires.

Participating physician/provider shall maintain covered persons’ medical records and personal identifiable health information as confidential so as to comply with applicable state and federal laws regarding the confidentiality of medical records, including, without limitation, the Health Insurance Portability and Accountability Act of 1996, as amended. The records shall be maintained in accordance with prudent record-keeping procedures and as required by practice standards and law, but in no event shall any medical records be retained for less than six years for adult covered persons and, with respect to minor covered persons, six years from the date of majority, as applicable, following termination or for such longer period as my be required by law.

D. Timetable

A new provider application may be processed within 60 days. Clean applications are processed more quickly.

An application is considered clean if:

  • The CAQH/application is filled out accurately and has been attested to within 180 days of filing the application.
  • All related credentialing documents are attached and current.
  • The application is in compliance with all the Highmark Blue Cross Blue Shield of Western New York credentialing policies and procedures.
  • Primary source verification is successfully completed by Blue Cross Blue Shield credentialing specialists. 
  • The credentialing Medical Director has signified approval of the application. 
  • Provider information has been successfully updated in the claims processing system.

New provider applications that do not meet our established credentialing criteria will have the deficiencies noted and will require further intervention by the Credentialing Specialist. These applications will require additional time to process, however, they will be completed as quickly as possible.

The credentialing process will be completed within 60 days from the receipt of a completed application. A notice is sent to the provider that informs them as to whether they are credentialed, whether additional time is needed, or that their application is denied.

After review and approval by the Credentials Committee, the Credentialing Specialist forwards the provider's approved credentialing file to the appropriate Provider File Enrollment staff for entry into the provider system. This entry generates a welcome letter, which contains the effective date of participation, the provider number, and a copy of the executed contract. 

Recredentialing Overview

 

A. Collection of Information

The objective of the Recredentialing Program is to ensure the retention of practitioners who have the same qualifications that are required for initial participation under the Practitioner Credentialing Program. The information provided will be evaluated in accordance with the practitioner credentialing criteria.

The decision to retain or not retain a participating practitioner is based on the totality of information available, including, but not limited to the information gathered through the re-credentialing process and verified as complete by the Credentialing Committee. The information gathered is treated in a confidential manner and the disclosure of such information will be limited to those parties who have an appropriate reason to have access to the information. Review of information to evaluate continued participation of practitioners is ongoing and periodic.

All recredentialing information is reviewed by the Chief Medical Officer or designee. The recredentialing materials, when complete, are presented to the Credentialing Committee. The Credentialing Committee makes the final decision regarding continued participation. Recredentialing criteria are developed for each type of health care professional who participates with Blue Cross Blue Shield. 

These criteria are developed and adopted by the Credentialing Committee. Criteria include specific requirements relative to each specialty.

B. Recredentialing Process

As a participating provider, you will be re-credentialed at a minimum of every 36 months.

Your CAQH application must be updated for the re-credentialing process to be completed.

A critical component of recredentialing includes the evaluation of the applicable information obtained through the following sources as applicable:

  1. Quality reviews
  2. Office site reviews, as applicable
  3. Medical records reviews, as applicable
  4. Utilization data
  5. Member satisfaction surveys
  6. Member complaints
  7. Adherence to the policies and procedures of Blue Cross Blue Shield 
  8. Verification of renewal of credentials with expiration dates.

Credentials that expire include:

  • State license/registration to include sanction status
  • DEA certificate
  • Malpractice coverage
  • Board certification, where applicable
  • Medicare/Medicaid sanction status
  • Medicare Opt-Out status
  • Medicare Preclusion List

Proof of renewal of these documents is required upon recredentialing from primary sources for participating practitioners. Copies of documents may be requested from participating practitioners through email. Documents may also be obtained directly from the CAQH application.

C. Recredentialing on CAQH

  • Practitioners will be required to complete the re-credentialing process, at a minimum, on a triennial basis (at least every 36 months). Providers must regularly update their CAQH application for the re-credentialing process to be completed timely
  • All physicians are required to be currently board certified in their area of specialty. 
  • As in the application for practitioner participation, the information requested pertains to, but is not limited to, hospital privileges, professional disciplinary actions, license suspension or revocation (whether or not stayed), malpractice history, the physical/mental health of the practitioner, and chemical dependency/substance abuse history. As in the Credentialing Program, any practitioner who answers affirmatively to any of the disclosure questions, and who does not provide adequate information regarding the matter, must be contacted to obtain details and documentation
  • .Recredentialing of any practitioner who answers affirmatively to any disclosure question is subject to review by the Credentialing Committee.
  • Providers that are sanctioned by the NYS Medicaid Program will be removed from participation in the Blue Cross Blue Shield Medicaid/CHP/FHP panels. Providers that are sanctioned by the Medicare Program will be removed from participation in all government program panels.

The CAQH application must be signed and dated by the practitioner to be considered complete.

D. Ongoing Re-evaluation

Each practitioner's performance as a participating practitioner will be monitored on an individual basis. Each physician must comply with the requirements under contractual obligations with Blue Cross Blue Shield. Data will be maintained in the Internal Performance Evaluation Directory and incorporated as it becomes available. This information will be reviewed by the Credentialing Committee for the purpose of practitioner recredentialing.

  1. Clinical Measures - sources of information may include, but are not limited to, Utilization Management reports, medical record reviews and focused quality of care reviews.
  2. Service Measures - sources of information may include, but are not limited to, information from grievances filed, member complaints, feedback regarding PCP changes and member satisfaction surveys. 

E. Administration of Ongoing Review

A practitioner's profile will accumulate continuously as data becomes available. The data will be incorporated in each participating practitioner's credentialing file. In addition, it may be captured in a report card that summarizes number and type of occurrence (e.g., grievances and complaints, results of medical record reviews and quality of care reviews).

F. Timetable

Applicable physicians and health care professionals will be reviewed, at a minimum, on a 36 month re-credentialing cycle. Blue Cross Blue Shield may require participating practitioners to be re-credentialed more frequently at the recommendation of the Medical Director, Credentialing Committee or the Quality Improvement Committee or any other internal source.

Credentialing Process - Non-MD Providers

 

A. Application for Practitioner Participation

Instructions for enrolling as a participating provider can be found on our website.

Initial Credentialing Providers can enroll in our health plan by filling out the Universal Credentialing Application with CAQH, the Council for Affordable Quality Healthcare.

How it Works To access the Universal Provider Datasource®, go to upd.caqh.org:

  • Log on with your username and password.
  • Enter your CAQH Provider ID (if unknown, call CAQH at 1-888-599-1771).
  • Enter or update your information.
  • Authorize Highmark Blue Cross Blue Shield of Western New York access to your information electronically.
  • If you do not have a CAQH application, refer to the 'First Time Here' information and click 'Register Now'.
  • Complete this form and return it to the fax number on the form.

After you have completed the CAQH application, please complete the Provider Enrollment Form (PEF) and Disclosure of Ownership and Control form and return both to 716-887-2056.

Participating Provider Agreement, Disclosure of Ownership and Control form, and instructions will be sent by the Provider Enrollment Department to the practitioner if the panel the practitioner is seeking participation in is open. Should a prospective practitioner request an application for a specialty in which the panel is closed, the practitioner may submit a letter of interest. These letters are kept on file until such time that the panel is reopened to that specialty. All appropriate practitioners operating in the service area are contacted when the panel is reopened in a requested specialty.

The application will be processed if complete information is provided on the CAQH application. If the information supplied on the application is incomplete, the application processor is responsible for contacting the applicant, initially by phone, to obtain details and documentation, as appropriate. Information will be deemed incomplete if information or documentation requested on the application is not provided, if responses provided require further explanation, if details related to affirmative answers to disclosure questions are not provided, or if any documents have expired prior to making a decision to accept or not to accept an applicant.

Upon receipt of a signed provider agreement and complete CAQH application:

  • The Provider Enrollment specialist reviews the application for completeness.
  • The applicant is notified if any additional information is needed.
  • Primary source verification of specified credentialing criteria documentation will be initiated by the credentialing specialist.
  • The credentialing specialist will also verify if the provider has elected to opt-out of Medicare, as well as verify that the provider is not excluded from participation with Medicaid Managed Care or Medicare. Providers that are sanctioned by the New York State Medicaid Program will be excluded from participation in the Blue Cross Blue Shield Medicaid/CHP/FHP panels. Providers that are sanctioned by the Medicare program will be excluded from participation in all government program panels.
  • The completion of an application does not guarantee acceptance into the Blue Cross Blue Shield panel. The prospective practitioner will not be reimbursed as an in-network provider until they have been notified by Blue Cross Blue Shield of your approval. The practitioner will be notified, in writing of our decision. Blue Cross Blue Shield does not back-date any effective date for legal reasons.
  • Blue Cross Blue Shield reserves the right to deny participation to any practitioner that is an employee or an independent practitioner of a direct competitor.

If there is a substantial difference between the information provided by the practitioner and primary source verification, the practitioner will be notified and required to provide documentation prior to their credentials being presented to the Credentialing Committee.

Upon receipt of all relevant documents, the credentials are reviewed by the Chief Medical Officer or designee. The Chief Medical Officer or designee will make the final determination regarding participation for level 1 practitioners. All level 2 or level 3 practitioners will be individually presented to the Credentialing Committee. The practitioner is notified, in writing of the final decision.

The applicant will be provided with materials and appropriate office staff training by the Provider Relations and Contracting account specialist upon acceptance into Blue Cross Blue Shield.

B. Timetable

A new provider application may be processed within 60 days. Clean applications are processed more quickly.

An application is considered clean if:

  • The CAQH/application is filled out accurately and has been attested to within 180 days of filing the application.
  • All related credentialing documents are attached and current.
  • The application is in compliance with all the Highmark Blue Cross Blue Shield of Western New York credentialing policies and procedures.
  • Primary source verification is successfully completed by Blue Cross Blue Shield credentialing specialists.
  • The Chief Medical Officer or designee has signified approval of the application.
  • Provider information has been successfully updated in the claims processing system.

New provider applications that do not meet our established credentialing criteria will have the deficiencies noted and will require further intervention by the Credentialing Specialist staff. These applications will require additional time to process; however, they will be completed as quickly as possible.

The credentialing process will be completed within 60 days from the receipt of a completed application. A notice is sent to the provider that informs them as to whether they are credentialed, whether additional time is needed, or that their application is denied.

The completion of an application does not guarantee acceptance into the Blue Cross Blue Shield panel. The prospective practitioner may not make any appointments or see any patients until they have been notified by Blue Cross Blue Shield that they have been approved for participation. Blue Cross Blue Shield does not back-date any effective date for legal reasons.

After review and approval by the Credentialing Committee, the Credentialing Specialist forwards the provider's approved credentialing file to the appropriate Provider File staff for entry into the provider system. This entry generates a welcome letter which contains: the effective date of participation, the provider number, and a copy of the executed contract.

Credentialing Process - Facility/Durable Medical Equipment Providers

 

Application for Facility/DME Participation

The facilities that these instructions apply to include the following: skilled nursing facilities (SNF); home care agencies; hospitals; free standing surgical centers; facilities providing mental health and substance abuse services, including, but not limited to facilities providing inpatient, residential, and ambulatory services; hospice; clinical labs; comprehensive outpatient rehab facilities (CORF); end stage renal disease facilities; portable X-ray; federally-qualified health centers (FQHC); personal care; durable medical equipment (DME); ambulance; urgent care; independent diagnostic testing facilities (IDTF); and facilities seeking participation/re-participation with Highmark Blue Cross Blue Shield of Western New York.


Medicaid Integrity/Disclosure of Ownership

The Medicaid Managed Care/Family Health Plus Plan Model Contract (18.9 (c)) indicates that the contractor requires all network providers to monitor staff and employees against the stated exclusion list (List of Excluded Individuals and Entities and the Restricted, Terminated or Excluded Individuals or Entities List) and report any exclusions to the managed care plan/contractor on a monthly basis.

Also, in accordance with federal regulations (Section 42 CFR 455.106) and the Medicaid Managed Care/Family Health Plus Plan Model Contract (18.12 (b)), the managed care health plan/contractor requires providers to disclose health care-related criminal conviction information from all parties affiliated with the provider. Upon entering into an initial agreement or renewal of any agreement between the managed care health plan/contractor and its providers, the managed care health plan/Contractor must disclose to the SDOH Division of Health Plan Contracting and Oversight in 20 working days of the disclosure date any conviction of a criminal offense related to that provider or provider's managing employee involvement in any program under Medicare, Medicaid, or Title XX services program (Block grant programs).

As per federal regulation, 42 CFR 455.104 and Medicaid Managed Care/Family Health Plus Plan Model Contract 18.6 (b), Blue Cross Blue Shield requires that participating providers disclose complete ownership, control and relationship information upon submitting the application, executing the provider agreement, and within 35 days after any change in ownership. In accordance with federal regulation 42 CFR 455.105 and the Medicaid Managed Care/Family Health Plus Plan Model Contract 18.6 (c), and as cited in the Participating Provider Agreement within 35 days of the date of a request by the SDOH, OMIG or DHHS, the managed care organization/contractor will require from any subcontractor disclosure of ownership, with whom an individual network provider has had a business transaction totaling more than $25,000 during the 12-month period ending on the date of request.

Disclosure of Ownership and Control form must be completed as part of the credentialing process to ensure compliance with the above-referenced program requirements. Blue Cross Blue Shield requires that such providers not employ or contract with any employee, subcontractor or agent who has been debarred or suspended by the federal or state government or otherwise excluded from participation in the Medicare or Medicaid program.

Participating Facility AgreementDisclosure of Ownership and Control form, enrollment application, and instructions will be sent by the Facility Contracting Department to the facility if the panel the facility is seeking participation in is open. Should a prospective facility request an application for a specialty in which the panel is closed, the facility may submit a letter of interest. These letters are kept on file until such time that the panel is reopened to that specialty. All appropriate facilities operating in the service area are contacted when the panel is reopened in a requested specialty.

The application will be processed when complete information is provided for the enrollment application. If the information supplied on the application is incomplete, the application processor is responsible for contacting the applicant, initially by phone, to obtain details and documentation, as appropriate. Information will be deemed incomplete if the information or documentation requested on the application is not provided, if responses provided require further explanation, if details related to affirmative answers to disclosure questions are not provided, or if any documents have expired prior to making a decision to accept or not to accept an applicant.
The following CMS-approved accreditation organizations will be acceptable accreditations for facilities:

Organization Program Type
Accreditation Association for Ambulatory Health Care (AAAHC)

Ambulatory Surgical Center (ASC)

DME

Accreditation Commission for Health Care, Inc.

Home Health Agencies (HHA)

Hospice

American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)

Ambulatory Surgical Center (ASC)

Rural Health Clinics (RHC)

American Osteopathic Association/Healthcare Facilities Accreditation Program

Ambulatory Surgical Center (ASC)

Hospitals

Community Health Accreditation Program

Home Health Agencies

Hospice

DME

DNV Healthcare (DNV) Hospitals
The Joint Commission (JC)

Ambulatory Surgical Centers

Home Health Agencies

Hospice

Hospitals

Psychiatric Hospitals

Commission on Accreditation of Rehabilitation Facilities DME
Healthcare Quality Association on Accreditation DME
Center for Improvement in Healthcare Quality (CIHQ) Hospital

Upon receipt of submitted application:

  1. The credentialing specialist reviews the application for completeness.
  2. The applicant is notified if any additional information is needed.
  3. Primary source verification of specified credentialing criteria documentation will be initiated by the credentialing specialist to include:
    1. All sections of the application and Disclosure of Ownership and Control form answered/completed.
    2. A copy of their current Accreditation certificate or a copy of their Medicare certification letter. If the actual certificate is not included in the application, the appropriate websites will be queried. The provider must maintain current Accreditation or Medicare certification.
    3. If not accredited, a copy of the last Department of Health review to include deficiencies and their plan of correction, if applicable. If not included, the DOH website will be queried.
    4. Operating license:
      • A copy of the New York State operating license or verification via Internet or Health Facility Directory published by the New York State Education Department.
      • For behavioral health entities, a copy of the Office of Mental Health (OMH) or Office of Alcohol & Substance Abuse Services (OASAS) operating license or verification via internet published by OMH or OASAS.
      • Blue Cross Blue Shield will accept OMH and OASAS licenses and certifications in place of any credentialing process for individual employees, subcontractors or agents of such providers if applicable.
    5. A sample of the grievance Policy/Procedure (credentialing only) - if not accredited
    6. A sample of grievance logs and actions taken (credentialing only) - if not accredited
    7. A copy of the Quality Improvement Program (credentialing only) - if not accredited
  4. The Credentialing Specialist will also verify if the facility has elected to opt-out of Medicare, as well as verify that the provider is not excluded from participation with Medicaid Managed Care or Medicare.
  5. The completion of an application does not guarantee acceptance into the Blue Cross Blue Shield panel. The prospective facility may not make any appointments or see any patients until they have been notified by Blue Cross Blue Shield that they have been approved for participation. Blue Cross Blue Shield does not back-date any effective date for legal reasons.
  6. Blue Cross Blue Shield reserves the right to deny participation to any facility that is an employee or an independent practitioner of a direct competitor.
  7. Each facility's performance, as a participating facility, will be monitored on an individual basis. Each facility must comply with the contractual obligations with Blue Cross Blue Shield, including having a valid unsanctioned license, whether or not stayed, to practice medicine in the State of New York.
  8. All facilities will be required to be Accredited or Medicare Certified, as evidenced by their Medicare Provider number. Exceptions apply for specific DME suppliers who do not participate with Medicare and providers who participated with NYS Medicaid programs only (for example: Personal Care Agencies)
  9. The credentialing staff presents the credentialing file to the Chief Medical Officer or designee for review.
  10. The Chief Medical Officer or designee reviews the file, makes the final determination of participation/re-participation and documents the decision on the Credentialing Process Form and will verify review by signing in the space provided.
  11. A list of all facilities that meet the minimum requirements of Blue Cross Blue Shield is presented to the Credentials Committee. The time frame to verify credentials and receive sign-off from the credentials committee will take no longer than 180 days as defined by CMS.
  12. If the facility is accepted, the credentialing staff forwards the credentialing file to the appropriate Provider Enrollment staff for entry into the provider data system.
  13. The facility will be notified, via e-mail, within sixty (60) calendar days of being credentialed, of their participation status.

 

Recredentialing

At a minimum, every three years, the credentialing staff will obtain information on the following for each facility as applicable:

Using an internal report that lists participating facilities and contains their operating certificate, provider number, and Medicare number, the Credentialing Department will research via the New York State website or the Health Facility Directory to ensure that the facility is accredited, Medicare certified, or has had a recent DOH review and sanctions.

Rights of the Practitioner: To Review Credentialing/Recredentialing Information

Blue Cross Blue Shield is committed to maintaining accurate information and ensuring that providers are informed in the event that credentialing information obtained from other sources varies substantially from the information obtained from the practitioner.

The practitioner has the right to: review the information submitted in support of their credentialing application; correct erroneous information; receive the status of their credentialing / recredentialing application, upon request. If there is information substantially different from information submitted by the practitioner, the practitioner will be notified by certified letter of the discrepancy and asked to respond within 15 business days. If no correction is received in the allotted time, information received from the primary source will be considered to be correct and any decisions will be based on the primary source information.

Restricted Procedures: Credentialing

In the interest of providing quality care for our members, Blue Cross Blue Shield requires additional training for certain procedures. To measure the additional training, we require that a physician be board certified to perform the following or provide documentation of appropriate training:

Restriction Procedures Accepted Board
Allergy Testing and Therapy Codes

American Board of Allergy and Immunology*
*Conjoint Board of the American Board of Internal Medicine or American Board of Pediatrics

Holter Monitor EKG
Stress Tests
Echocardiograms

American Board of Internal Medicine with a subspecialty in Cardiovascular Disease

American Board of Pediatrics with a subspecialty in Pediatric Cardiology

Esophagoscopy
Upper GI/Endoscopy
Small Bowel & Stoma Endoscopy
Sigmoidoscopy
(Flexible, Fiber optic)
Colonoscopy - Beyond Splenic Flexure

American Board of Gastroenterology

Mammography American Board of Radiology
Fetal Non-Stress American Board of Obstetrics and Gynecology
  • The Corporate Credentialing area will also research the physician's:
  • current credentials
  • area of study/programs attended during residency, fellowship, and continuing education
  • delineation of primary admitting hospital privileges
  • requirements/criteria used by hospital to privilege the requested procedure/service
  • references

This information is presented to the Blue Cross Blue Shield Medical Director for a decision.

  • A certified, confidential letter is sent to the physician by the Corporate Manager of Credentialing, regarding the decision. If the physician receives a denial, they have 15 days to submit additional information. Following 15 days, the request becomes inactive. If the physician submits additional information, it is taken to the Blue Cross Blue Shield Medical Director for further review. 
  • Designees of Provider Relations and Contracting, Quality Management and Utilization Management are notified of the outcome (cc:decision letter).

Special Consideration Criteria and Termination Criteria

These guidelines are based on the New York State Public Health Law Article 44, New York State Department of Health Chapter 98, Health Care Quality Improvement Act and National Committee of Quality Assurance Standards. They were reviewed by our Physician Credential Committee and accepted.
A practitioner (physician or non-physician) MAY NOT be terminated solely for the following reasons:

  1. If the practitioner advocated on behalf of an enrollee;
  2. Filed a complaint against Blue Cross Blue Shield;
  3. Appealed a decision of Blue Cross Blue Shield;
  4. Provided information or filed a report pursuant to PHL - 4406-C regarding prohibitions of the Plan(s);
  5. Requested a hearing or review.
     

On-Going Course of Treatment

Blue Cross Blue Shield will permit an enrollee to continue an ongoing course of treatment for a transitional period (up to 90 days) as long as the practitioner being terminated is not causing imminent harm to the member and the practitioner agrees to the following:

  1. To meet the Blue Cross Blue Shield Quality Assurance Standards;
  2. To accept as payment in full the payment rates that were in effect when the practitioner participated with Blue Cross Blue Shield;
  3. Agrees to provide Blue Cross Blue Shield with all necessary information related to the member's care and;
  4. Agrees to adhere to all relevant policies and procedures established by Blue Cross Blue Shield including, but not limited to, rules regarding preauthorization of services and referrals;
  5. Assist in the transition of the member's medical records;
  6. Freely communicating with patients regarding any aspect of their care. This shall include but not be limited to, discussions involving testing, diagnosis, treatment, risks, and outcome choices as well as costs and insurance coverage or reimbursement available under the patient's current health insurance contract.
     

A. Corrective Action

Responsibility for decisions in regard to special consideration rests with the Medical Director or designee.
The Chief Medical Officer or designee may take the following actions with individual practitioners or providers to ensure quality of care and service to members and/or subscribers through integrated review and evaluation mechanisms that are efficient and effective in resolving instances of substandard care or patient care outside the accepted professional practice:

  1. Direct consultation and education with the practitioner under review
  2. Probationary status
  3. Hold all payment of claims
  4. Conduct focused review of ambulatory or hospital care
  5. Suspend or terminate the practitioners' agreement (see Termination/ Suspension)


The Chief Medical Officer or designee will notify the practitioner of his decision and the basis thereof, in writing. If remedial action is taken, the Medical Director or designee will encourage improved quality of care and competence through education. Blue Cross Blue Shield will work closely with the practitioner to educate and assist them in achieving compliance with Blue Cross Blue Shield standards. Based on the decision of the Medical Director or designee, Blue Cross Blue Shield will re-evaluate the practitioner's performance at predetermined times in regard to the identified concerns.

 

B. Termination without Recourse to a Hearing

Blue Cross Blue Shield may terminate a practitioner without providing the practitioner recourse to a hearing for any of the following reasons:

  1. Imminent harm: Blue Cross Blue Shield, in its sole judgement and based upon its review of relevant information, determines that the practitioner poses an imminent harm to patient care
  2. Fraud: Blue Cross Blue Shield determines that the practitioner has engaged in fraud; the determination of fraud may be the result of a determination made by Blue Cross Blue Shield, in its sole judgement, with respect to internal cases of fraud or a determination made by a governmental, law enforcement or other appropriate outside agency with respect to external cases of fraud
  3. Disciplinary action: a final disciplinary action has been taken by a state licensing board or other governmental agency that impairs the practitioner's ability to practice
  4. Death or retirement: the practitioner is deceased or has retired from active participation in a medical practice

 

C. Termination

In accordance with Public Health Laws 4406-d, Blue Cross Blue Shield offers specific rights to a provider if it becomes necessary to terminate his or her provider agreement. In no event shall determination be effective earlier than 60 days from receipt of the notice of termination or otherwise provided by law.

Responsibility for decisions in regard to termination rests with the Medical Director or designee. When circumstances are of such a nature that prompt and immediate action is necessary to maintain the minimum quality standards of Blue Cross Blue Shield and/or if the practitioner poses an imminent danger to Blue Cross Blue Shield members, the Medical Director or designee has the authority to terminate the practitioner agreement immediately, subject to appeal.

The Chief Medical Officer or designee will initiate action under the following circumstances:

  1. Engages in conduct of an illegal, immoral or inappropriate nature, which Blue Cross Blue Shield, in its sole judgement, determines capable of negatively impacting Blue Cross Blue Shield and/or its practitioner network(s)
  2. Loses malpractice insurance coverage or fails to maintain malpractice insurance coverage in the minimum amounts required by Blue Cross Blue Shield
  3. Loses Drug Enforcement Agency certification
  4. Loses hospital privileges (if the practitioner only has privileges at one hospital), unless the practitioner arranges to have another practitioner perform admissions on the practitioner's behalf. (See "On-Call Relationships" provided in the Blue Cross Blue Shield application, "On-Call Relationships" provided in the Blue Cross Blue Shield application, Allied Health Practitioner; and "On-Call Relationships and "Appropriate Coverage Arrangements for PCPs" provided in the Blue Cross Blue Shield application, Physician)
  5. Falsifies and/or materially omits or misstates information on the practitioner's credentialing or recredentialing application and/or profile
  6. Fails to comply with credentialing and/or recredentialing policy, e.g., fails to return applicable documentation, including the application, reapplication, or copies of requested verification and/or fails to respond to requests for additional information
  7. Fails to comply with Blue Cross Blue Shield Utilization Management and/or Quality Management Policies and Protocols as are communicated to the practitioner from time to time
  8. Fails to meet probationary requirements (see Blue Cross Blue Shield Credentialing Program; Probationary Status Policy and Procedure, as amended, which specifies the range of actions that may be taken to improve practitioner performance prior to termination)
  9. Fails to cooperate with Blue Cross Blue Shield in obtaining copies of medical records and/or in performance of Blue Cross Blue Shield audit functions
  10. Violates any provision(s) of the Practitioner Agreement, or Blue Cross Blue Shield otherwise has the right to terminate the practitioner under the terms of the Practitioner Agreement or applicable law

In addition, Blue Cross Blue Shield may terminate a practitioner (with recourse to a hearing) for any other competency or professional conduct reason, which Blue Cross Blue Shield, in its sole judgement, determines to be appropriate under the circumstances.

 

D. Appeal

Once a practitioner is identified for termination, a letter is delivered by certified mail to the practitioner.
The notice of termination will include information advising of the following rights:

  • An explanation of the reason for the termination will be provided.
  • The practitioner may request a hearing or review, at the provider's discretion, before a panel of at least three people appointed by Blue Cross Blue Shield. At least one-third of the panel will consist of clinical peer in the same or similar specialty.
    • The request for the hearing must be made within 35 days from the date the notice was provided.
    • The hearing will be held within 30 days of Blue Cross Blue Shield's receipt of a request for a hearing.
    • The practitioner will receive the written decision of the panel within 20 calendar days of its decision. The panel will determine whether the practitioner should be reinstated with or without conditions or whether his/her participating agreement should be terminated.
    • If the practitioner is terminated, they are not eligible to reapply for participation unless Blue Cross Blue Shield determines there has been a substantial change in information and it has been at least 12 months since the termination.

A hearing is not available if a practitioner is being terminated for one of the following reasons:

  1. There has been a final disciplinary action by a state licensing board or other governmental agency that impairs the provider's ability to practice.
  2. A determination of fraud on the part of the practitioner.
  3. The corporation obtains information that, in the corporation's sole judgment, indicates the practitioner may cause or is causing imminent harm to Blue Cross Blue Shield members.

 

E. Non-Renewal

The practitioner or Blue Cross Blue Shield may exercise a right of non-renewal of his or her participating agreement either at the end of the period noted in the contract, or with 60 days' notice, each January first, occurring after the contract has been in effect at least one year. The practitioner will qualify for appeal rights if non-renewed.

 

F. Re-Application

Any practitioner, physician and non-physician, who is terminated by Blue Cross Blue Shield either voluntarily or involuntarily, may only re-apply to participate in Blue Cross Blue Shield's network(s) if:

(a) There has been a substantial change in the information that led to the termination; and
(b) At least two (2) years have passed since the effective date of termination or non-renewal

 

Primary Care Physician Responsibilities

A primary care physician's role is that of a medical manager, providing and coordinating medical care for Blue Cross Blue Shield members. A primary care physician is responsible for determining the health care needs of his/her patients, for directly providing many of these needs and for coordinating the services of other providers. Primary care specialties include family practice, general practice, internal medicine, geriatrics, adolescent medicine, and pediatrics.
Blue Cross Blue Shield primary care physicians agree to:

  • Support and comply with the terms of Blue Cross Blue Shield.
  • Provide care that is medically appropriate and proficiently delivered to produce optimal patient outcomes and satisfaction.
  • Coordinate the member's access to high quality, cost-effective health care delivery; make all reasonable efforts to provide diagnostic and treatment care within his/her expertise; and refer the patient to participating network providers as defined in the provider directory.
  • Collect specified copayments from members for office visits.
  • Ensure the protection of confidentiality of members' medical records.
  • Cooperate with all Blue Cross Blue Shield medical and quality management policies and procedures; demonstrate a willingness to examine his/her practice patterns as they pertain to feedback from the health plan and remains open to the possibility of modifying his/her clinical behavior to conform with the professional norms.
  • Be available 24 hours a day, seven days a week or arrange coverage with a participating physician to provide patient access during his/her absence.
  • Maintain an office that is clean, accessible, safe, supportive of patient's needs and supportive of the health plan's policies and procedures. If office and/or facilities are not wheelchair accessible, the practitioner must provide a documented plan of how wheelchair dependent patients are accommodated.
  • Agree to comply with the terms of the health plan's preauthorization and credentialing requirements as well as other contract terms, policies and procedures.
  • Maintain current credentialing standards.
  • Participate in member satisfaction surveys.
  • For Medicaid Managed Care- primary care practitioners must adhere to specific member-to-PCP ratios. These ratios assume that the practitioner is a full time equivalent (FTE), defined as a provider practicing forty (40) hours per week:
      • No more than 1,500 enrollees for each physician, or 2,400 for a physician practicing in combination with a registered physician assistant or a certified nurse practitioner.
      • No more than 1,000 enrollees for each certified nurse practitioner
      • These ratios will be prorated for participating providers who represent less than a FTE.

Specialist Physician Responsibilities

The specialty care physician is responsible for responding to the referral from the primary care physician. Those responsibilities include but are not limited to the following:

  • Support and comply with the terms of Blue Cross Blue Shield provider agreement.
  • Provide care that is medically appropriate and proficiently delivered to produce optimal patient outcomes and satisfaction.
  • Be available 24 hours a day, seven days a week or arrange coverage with a participating physician to provide patient access during his or her absence.
  • Work closely with the primary care physician to enhance continuity of health services.
  • Advise the PCP of any ongoing treatment program and if another specialist is needed.
  • Demonstrate his or her commitment to the patient-physician relationship as evidenced by communicating effectively the recommended medical treatments and/or lifestyle changes to patients, while maintaining ongoing communication with the PCP to ensure continuity of care.
  • Collect specified copayments from members for office visits.
  • Cooperate with all Blue Cross Blue Shield policies and procedures, and demonstrate a willingness to examine his/her practice patterns as they pertain to feedback from the health plan.
  • Maintain an office that is clean, accessible, safe, supportive of patient's needs and supportive of the health plan's policies and procedures. If offices and/or facilities are not wheelchair accessible, the practitioner must provide a documented plan of how wheelchair dependent patients are accommodated.
  • Agree to comply with the terms of the health plan's preauthorization and credentialing requirements as well as all other contract terms, policies and procedures and protocols.
  • Ensure the confidentiality of members' medical records.
  • Maintain current credentialing standards.


On-Call Coverage Requirements

Providers should make arrangements with other participating providers to ensure that Blue Cross Blue Shield members have access to health care 24 hours per day, seven days per week. An "on-call provider" covers for another. The name of the on-call providers should be indicated on the provider application form at the time of credentialing and re-credentialing. Please see the attached (Appropriate Coverage Arrangements for PCPs).
Providers should follow the guidelines below when selecting providers to cover their practices:

  1. Individual provider practices are limited to five on-call providers.
  2. All providers of the same specialty within a group can be on call for each other.
  3. Specialists cannot be on call for PCPs.
  4. Specialists can only be on call for specialists in the same field.
  5. All on-call providers must be participating providers with Blue Cross Blue Shield.

It is the responsibility of the provider to notify the File Data Management Department of any changes to who is covering for his/her practice. If a provider is covering on a temporary basis only, Provider File Data Management should be notified of the specific dates that he/she will be covering.

Appropriate Coverage Arrangements for PCPs

The following criteria explain that family practice physicians must have a coverage agreement for each major component of their active practice with a physician that has an active practice in the same component (adult medicine, pediatrics, and OB-GYN). It may be necessary for the family practice physician to have more than one practitioner for coverage agreement(s) for their active practice(s) as described in the table below. Pediatric practice physicians must have coverage agreement(s) with physicians that have an active pediatric component within practice(s).
Adult medicine physicians must have coverage agreement(s) with physicians that have an active adult medicine component within their practices.

Adult Medicine Pediatric Medicine Family Practice

All of the following may cover for each other for adult medicine:

 

Internal Medicine

 

Family Practice

 

General Practice

 

If a family practice physician has an obstetric practice, the practitioner must have either of the following:

OB-GYN cover for the obstetric portion of his practice

Or

A family practice physician that has an active obstetric practice

 

 

 

 

 

 

 

 

 

 

 

 

 

A pediatrician must have either of the following:

 

A pediatrician

Or

A family practice physician that has an active pediatric practice.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family practice physician with an active practice of adult medicine must have the following cover for each other for adult medicine:

 

Internal Medicine

 

Family Practice

 

General Practice

and

Family practice physician with a pediatric practice must have either of the following:

 

A pediatrician

Or

A family practice physician that has an active pediatric practice.

And

Family practice physician with an obstetric practice must have either of the following:

OB-GYN cover for the obstetric portion of his practice

Or

A family practice physician that has an active obstetric practice

 

 

 

 

 

 

It is important to notify Blue Cross Blue Shield Provider File Data Management Department concerning any additions or deletions of on-call physicians. Notifying us about an on-call relationship before services are rendered helps eliminate claim denials for treatment delivered by that provider. If another provider will be covering for you on a temporary basis only, please inform our Provider File Data Management Department of the specific dates he will be covering. Members often call our Member Service Department regarding coverage for their PCP. If we have a provider listed as a covering physician for you and the information is incorrect, the patient will not have access to care in your absence.


Properly Terminating the Physician-Patient Relationship

When a physician begins to care for a patient, the physician is obligated to continue to provide care to the patient as long as the patient needs treatment. A physician may terminate the relationship provided the physician gives the patient reasonable notice and a sufficient opportunity to make other arrangements for care. Otherwise, the physician may be guilty of abandonment, resulting in a malpractice judgment or disciplinary action.

To avoid a malpractice claim or possible disciplinary action, the American Medical Association (AMA) recommends a physician take the following steps to terminate the physician-patient relationship:

  1. Give the patient written notice, preferably by certified mail, return receipt requested;
  2. Provide the patient with an explanation for terminating the relationship;
  3. Agree to continue to provide treatment and access to services for a reasonable period of time, 30 days for care, 60 days for emergent/urgent services, to allow the patient to secure care from another physician;
  4. Provider resources and/or recommendations to help the patient locate another physician of a like specialty;
  5. Offer to transfer records to a newly designated physician upon signed patient authorization to do so.

We further recommend placing a copy of the written notice in the patient's chart and clearly stating in the chart after the last visit that the patient is no longer seeing the physician. If a physician follows these steps, the fact of termination and the date of termination will be clear, making it unlikely the physician will be subject to a malpractice suit or professional discipline for abandoning the patient.

Physicians should be aware; however, that properly terminating a physician-patient relationship as set forth above may not insulate a physician from disciplinary action for having sexual contact with a patient.

As is illustrated in sexual contact cases, taking the steps outlined by the AMA may not actually terminate the professional relationship. In a sexual contact case, the Office of Professional Medical Conduct will look to see if the physician took formal steps to terminate the relationship and will closely examine the nature of the professional relationship in order to determine whether the professional relationship has actually been terminated.

New York State has their policy statement on Physician Sexual Misconduct at health.state.ny.us/nysdoh/opmc/miscon.htm; or, to request a copy, call 1-800-663-6114.
If you would like examples of letters that terminate a physician-patient relationship, please contact the Credentialing Department at (716) 887-7500.

Hospital-based Provider Credentialing Process

Certain providers who are subject to credentialing and are hospital-based will be considered an active participating provider upon receipt of an executed participating provider agreement. Currently, hospital-based providers include the following specialties:

  • Anesthesiologists who provide basic anesthesia services only
  • Emergency room (ER) physicians
  • Hospitalists
  • Pathologists

Hospital-based providers will be required to meet all credentialing criteria as defined in this provider manual. Hospital-based physicians are not reviewed as part of the re-credentialing process as long as they maintain their hospital privileges.


Provisional Credentialing

Effective October 1, 2009, Highmark Blue Cross Blue Shield of Western New York updated it's credentialing policy concerning the application process for credentialing newly licensed health care professionals (HCP) or HCPs relocating from another state, who are joining a group practice of in-network providers.

An HCP joining a group practice can be considered a "provisionally" credentialed provider on the ninety-first day after submitting a complete application to Blue Cross Blue Shield. If we do not approve or decline the application within 90 days, this status will continue until we either credential the provider or decline the application. During this provisional period the HCP is considered an in-network provider for the provision of covered services to members, but may not act as a primary care provider (PCP).

The law further states that if the application is ultimately denied, the provider will revert back to non-participating status. The group practice wishing to include the newly licensed or relocated HCP must agree in writing, prior to the provisional status becoming effective, to refund any payments made by Blue Cross Blue Shield for in-network services delivered by the provisionally credentialed HCP that exceed any out-of-network benefit.

In addition, the provider group must agree to hold the member harmless from payment of any services denied during the provisional period except for collection of copayments that would have been payable had the member received services from an in-network provider.


Other Guidelines


Fraud Waste and Abuse (Medicare and Medicaid)

Your contract with us requires you to comply with specific policies to detect and prevent fraud, waste, and abuse.
Per state and federal regulations, as noted in the New York State Department of Health Standard Clauses for Managed Care Provider/IPA Contracts in your Agreement, you must send us details on the following items:

  • Disclose to the plan the identity of any person affiliated with the provider (owner/person with control interest, agent or managing employee) who has been convicted of a criminal offense related to that person's involvement in Medicare, Medicaid or Title XX services programs. Monitor your managing employees and agents monthly against the following websites:
    • Office of the Medicaid Inspector General (OMIG) at omig.ny.gov.
    • List of Excluded Individual and Entities - Office of Inspector General (OIG) at exclusions.oig.hhs.gov
    • System for Award Management (SAM) at sam.gov
  • Report to us monthly any individuals that were found to be on the exclusions list(s).
  • Upon request made by the New York State Department of Health (NYSDOH), Office of Medicaid Inspector General (OMIG), or Department of Health and Human Services (DHHS), you must obtain ownership information from any subcontractor with whom you had a transaction totaling more than $25,000 during the 12-month period ending on the date of the request.
    • You must send a copy of the information to us within 35 days of such request.

You are also obligated to:

  • Disclose complete ownership, control, and relationship information. In accordance with state and federal regulation, we are required to obtain a Disclosure of Ownership and Control form from contracted providers rendering services to our members.
  • Maintain and make available, upon request and at no charge, records related to monthly monitoring and reporting of criminal convictions and exclusions.


The Practitioner/Facility Disclosure of Ownership and Control form is located on our website at bcbswny.com/provider

Exclusion Checks
Providers of health care services are required to perform exclusion checks by CMS 42 C.F.R.
§422.503(b)(4)(vi)(F), 422.752(a)(8), 423.504(b)(4)(vi)(F), 423.752(a)(6), 1001.1901, and §1862(e)(1)(B). The Medicare Managed Care

Manual Chapter 21 states the following:
"Sponsors must review the DHHS OIG List of Excluded Individuals and Entities (LEIE list) and the GSA Excluded Parties Lists System (EPLS) prior to the hiring or contracting of any new employee, temporary employee, volunteer, consultant, governing body member, or FDR, and monthly thereafter, to ensure that none of these persons or entities are excluded or become excluded from participation in federal programs. Monthly screening is essential to prevent inappropriate payment to providers, pharmacies, and other entities that have been added to exclusions lists since the last time the list was checked. After entities are initially screened against the entire LEIE and EPLS at the time of hire or contracting, sponsors need only review the LEIE supplement file provided each month, which lists the entities added to the list that month, and review the EPLS updates provided during the specified monthly time frame."

Preclusion List (Medicare)
Centers for Medicare & Medicaid Services (CMS) will make available a Preclusion List to Blue Cross Blue Shield as a Medicare Part D sponsor and Medicare Advantage Organization (MAO).
Individuals or entities that fall within the following criteria will appear on the list:

  • Are currently revoked from Medicare, are under an active re-enrollment bar, and CMS has determined that the underlying conduct that led to the revocation is detrimental to the best interests of the Medicare program; or
  • Have engaged in behavior for which CMS could have revoked the prescriber, individual or entity to the extent applicable if they had been enrolled in Medicare, and CMS determines that the underlying conduct that would have led to the revocation is detrimental to the best interests of the Medicare program.

In accordance with Title 42 of the Code of Federal Regulations (CFR) Part 422.222 and 422.224, a MAO must not make payment for a health care item or service furnished by a provider included on the Preclusion List. Therefore, no payment can be made, directly or indirectly, on any basis, for any item or service furnished to a Medicare enrollee by a precluded individual or entity. Additionally, Medicare plans must remove any contracted provider, who is included on the Preclusion list, from their network.

As a MAO, Blue Cross Blue Shield is required to ensure that our contracted providers are properly credentialed and not on the Preclusion List. Additionally, when periodically re-validating credentialed providers, we are required to again confirm that our contracted providers are not included on the Preclusion List.

Included below is a link to the CMS site describing the Preclusion List:
CMS.gov Preclusion List

Non-discrimination Policy

Participating physicians and providers have a policy and procedure in place and agree not to differentiate or discriminate against members in the delivery of health care services based on, but not limited to: race, ethnicity, national origin, religion, sex, age, mental or physical disability, medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment.

The hours of operation that practitioners offer to Medicaid members must be no less than those offered to commercial members.

Provider Directory Data Accuracy

Effective January 1, 2016, the Centers for Medicare & Medicaid Services (CMS) began enforcing regulations about changes in the Medicare program regarding accurate provider directory information.

As a participant in the Medicare program, Highmark Blue Cross Blue Shield of Western New York is required to adhere to CMS regulations, including displaying provider practice information in our provider directories and the Find a Doctor search tool on our website.

If your contact information is not accurate, our members could have difficulty scheduling appointments and receiving medical services from you; therefore, we will be contacting you on a quarterly basis to validate your contact information.

The following information will be verified:

  • Practitioners at all locations
  • Specialties
  • Street address
  • Phone number
  • NPI
  • Tax Identifier
  • Practice Fax
  • Practice Manager email
  • Patients availability to schedule appointments timely
  • Provider accepting new patients
  • Provider on-call or covering at location
  • Enrollment status with Medicare
  • Practice name
  • Hospital affiliation
  • Provider type

Please review your current information on your provider dashboard and ensure that it is accurate.

If you need to make any changes, please provide them via the Provider Demographic Change Form located on our website under Provider > Tools & Resources > Forms.

Changes in Status

Physicians are contractually obligated to promptly notify Blue Cross Blue Shield, in writing, if there are any changes to their practice. Please refer to your Participating Physician Agreement, Section 2.6 Notification.
Physicians must notify Blue Cross Blue Shield within 30 days if and when any of the information submitted in the most recent application changes. If a practitioner is no longer participating and wishes to be reinstated, that practitioner must reapply and go through the full credentialing process if the break in participation is 30 days or more. The Credentialing Committee must review all credentials and make a final determination prior to the practitioner's re-entry into the network. A Demographic Change Form, which can be used to notify us when your office location changes (open/close, addition) or when an update for a tax identification number is needed, can be found on our provider website. Physicians are also required to notify their Blue Cross Blue Shield patients, within 72 hours, of any changes in office hours, location, and/or phone number. Blue Cross Blue Shield will complete your demographic update request within 30 days of receipt.

Members Seeking Care in an Inpatient/Outpatient Setting

Every member seeking services both in an inpatient and outpatient setting is afforded the right to request the services be performed by their attending physician of record.

Medical Records, Information and Confidentiality Policies

Blue Cross Blue Shield is entitled to receive from any provider who renders service to a member all information reasonably related to the terms of their contracted agreement. Subject to applicable confidentiality requirements, members authorize any provider rendering service to disclose all facts pertaining to such member's care and treatment by the provider and to permit copying of such reports and records by the health plan. This authorization is obtained during the member's enrollment.

Confidentiality

Blue Cross Blue Shield will preserve the confidentiality of the member's health and medical records consistent with the requirements of applicable New York State and federal law.

Blue Cross Blue Shield's confidentiality policy expects that the physicians will maintain confidentiality of all materials and records that are proprietary to Blue Cross Blue Shield or are used in connection with Blue Cross Blue Shield's credentialing, reimbursement, quality assurance or other peer review programs, in accordance with the terms of the physician's application form and contract with Blue Cross Blue Shield and the requirements of state or federal law.

Confidentiality of behavioral health and substance use information

Blue Cross Blue Shield requires each health care provider to develop policies and procedures to assure confidentiality of MH/SU related information that includes:

(a) Initial and annual in-service education of staff, contractors
(b) Identification of staff allowed access and limits of access
(c) Procedure to limit access to trained staff (including contractors)
(d) Protocol for secure storage (including electronic storage)
(e) Procedures for handling requests for BH/SU information protocols to protect persons with behavioral health and/or substance use disorder from discrimination

Records

The health plan keeps records of all members, but will not be liable for any obligation dependent upon information from the group or members prior to its receipt in a form satisfactory to the health plan. If the health plan has not acted to its prejudice by relying on incorrect information furnished by the group or members, such information may be corrected.

Provider Education and Support

Blue Cross Blue Shield provides notification to the provider community through the publication of the Provider and Facility Reference Manual, Chiropractic Reference Manual, Dental Manual, Quarterly Newsletters, Stat Bulletins, and Medical Protocols.

On-site/Medical Records Reviews: Additional/New Office Location

Imaging Provider Accreditations Requirements


Imaging Accreditation Standards

The following guidelines are proprietary and confidential.

As part of our ongoing efforts to maintain quality provider panels, Blue Cross Blue Shield requires specific quality standards be met by imaging services providers for continuing participation in our network. These standards have been developed by national professional societies and are accepted across the country. These standards primarily apply to the following services:

  • MRI
  • MRA
  • CT and PET/CT
  • CTA and CCTA
  • PET

Blue Cross Blue Shield requires that imaging facilities and service providers acquire and maintain accreditation for the modalities provided. Providers can receive accreditation by completing either of the following accreditation programs:

  • American College of Radiology (ACR)
  • Intersocietal Commission for the Accreditation of Magnetic Resonance Imaging (IAC)

Details for accreditation programs are available at their respective websites -

All practitioners must maintain current Blue Cross Blue Shield credentials in order to continue as participating in imaging network practitioners.

Should we become aware that a specific modality/modalities are non-compliant with their accreditation status, claims paid to the provider for all imaging services provided from the time of the accreditation expiration through the date of renewal of the accreditation, will be retracted. Note: these services remain the provider's responsibility and cannot be billed to the patient.

In addition, it will be mandatory for all imaging providers and facilities to:

  • Provide a verbal report within three business days and a written report within seven business days from the date of service to the ordering provider for routine services. Urgent studies require a verbal report on the same day of service and a written report within five business days. Mammography reports must be completed within 30 days, per Mammography Quality Standards Act (MQSA) guidelines.
  • Have a documented quality control program inclusive of both imaging equipment and film processors.
  • Have a documented radiation safety program and ALARA (ALow AReasonably Achievable) Program.
  • Have a current (within three years) letter of state inspection, calibration report or physicist's report (if applicable) if utilizing equipment producing ionizing radiation.
  • Have documented compliance with all state and regulatory requirements.
  • Assure that any and all covered imaging services (not just MRI, MRA, CT, CTA and PET) must be provided on imaging equipment (i) owned by the provider or (ii) leased by the provider on a full-time basis. Owned or leased on a full-time basis is defined as (a) the practitioner has possession of the equipment on the practitioner's property and the equipment is under the practitioner's direct control and (b) the practitioner has exclusive use of the equipment, such that the practitioner and only the practitioner uses the equipment.
  • Assure that all contrast-enhanced procedures must be performed under the attendance and direct supervision of a Blue Cross Blue Shield credentialed imaging provider and New York State licensed physician. The clinical staff or technicians must have current Basic Life Support (BLS) certification (ACLS certification is highly recommended).
  • Be staffed on-site by a Blue Cross Blue Shield credentialed practitioner, board-certified within a specialty whose scope and expertise is related to the study being performed.
  • Have studies they have performed interpreted and reported on by a Blue Cross Blue Shield credentialed diagnostic radiology or nuclear medicine practitioner.
  • Assure staffing such that they employ a minimum of one American Registry of Radiologic Technologists (ARRT) certified technologist on a full-time basis at each site.
  • Ensure that providers performing PET are board-certified in diagnostic radiology, nuclear medicine or nuclear cardiology along with technologists certified in nuclear medicine through ARRT, CNMT or NMTCB.
  • Be subject to unannounced site inspections. Providers, who are found to have misrepresented information on their application or to be noncompliant with any of the above criteria, will be subject to termination.
  • Accept that global billing of imaging services is required. Only the practitioner performing the imaging study is permitted to bill for the service.
  • Participate in periodic over-reads of studies selected by the plan by an independent radiologist as part of the plan's quality assurance program as identified by the plan.
  • In accordance with the Blue Cross Blue Shield agreement, practitioners must notify us in the event there is a material change to or within a practice. Blue Cross Blue Shield reserves the right to revoke any granted privileges if the obligations of the practitioner contract are not adhered to. Practitioner privileges will be terminated at the time a Blue Cross Blue Shield practitioner contract is terminated.
  • Agree that Blue Cross Blue Shield medical policy will apply to the delivery of services detailed in the criteria.

Cone Beam CT Scanners

Services for Cone Beam CT scanners are not eligible for reimbursement. Full-service CT units must be a minimum of four-slice. In addition to the updated standards, all other criteria noted previously must continue to be met.

Applies To Metric
MRI and MRA 
  • ACR Accreditation or IAC must be obtained and maintained
  • Must provide full body scanning capability (“total service”). Machines must have been manufactured after January 1, 2002 to qualify.
  • Devices with field strength of 1.0T must have parallel processing capability.  Otherwise, the device will be limited to performing examinations of the brain, spine, and extremities.
  • Devices with field strength of less than 0.3T will not be permitted.
  • Devices with field strength of 1.5T or greater will be permitted to perform all examinations, including angiographic, Magnetic Resonance Cholangiopancreatography (MRCP) and breast studies.
  • Devices to be used for cardiac work must have electrocardiogram (EKG) gating and at least eight (8) channel parallel processing.
  • Breast MRI must be performed using 
    • Bilateral  breast coil
    • The facility must have the equipment to perform mammographic correlation, directed breast ultrasound, and MRI-guided intervention, or create a referral arrangement with a cooperating facility that could provide these services
    • ACR or  IAC Accreditation must be obtained and maintained
CT, CTA, CCTA,  and PET/CT
  • ACR or IAC Accreditation must be obtained and maintained
  • A full service CT unit must demonstrate helical or spiral image acquisition capability.
  • CTA of lower extremities requires a minimum of 16 slices per rotation.
  • CCTA, when approved, will require a minimum of 64 slices per rotation.
  • Cone Beam CT scanners are not accepted.
  • These standards apply to any diagnostic CT studies performed on a PET/CT device
PET
  • ACR or IAC  Accreditation must be obtained and maintained
  • Only high performance full ring PET systems will be considered.
  • Sodium iodide detector systems are not acceptable.
  • PET equipment must be fusion capable.  Equipment and related workstations must have the ability to register PET and CT information as a single image
Mobile Services
  • Will not be considered except for FDA certified mammography or in a SNF or hospital setting using mobile services.