Provider Network Participation Policy

(1)

Provider Network Participation Policy

Blue Cross and Blue Shield of Montana

HCS

Administrative

Policy

Version:

8

Original Effective Date: 05/03/2004 Version Effective Date: 09/23/2013 Replaces: N/A

Scope This policy applies to the following networks: BCBSMT Traditional Participating Provider BCBSMT Managed Care

Montana HealthLink (PPO) - includes HealthLink PPO network with the traditional provider network wrapped around it for Blue Card purposes Healthy Montana Kids (HMK)

TriCare

MedicareBlue PPO (Medicare Advantage)

Purpose The purpose of this policy is to document the types of professional and facility Health Care Providers(providers) and specialties allowed to participate in the provider networks offered or administered by BCBSMT.

Policy BCBSMT contracts with providers located in and licensed by the State of Montana, or in the contiguous counties bordering the state of Montana, as necessary, to provide the benefits and services described in the health plans offered or administered by BCBSMT.

BCBSMT does not contract with out-of-state ancillary DME, Laboratory and Specialty Pharmacy Providers unless there is a compelling reason to do so. BCBSMT does not contract with DME providers for home sleep studies. Providers are not allowed to be a participating provider at one location and a nonparticipating provider at another location.

The only exception to this requirement is allowed when the provider is an owner at one location and a non-owner employee at the other location, and the employer at the location where the provider is employed requires participation for employment. When this

exception does occur, BCBSMT will not list the provider in any of its provider directories.

In addition to the above, BCBSMT may individually consider circumstances in the interest of BCBSMT members and to preclude any confusion in the marketplace.

The specific provider types or specialties included in each of the networks are described below in descending order of participation.

(2)

BCBSMT Traditional Participating Provider Network

The BCBSMT Traditional Participating Provider Network can include the following types of providers or specialties:

Air Ambulance

Autism DX and/or TX Agency Birthing Center

Certified Nurse Midwife Certified Registered Nurse

Anesthetist

Chemical Dependency Center Chiropractor

Clinical Nurse Specialist Dentist

Durable Medical Equipment (DME)

Home Health Hospice Care Hospital

Inpatient Mental Health Facility I.V. Infusion Therapy

Laboratory

Licensed Clinical Professional Counselor

Licensed Clinical Social Worker

Mental Health Center Nurse Practitioner Occupational Therapist Optometrist

Outpatient Laboratory and X-Ray Facility

Oxygen Supplies Physical Therapist Physician Assistant Physician (MD and DO) Podiatrist

Psychologist Radiology Center

Psychiatric Residential Treatment Facility (PRTF)

Skilled Nursing / Extended Care Sleep Center / Lab

Speech Therapist/Pathologist Surgery Center

Vascular Diagnostic Services

Credentialing is required for all provider types for prior to participation in the Traditional Participating Provider Network, with the exception of the following:

Air Ambulance

Federal Employee Program

All FEP eligible provider types are contracted through the HealthLink PPO Network. Eligible providers many not opt out of FEP.

BCBSMT Managed Care Network

The BCBSMT Managed Care Provider Network includes the following types of providers or specialties:

(3)

Audiologist

Anesthetist

Chemical Dependency Center Chiropractor

Clinical Nurse Specialist Durable Medical Equipment

(DME) Hospital

I.V. Infusion Therapy Laboratory

Licensed Addiction Counselor (LAC and CCDC)

Licensed Clinical Social Worker Mental Health Center

Nurse Practitioner Occupational Therapist Optometrist

Oxygen Supplies Physical Therapist Physician Assistant Physician (MD and DO) Podiatrist

Psychologist

Registered Dietician

Skilled Nursing/ Extended Care Sleep Center / Lab

Vascular Diagnostic Services

All providers, with the exception of the following, must be participating in the BCBSMT Traditional Participating Provider Network to be eligible for the BCBSMT Managed Care Provider Network:

Audiologist

Chemical Dependency Center Licensed Addiction Counselor Mental Health Center

Registered Dietician Sleep Center / Lab

Credentialing is required for all providers in the Managed Care Provider Network except:

(4)

Montana HealthLink (PPO) Provider Network

The BCBSMT HealthLink Provider Network includes the following types of providers:

Hospital

Surgery Center

All providers must be participating in the BCBSMT Traditional Participating Provider Network to be eligible for participation in the BCBSMT HealthLink Provider Network.

The traditional provider network is wrapped around the HealthLink PPO Provider Network to create a full network for BlueCard purposes and is defined as the BCBSMT PPO product for the purpose of BlueCard.

Healthy Montana Kids (HMK)

Provider Network

The HMK Provider Network includes the following types of providers or specialties:

Ambulance Audiologist

Certified Nurse Midwife Certified Diabetic Educator Certified Registered Nurse

Anesthetist

Chemical Dependency Center Clinical Nurse Specialist Family Planning

Hospital

Indian Health Service I.V. Infusion Therapy Laboratory

Licensed Addiction Counselor (LAC and CCDC)

Licensed Clinical Social Worker Mental Health Center

Naturopathic Physician Nurse Practitioner

Occupational Therapist Optician

Optometrist

Physical Therapist Physician Assistant Physician (MD and DO) Podiatrist

Psychologist

Public and General Preventive Medicine

Radiology Center Registered Dietician

Rehabilitation Therapy Center Sleep Center / Lab

Vascular Diagnostic Services HMK providers are not required to participate in the BCBSMT Traditional Participating Provider Network.

Credentialing is required for all physicians who participate in the HMK Provider Network.

(5)

TriWest Provider Network

The TriWest Provider Network includes the following types of providers or specialties:

Ambulance Audiologist Birthing Center

Anesthetist

Chemical Dependency Center Clinical Nurse Specialist

Dentist (providing medical care) Home Health

Hospice Care Hospital

IV Infusion Therapy Laboratory

Licensed Clinical Social Worker Medical Equipment

Mental Health Center

Nurse Practitioner Occupational Therapist Oral Surgeon (DMD/DDS) Optometrist Oxygen Supplies Physical Therapist Physician Assistant Physician (MD and DO) Podiatrist

Psychologist

Psychiatric Hospital Radiology Center Registered Dietician

Psychiatric Residential Treatment Facility

Respiratory Therapist

Skilled Nursing / Extended Care Sleep Center / Lab

TriWest providers are not required to participate in the BCBSMT Traditional Participating Provider Network.

(6)

MedicareBlue PPO Provider Network (Medicare Advantage)

The BCBSMT MedicareBlue PPO Provider Network includes the following types of providers or specialties:

Ambulance Audiologist

Anesthetist Chiropractor

Clinical Nurse Specialist Durable Medical Equipment

(DME)

Federally Qualified Health Center (FQHC) Home Health Hospice Care Hospital IV Infusion Therapy Laboratory

Licensed Clinical Social Worker

Mental Health Center Nurse Practitioner Occupational Therapist Optometrist Oral Surgeon (DMD) Oxygen Supplies Physical Therapist Physician Assistant Physician (MD and DO) Podiatrist (DPM) Psychologist Radiology Center Registered Dietician Rural Health Clinic (RHC) Skilled Nursing / Extended Care Sleep Center / Lab

Vascular Diagnostic Services Credentialing is required for all providers in the BCBSMT MedicareBlue PPO Provider Network except:

Ambulance

Rationale/ Source

(7)

Cross-References

For additional information, refer to the following:

Document Name Credentialing Application Requirements

Credentialing Approval Policy Credentialing Individual Review

Practitioner Credentialing Procedure and Decision Making Process Scope of Credentialing and Recredentialing for Allied Health Providers Scope of Credentialing and Recredentialing for Facilities

Scope of Credentialing and Recredentialing for Mental Health Providers Scope of Credentialing and Recredentialing for Mid-Level Health Care Providers Scope of Credentialing and Recredentialing for Physicians

DocuWare Index Number: 010145

Formal Review or Revision Date History

This policy was reviewed or revised, and approved as documented below:

Version and Approval Date Version and Approval Date Version and Approval Date V-01 05/03/2004 V-02 10/12/2004 V-03 03/28/2005 V-04 03/13/2006 V-05 9/17/2008 V-06 11/1/2008 V-07 04/22/2009 V-7.2 05/27/2009 V-08 09/23/2013

Governance Responsibility for adoption and/or implementation of this policy is as follows:

Executive Approval Date

Signature on File 09/23/2013

Paul Pedersen

Sr. Director, Provider Network Administration and Contracting

Signature on File 09/23/2013

Mark A. Burzynski DSVP Provider Services MT