Provider Manual 2016
Blue Cross and Blue Shield of Vermont
and The Vermont Health Plan
Table of Contents
Provider Manual 2016
Blue Cross and Blue Shield of Vermont
and The Vermont Health Plan ...i
Section 1
Getting in Touch with BCBSVT and TVHP ...1Plan Definitions...2
Office Training and Orientation ...3
Provider Participation and Contracting ...3
Provider Roles and Responsibilities ...7
Access Standards ...10
Availability of Network Providers ...11
Opening/Closing of Primary Care Provider Patient Panels...11
PCP Initiated Member Transfer ...11
Transitioning Pediatric Patients ...11
Notification of Change In Provider and/or Group Information ...12
Utilization Management Denial Notices: Reviewer Availability ...13
Complaint and Grievance Process ...13
Health Insurance Portability and Accountability Act (HIPAA) Responsibilities ...14
Member Rights and Responsibilities...15
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan Privacy Practices ...15
Section 2
Blue Cross and Blue Shield of Vermont Web Site ...17Section 3
Member Eligibility ...18Member Identification Cards ...19
Member Proof of Insurance ...22
Section 4
Medical Utilization Management (Care Management) ...24Section 5
Quality Improvement (QI) Program ...30BCBSVT/TVHP Special Health Programs ...31
Provider Selection Standards ...33
Section 6
General Claim Information ...35When to Collect a Co‑payment ...37
Claim Specific Guidelines ...41
Claim Submission and Reimbursement Guidelines ...41
Section 7
The BlueCard™ Program Makes Filing Claims Easy ...53How Does the BlueCard Program Work? ...53
Claim Filing ...56
Frequently Asked Questions ...59
Glossary of BlueCard Program Terms ...61
BlueCard Program Quick Tips ...62
Section 8
Blue Cross and Blue Shield of Vermont and the Blueprint Program: ...63Section 9
The Federal Employee Program (FEP): ...671
Section 1
Getting in Touch with BCBSVT and TVHP
A customer service team specializing in provider issues staffs the following lines. The lines are open weekdays from 7 a.m. until 6 p.m. Please have the following information available when you call:
• Your National Provider Identifier(s).
• Your patient’s identification number, including the alpha prefix and suffix if applicable.
BCBSVT & TVHP Telephone Directory
http://www.bcbsvt.com/provider/contact‑info
Contact Us:
By Mail
PO Box 186, Montpelier, VT 05601‑0186
In Person
445 Industrial Lane, Montpelier, VT 05602
On The Web
Our website, www.bcbsvt.com, has a variety of services for providers and members. Section 2 of this manual has more information about it.
Secure Messaging
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires our electronic communications that contain Protected Health Information (PHI) to be secure. To comply with this important and practical security measure, we use services of a company called Proofpoint to protect our e‑mail and ensure all PHI remains confidential.
When a BCBSVT/TVHP employee sends you an e‑mail that contains PHI, Proofpoint detects the PHI and protects the e‑mail. You will receive an e‑mail notification that you have been sent a Proofpoint secure message. The notification tells you who the secure message is from and includes a link to retrieve the e‑mail message. The first time you use the Proofpoint message service to retrieve a message, you must create a password. Thereafter, you can use the same password each time you log into the Proofpoint Center to retrieve an encrypted BCBSVT/TVHP e‑mail.
Please note—Proofpoint secure messages are posted and available for 30 calendar days. If the message
is not opened during that timeframe, the message is removed and the sender notified.
2
Plan Definitions
Accountable BlueSM
The Accountable Blue product is modeled after our Vermont Health Partnership® products. Members, however, have a reduced liability when they receive care from providers who are part of the Accountable Blue Team, mindful that there is no standard level of benefits
available to members. The Accountable Blue Team consists of Central Vermont Medical Center and other Central Vermont providers. Please refer to Vermont Health Partnership definition for full details.
CBA Blue®
CBA Blue is a third‑party administrator (TPA) owned by BCBSVT. Providers contract for CBA through BCBSVT. CBA Blue members have unique prefixes. A complete listing of prefixes for CBA Blue members is available on our provider website at www.bcbsvt.com under references/prefixes.
Claims for CBA Blue members need to be submitted to CBA Blue directly. Please contact CBA Blue directly with any customer
service or claim processing related questions.
Their contact information is available on our Contact Information For Provider listing on our provider website at www.bcbsvt.com under contact us.
Federal Employee Program (FEP)
The Federal Employee Program (FEP) is a health care plan for government employees, retirees, and their dependents. It provides hospital, professional provider, mental health, substance abuse, dental and major medical coverage of medically necessary services and supplies. BCBSVT processes claims for FEP services rendered by Vermont providers to FEP members. Members with FEP coverage have ID numbers that begin with alpha prefix R.
Indemnity (Fee-for-Service) and Preferred Provider Organization (PPO)
Comprehensive: Comprehensive coverage has an annual deductible amount and coinsurance up to an annual “out‑of‑pocket” limit. It provides benefits for medical and surgical services performed by licensed physicians and other eligible providers, necessary services provided by inpatient/outpatient facilities and home health agencies, ambulance services, durable medical equipment, medical supplies, mental health/substance abuse services, prescription drugs, physical therapy and private duty nursing. The provider network for Comprehensive coverage is the participating provider network.
Vermont Freedom Plan® (VFP): the Vermont Freedom Plan combines the features of our Comprehensive coverage with a managed benefit
program. The plan encourages patient responsibility and involvement in health care by encouraging members to choose participating providers. Patients may seek services from non‑participating providers, but in most cases they will pay higher deductible and/or coinsurance amounts. The Vermont Freedom Plan provides coverage with no deductible for office visits, well‑baby care, and physicals. This plan requires members to pay a deductible and/or co‑payment. The provider network for the Vermont Freedom Plan is our preferred provider network (PPO). All plans have a prior approval requirement for select medical procedures, durable medical equipment and select prescription drugs.
Vermont Blue 65SM
Medicare Supplemental Insurance (formerly Medi-Comp)
Vermont Blue 65 (formerly Medi-Comp): is a supplement available to individuals who have Medicare Parts A and B coverage. Effective 1/1/2005, BCBSVT changed the name of its Medicare Supplemental plans from Medi‑Comp I, II, III, A and C to Vermont Blue 65 Plans I, II, III, A and C. It helps pay co‑payments and coinsurance for Medicare‑approved services. In some cases, the individuals will have to pay for all or part of the health care services. Benefits are provided only for approved Medicare‑ eligible services provided on or after the effective date of coverage.
BlueCard®
See BlueCard Section 7 for details
New England Health Plan (NEHP)
See BlueCard, Section 7, for details.
The Vermont Health Plan (TVHP)
The Vermont Health Plan (TVHP) is a BCBSVT affiliate that is a Vermont‑ based managed care organization offering a cost‑effective, high‑quality portfolio of managed care products. The Vermont Health Plan offers an HMO product, BlueCare, and a point‑of‑service plan, BlueCare Options. TVHP plans encourage members to stay healthy by providing preventive care coverage at no cost to the member. Members must get prior approval for certain medical procedures, durable medical equipment and certain prescription drugs. They must also get prior approval for out‑of‑network services.
Members must use network providers for mental health and substance abuse care. These services also require prior approval.
BlueCare Access: Members use the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive the preferred level of benefits.
Blue Care®: A PCP within The Vermont Health Plan’s network coordinates a member’s health care. Members must get prior
3
approval for certain services and prescription drugs. No out‑ of‑network benefits are available without prior approval.
Blue Care Options: A network PCP coordinates a member’s health care, but members have the option of seeking care out of network at a lower benefit level (standard benefits). Standard benefits apply when members fail to get the Plan’s approval to use non‑network providers, (subject to the terms and conditions of the subscriber’s contract). Members pay higher deductibles and coinsurance with standard benefits. If members receive care within the network or get appropriate prior approval, they receive a higher level of benefits (preferred benefits). Members with TVHP benefits can be identified by alpha prefix ZIE.
Vermont Health Partnership (VHP)
Members covered under Vermont Health Partnership select a network PCP. Members pay a co‑payment for services provided by their PCP's (except defined preventive care)as well as specialty office visits. VHP covers hospital care, emergency care, home health care, mental health and substance abuse treatment. Co‑payments or deductibles may apply. Members must get prior approval for out‑of‑network care, certain medical procedures, durable medical equipment and certain prescription drugs. VHP offers two levels of benefits, preferred and standard. Members get preferred benefits when using VHP network providers, or when they get our prior approval to use out‑of‑network providers. Standard benefits are available for some out‑of‑network services, meaning higher out‑of‑pocket expenses for the member. Members must use network mental health and substance abuse care providers and must get prior approval.
Members with VHP benefits can be identified by the alpha prefix ZIH.
University of Vermont Open Access PlanSM
University of Vermont Open Access Plan: This open access plan is based on our Vermont Health Partnership product. It differs in that it allows members to utilize the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive a preferred level of benefits. Please refer to Vermont Health Partnership definition for full details.
Riders
Riders amend subscriber contracts. They usually add coverage for services not included in the core benefits. Employer groups may purchase one or more riders. Examples include:
• Prescription Drugs • Vision Examination • Vision Materials
• Fourth Quarter carry over of deductible • Benefit Exclusion Rider
• Infertility Treatment • Sterilization • Non‑covered Surgery • Dental Care
Office Training and Orientation
Your BCBSVT provider relations consultant can assist you in several ways. • Provider contracting information and interpretation
• On‑site visits
• Provider and office staff education and training
• Information regarding BCBSVT policies, procedures, programs and services • Information regarding electronic claims options
Provider Participation and Contracting
Providers contract with BCBSVT and/or TVHP either directly or through PHOs. If you contract with BCBSVT and/or TVHP through a PHO or physician/hospital group, you may obtain a copy of your contract with us from the PHO administrative offices with which you are affiliated. If you contract directly with BCBSV T/TVHP, you are given a copy of the contract signed by all parties at the time of its execution.
Contracting
Provider contracts define the obligations of all parties. Responsibilities include, but are not limited to: obligations relating to licensure,
professional liability insurance, the delivery of medically necessary health care services, levels of care, rights to appeal, maintenance of written health records, compensation, confidentiality, the term of the contract, the procedure for renewal and termination and other contract issues. All parties affiliated are responsible for the terms and conditions set forth in that contract. Refer to your contract(s) to verify the BCBSVT and/ or TVHP products with which you participate. You may have separate contracts or amendments for participation in different BCBSVT and/or TVHP products such as Indemnity (fee‑for‑service), Federal Employee Program, Vermont Health Partnership or The Vermont Health Plan.
4
Participation
The following provider contracts are available:
Indemnity (fee-for-service)/Vermont Health Partnership
A combined contract that includes participation in: • Accountable Blue
• BlueCard (out‑of‑area) Program • CBA Blue
• Federal Employee Program (excluding dental services)
• Medicare Supplemental Insurance (Vermont Blue 65, formerly Medi‑comp) • Preferred Provider Organization (PPO) (Vermont Freedom Plan)
• Traditional Indemnity (Fee‑for‑Service) Plans (J Plan, Comprehensive and Vermont Freedom Plan) • University of Vermont Open Access • Vermont Health Partnership
• Any other program bearing the BCBS service marks
The Vermont Health Plan Contract
• Contracts may be direct or through a contracted PHO
Providers who are under contract with BCBSVT for TVHP, are "participating providers" or "in‑network providers." These providers submit claims directly to us, and receive claim payments from us. Participating and network providers accept the Plan's allowed price as payment in full for covered services, and agree not to balance bill Plan members. TVHP members pay any co‑payments, deductibles and coinsurance amounts up to the allowed price, as well as any non‑covered services.
Incentives for Participation
Participation with the Plan offers the following advantages: • Direct payment for all covered services offers predictable cash flow,
and minimizes collection activities and bad debt exposure.
• Claims you submit are processed in a timely manner. We make available either electronic (PDF or 835 formats) or paper remittance advices which detail our payments, patient responsibilities, adjustments and/or denials. • Electronic Fund Transfers (EFT) for payments. Please note: if you
select EFT you will no longer receive a paper remittance advice. A PDF format remittance advice is available on line to print or download or the 835 transaction is also available. • Members receiving services are provided with an Explanation
of Benefits (EOB) statement identifying payments, deductible, coinsurance and co‑payment obligations, adjustments and denials. The member’s EOB explains the provider’s commitment to patients through participation with BCBSVT and/or TVHP. • The Plan has dedicated professionals to assist and educate
providers and their staff with the claims submission process,
policy directives, verification of the patient’s coverage and clarification of the subscriber’s and provider’s contract. • Online and paper provider directories contain the name, gender,
specialty, hospital and/or medical group affiliations, board certification, if the provider is accepting new patients, languages spoken by the provider and office locations of every eligible provider. These directories are available at no charge to current and potential members and employer groups. This information is also available to provider offices for references or referrals on our website at
www.bcbsvt.com. For more information on provider directories,
refer to Providers Listing in Member Directories later in this section. • Providers and their staff are given information on policies, procedures,
and programs through informational mailings, newsletters, workshops and on‑site visits by provider relations consultants. • The Plan accepts electronically submitted claims in a HIPAA
compliant format and provides advisory services for system eligibility. Automatic posting data is available to electronic submitters. • Participating providers have around‑the‑clock access to the BCBSVT
website at www.bcbsvt.com, which provides claims status information, member eligibility, medical policies and copies of informative mailings.
Definition of Network Provider
BCBSVT/TVHP defines Primary Care Provider and Specialty Care Provider by the following:
Primary Care Provider (PCP):
The BCBSVT Quality Improvement Policy, PCP Selection Criteria Policy provides the complete details of the selection criteria. The policy is located on the secure provider portal at www.bcbsvt.com under BCBSVT Policies then the Quality Improvement link. Or, you can call your provider relations consultant for a paper copy. A network provider whom members in managed care health plans may select to manage their care. Providers are eligible to be PCPs if they have a specialty in family practice, internal medicine, general practice, pediatrics, geriatrics or naturopath. Certain Advance Practice Registered Nurses (APRN) can carry a patient panel.* Specifically, the APRN must practice in a state that permits APRNs to carry a patient panel and otherwise meet BCBSVT requirements for primary care providers requirement for PCP and defined by the BCBSVT Quality Improvement Policy, PCP Selection Criteria Policy. In addition, the APRN must have completed transition to practice requirements and must hold certification as an adult nurse provider, family nurse practitioner, gerontological nurse practitioner or pediatric nurse practitioner. *APRN's cannot be primary care providers for
New England Health Plan Members.
Specialty Care Provider (SPC): A network provider who is not considered a primary care provider.
5 Enrollment of Providers
To enroll, the group or individual must hold a contract with BCBSVT and/or TVHP, or a designated entity and the individual providers to be associated must be enrolled and credentialed.
Enrollment—The forms for enrolling are located on our provider website
at www.bcbsvt.com under forms, enrollment and credentialing.
There are two forms; Provider Enrollment Change Form (PECF) and Group Provider Enrollment Change Form (GPECF) Form(s) must be completed in their entirety and include applicable attachments as defined on the second page of each form. ). If you are a mental health or substance abuse clinician in addition to the forms mentioned above, you also need to complete and Area of Expertise Form.
The PECF must be used for adding a new physician/provider to a practice (new or existing practice), opening or closing of patient panel, changing physician/providers practicing location, termination* of a physician/ provider from group and changing of a physician/providers name.
*Please note: We will accept an email for termination
of a provider, rather than the PECF. Please see details below in "Deleting/Terminating a Provider" section.
The GPECF must be used for enrolling a new group practice including independent providers in private practice setting, or updating an existing group information such as; tax identification number, group billing national provider identifier (NPI), billing, physical or correspondence addresses and/or group name. Note: new groups/practices need to complete the GPECF and a PECF for each physician/provider that is going to be associated with that group/practice.
Mental Health and Substance Abuse clinicians must complete an Area of Expertise form in addition to the forms listed above Independent physicians/providers need to complete both the PECF and GPECF for enrollment or changes.
Blueprint Patient Centered Medical Homes (existing and new) need to inform BCBSVT of provider changes (defined above) by using the PECF or of group practice changes (defined above) by using the GPECF. The Blueprint Payment Roster Template is not our source of record for these changes..
PLEASE NOTE: BCBSVT is able to accept enrollment paperwork and
begin the enrollment and credentialing process even if a provider is pending issuance of a State of Vermont Practitioner’s license. If this is the case, simply indicate on the Provider Enrollment Change Form “pending” for license# in Section 3, Provider Information. Upon your receipt of the license, immediately forward a copy by fax or e‑mail at: fax (802) 371‑3489 or e‑mail providerfiles@bcbsvt.com or if you prefer the copy can be mailed to the attention of Network Management at BCBSVT, PO Box 186, Montpelier, VT 05601‑0186. Upon receipt of the Vermont State licensure, BCBSVT will continue
the enrollment process. Please be aware the enrollment process can not be fully completed until all paperwork is received.
Enrollment of Locum Tenen—You must complete a Provider Enrollment/Change form and indicate in Section 3, Locum Tenen who the provider is covering for and how long they will be covering. Locum Tenen’s who will be covering for another provider for a period of 6 months or less do not require credentialing. If the coverage is expected to exceed 6 months, then credentialing paperwork must be filed. Locum Tenens are not marketed in directories.
Provider Credentialing—The first step is to complete or update a Council for Affordable Quality Healthcare (CAQH) application. We are providing high level details below, however for complete detailed instructions, please refer to the Provider Quick Reference Guide on the CAQH website. Providers should use https://proview.caqh.org/pr to access their CAQH application.
Practice managers should use https://proview.caqh.org/pm to access the provider's CAQH application.
If you encounter any issue using the CAQH website or have questions on the process, please contact the CAQH Provider Help Desk at (888) 599‑1771.
1. Providers Currently Affiliated with CAQH
• Log onto https://proview.caqh.org/pr using your CAQH ID number • Re‑attest the information submitted is true and accurate to the best
of your knowledge. Please note that malpractice insurance information must be up‑to‑date and attached electronically. Also, practice locations need to be updated to indicate the group that the provider is being enrolled in.
• If you do not have a “global authorization”, you will need to assign BCBSVT as an authorized agent, allowing BCBSVT access to your credentialing information.
• PLEASE NOTE: if you are a provider in Massachusetts you will need to
produce the Vermont‑mandated CAQH form by changing the practice state in the setup section of the online application and answering any questions that are unique to the CAQH application. By changing the setup state, CAQH will pre‑populate much of the Vermont mandated application in order to aid the provider in completing the form.
2. Providers Not Yet Affiliated with CAQH
• CAQH has a self‑registration process. Go to
https://proview.caqh.org/pr, if you are the provider or if you are a practice manager, use https://proview.caqh.org/pm to complete an initital registration form. The form will require the provider/practice
6
to enter identifying information, including an email address and NPI number.
• Once the initial registration form is completed and submitted, the provider/practice manager will immediately receive an email with a new CAQH provider ID.
• Login to CAQH with the ID and create a unique username and password.
• Complete the online credentialing application; be sure to include copies of current medical license, malpractice insurance and if applicable Drug Enforcement Agency License.
• If you do not have a "global authorization", you will need to assign BCBSVT as an authorized agent, allowing BCBSVT access to your credentialing information.
• If a participating organization you wish to authorize does not appear, please contact that organization and ask to be added to their provider roster.
Providers Without Internet Access
• Providers without Internet access must contact CAQH’s Universal Credentialing DataSource Help Desk at (888) 599‑1771 and request a CAQH application be mailed to you.
• You must complete the application and return to CAQH for entry at: • ACS Health Care Solutions
Attn: (CAQH) 4550 Victory Lane
Indianapolis, IN 46203 or FAX (866) 293‑0414
• Please include copies of current medical license, malpractice insurance coverage and DEA certificate (if applicable).
• Assign BCBSVT as an authorized agent, allowing BCBSVT access to your credentialing information.
Once authorization has been given and your application is complete, CAQH will provide notification and Med Advantage* will begin to process your application and primary source verify your credentialing information. If for some reason your primary source verification exceeds
60 days, you will be notified in writing of the status and every 30 days thereafter, until the credentialing process is complete. Upon completion of credentialing, you or your group practice will receive a confirmation of your assigned NPI, networks in which you’re enrolled and your effective date.
Med Advantage
If you apply for credentialing through the BCBSVT/TVHP joint credentialing committee, primary source verification will be completed by our agent, the National Credentialing Verification Organization (NCVO) of Med Advantage.
Provider Listing in Member Directories
All providers are marketed in the on line and paper provider directories, except those noted below:
• Providers who practice exclusively within the facility or free standing settings and who provide care for BCBSVT members only as a result of members being directed to a hospital or a facility.
• Dentist who provide primary dental care only under a dental plan or rider • Covering providers (e.g., locum tenens)
• Providers who do not provide care for members in a treatment setting (e.g., board‑certified consultants)
The following provider information is supplied in the directories: • Name, including both first and last name of the physician or provider • Gender
• Specialty, determined based on education, training and when applicable, certifications held during the credentialing process. Providers may request to be listed in multiple specialties if their education and training demonstrates competence in each area of practice. Approved lists of specialties and certificate categories from one of the below entities is accepted:
• American Board of Medical Specialties: www.abms.org • American College of Nurse Midwives‑Certification Council:
www.addmidwife.org
• American Nurses Association: www.ana.org
• American Osteopathic Association: www.osteopathic.org • The Royal College of Pathologists: www.rcpath.org • The Royal College of Physicians: www.rcplondon.ac.uk • The College of Family Physicians of Canada: www.cfpc.ca • Hospital affiliations, admitting/attending privileges at listed hospitals • Board certification, including a list of board certification
categories as reported by the ABMS.
• Medical Group Affiliations, including a list of all medical groups with which the physician is affiliated.
• Acceptance of new patients • Languages spoken by the physician
• Office location, including physical address and phone number of office locations
Facility Credentialing
The BCBSVT Quality Improvement Policy, Facility Credentialing provides the complete details. The policy is located on the secure provider portal at www.bcbsvt.com under BCBSVT Policies then the Quality Improvement link. Or, you can call your provider consultant for a paper copy.
7 Reimbursement
We reimburse providers in one of two ways, using one of two methods:
Fee for Service: reimbursement for a service rendered, an amount paid to a provider based on the Plan’s allowed price for the procedure code billed.
Capitation: a set amount of money paid to a Primary Care Provider or PHO. The amount is expressed in units of per member per month (PMPM). It varies according to factors such as age and sex of the enrolled members.Primary Care Providers (PCPs) in private or group practices who are under a capitated arrangement will receive a monthly capitated detail report. The report is mailed before the 20th business day of every month. Each product is issued a separate capitation detail report and check. The report lists the members assigned to the PCP and the capitation amount the provider is being paid PMPM.
Capitation is paid during the three month grace period for individuals covered through the Exchange (prefix ZII). If the member is terminated at the end of the grace period, months two and three will be recovered. For full details on Grace Periods, see "grace period for individuals through the Exchange".
Paper Check: Providers, upon effective date of contract, are automatically set up to receive weekly paper remittance advice and check that are mailed using the US postal system.
Electronic Fund Transfer: Providers can opt to receive electronic fund transfers (EFT). Sign up for EFT is electronic and on the BCBSVT.com provider website. BCBSVT partners with Emdeon to offer this service. It is free and you do not have to submit claims or have a relationship with Emdeon to receive the service. Simply click on the link, complete the form and Emdeon will be in contact with you to complete the process. When you sign up to receive EFT you also commit to pick up your remits in an electronic format (either PDF or 835). The PDF versions of the remits are available on the Emdeon or BCBSVT websites. Thirty days after your first EFT payment, our paper remits will stop being mailed. Electronic remits remain ava
Provider Roles and Responsibilities
Open Communication
BCBSVT and TVHP encourage open communication between providers and members regarding appropriate treatment alternatives. We do not penalize providers for discussing medically necessary or appropriate care with members.
Conscientious Objections to the Provision of Services
Providers are expected to discuss with members any conscientious objections he or she has to providing services, counseling or referrals.
Follow-up and Self-care
Providers must assure that members are informed of specific health care needs requiring follow‑up and that members receive training in self‑care and other measures they may take to promote their own health.
Coordination of Care
VHP and TVHP members select Primary Care Providers (PCPs)
responsible for coordinating care. Providers are responsible for requesting information necessary to provide care from other treating providers. When a member is referred to a specialist or other provider, we require the specialist or provider to send a medical report for that visit to the PCP to ensure that the PCP is informed of the member’s status.
Primary Care Provider Coordinates Care
Except for self‑referred benefits, in a managed care plan all covered health services should be delivered by the PCP or arranged by the PCP. The PCP is responsible for communicating to the specialist information that will assist the specialist in consultation, determining the diagnosis, and recommending ongoing treatment for the patient. While none of our Plans (except the New England Health Plan) require referrals, we encourage members to coordinate all care through their PCPs.
Specialty Provider Responsibilities
Specialty providers are responsible for:
• Communicating findings surrounding a patient to the patient’s PCP to ensure that the PCP is informed of the member’s status • Obtaining prior approval as appropriate.
Continuity of Care
BCBSVT and TVHP support continuity of care. We allow standing referrals to specialists for members with life threatening, degenerative or disabling conditions. A specialist may act as a PCP for these members if the specialist is willing to contract as such with the Plan, accept the Plan’s payment rates and adhere to the Plan’s credentialing and performance requirements. A request for a specialist to act as his or her PCP must come from the patient, and our medical director must review and approve the request. Providers may contact the customer service unit to
initiate a request for a standing referral.
A pregnant woman in her second or third trimester enrolling in a managed care plan can continue to obtain care from her current provider if he or she is out‑of‑network until completion of postpartum care if the provider agrees to specific conditions. A new member with life threatening, disabling or degenerative conditions with an ongoing course of treatment with an out‑of‑network
8
provider may see this provider for 60 days after enrollment or until accepted by a new provider. Disabling or degenerative conditions are defined as chronic illnesses or conditions (lasting more than one year), which substantially diminish the person’s functional abilities. Our medical director must review and approve the request.
Confidentiality and Accuracy of Member Records
Providers are required to:
• Maintain confidentiality of member‑specific information from medical records and information received from other providers. This information may not be disclosed to third parties without written consent of the member. Information that identifies a particular member may be released only to authorized individuals and in accordance with federal or state laws, court orders or subpoenas. Unauthorized individuals must not have access to or alter patient records. • Maintain the records and information in an accurate and timely
manner, ensuring that members have timely access to their records. • Abide by all federal and state laws regarding confidentiality
and disclosure for mental health records, medical records, and other health and member information.
• Records must contain sufficient documentation that services were performed as billed on submitted claims.
• Providers are responsible for correct and accurate billing including proper use as defined in the current manuals: AMA Current Procedural Terminology (CPT) Health Care Procedure Coding System (HCPCS), and most recent International Classification of Diseases Clinical Modification (currently, ICD 9 CM).
Access to Facilities and Maintenance of Records for Audits
BCBSVT and TVHP (as the managed care organization), their providers, contractors and subcontractors and related entities must provide state and federal regulators full access to records relating to BCBSVT and TVHP members, and any additional relevant information that may be required for auditing purposes. Medical Record Audits may include the review of financial records, contracts, medical records, and patient care documentation to assess quality of care, credentialing and utilization.
Prior Approval/Referral Authorization
Participating and network providers are financially responsible for securing prior approvals and referral authorizations before services are rendered; even if a BCBSVT/TVHP policy is secondary to Medicare. For more information on services requiring Prior Approval or referral authorizations, please refer to Section 4.
Billing of Members
Covered Services: Participating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full
for covered services. Providers will not bill members for amounts other than applicable co‑payments, coinsurance or deductibles. We encourage providers to use their remittance advices as the source of member liability for collection of deductibles and coinsurance and bill members. Copayments, deductibles and coinsurance, however, can be billed to the member at the point of service, prior to rendering of service(s). In order to bill for these liabilities, providers must call our Customer Service Department to ensure the correct collection amount. If after receipt of the remittance advice the member liabilities are reduced, the provider must provide a quick turn‑around in refunding the member any amounts due.
Non-Covered Services
Non-Covered Services: In certain circumstances, a provider may bill the member for non‑covered services. In these cases, the collection should occur after you receive the remittance advice which reports the service as non‑covered and shows the amount due from the member. We require that you explain the cost of a non‑covered service to the member and get the member’s signature on an acknowledgement form, before you provide non‑covered services.
To verify if a service is covered, you may contact the appropriate customer service center.
Services where Medicare is primary, but provider (1) does not participate/accept assignment and (2) is contracted with BCBSVT:
Providers must adhere to the guidelines described in this section on "covered services" and/or "non‑covered services". Providers will submit the claims directly to Medicare on behalf of the member. As BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS), the claim will cross over directly for processing through the BCBSVT system. A remittance advice and any eligible payments will be made directly to the provider. Providers may collect from the member any payments Medicare made directly to the member as well as any member liabilities not collected at the point of service. The FEP program does not participate in the COBA program. The provider should make best efforts to obtain a copy of the Explanation of Medicare
9
Benefits (EOMB) from the member for submission to BCBSVT or assist the member with the submission of the claim and EOMB to BCBSVT. See Section 6, "Providers who do not accept Medicare
Assignment and are contracted with BCBSVT" for the details of how we price and process the claim.
Services where Medicare is primary, but provider (1) does not participate/accept assignment, and (2) is contracted with BCBSVT:
Providers must adhere to the guidelines described in this section on "covered services" and/or "non‑covered services". Providers will submit the claims directly to Medicare on behalf of the member. As BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS), the claim will cross over directly for processing through the BCBSVT system. A remittance advice and any eligible payments will be made directly to the provider. Providers may collect from the member any payments Medicare made directly to the provider. Providers may collect from the member any payments Medicare made directly to the member as well as any member liabilities not collected at the point of service. The FEP program does not participate in the COBA program. The provider should make best efforts to obtain a copy of the Explanation of Medicare Benefits (EOMB) from the member for submission to BCBSVT or assist the member with the submission of the lcaim and EOMB to BCBSVT. See Section 6 "Providers who do not accept Medicare
assignment and are contracted with BCBSVT" for the details of how we price and process the claim.
Waivers
Services or items provided by a contracted/network provider that are considered by BCBSVT to be Investigational, Experimental or not Medically Necessary (as those terms are defined in the member's certificate of coverage) may be billed to the patient if the following steps occur:
1. The provider has a reasonable belief that the service or item is Investigational, Experimental or not Medically Necessary because: (a) BCBSVT customer service or an eligibility request (using the secure provider web portal or a HIPAA‑compliant 270 transaction) has confirmed that BCBSVT considers the service or item to be Investigational, Experimental or not Medically Necessary; or (b) BCBSVT has issued an adverse determination letter for a service or item requiring Prior Approval; or (c) the provider has been routinely notified by BCBSVT in the past that for members under similar circumstances the services or items were considered Investigational, Experimental or not Medically Necessary.
2. Clear communication with the patient has occurred. This can be face
to face or over the phone but must convey that the service will not be reimbursed by their insurance carrier and they will be held financially responsible. The complete cost of the service has been disclosed to the member along with any payment requirements; and
3. A waiver accepting financial liability for those services has been signed by the member and provider prior to the service being rendered. The waiver needs to clearly identify all costs that will be the responsibility of the member and once signed, placed in the member’s medical records.
4. Unless the member chooses otherwise, a claim for the service or item must be submitted to BCBSVT. It allows the member to have a record of processing for his/her files, and if he/she has an HSA or some type of healthcare spending account, file a claim.
After Hours Phone Coverage
BCBSVT/TVHP requires that primary care providers (i.e., internal medicine, general practice, family practice, pediatricians, naturopaths, qualifying nurse practitioners) and OBGYNs provide 24‑hour, seven day a week access to members by means of an on‑call or referral system. Integral to ensuring 24‑hour coverage is members’ ability to contact their primary care provider and/or OBGYN after regular business hours, including lunch or other breaks during the day. After‑ hours telephone calls from members regarding urgent problems must be returned in a reasonable time not to exceed two hours.
Accessibility of Services and Provider Administrative Service Standards:
The BCBSVT Quality Improvement Policy, Accessibility of Services and Provider Administrative Service Standards provides the complete details on the definition, policy, methodology for analyzing practitioner performance and reporting. The policy is located on the secure provider portal at www.bcbsvt.com under BCBSVT Policies then the Quality Improvement link. Or, you can call your provider consultant for a paper copy.
Compliance Monitoring
BCBSVT/TVHP monitors access to after‑hours care through periodic audits. The plan places calls to providers' offices to verify acceptable after‑hours practices are in place. The Plan will contact providers not in compliance and work with those practices to develop plans of corrective action.
Reporting of Fraudulent Activity
If you suspect fraudulent activity is occurring, you need to report it to the fraud hot line at (800) 337‑8440. Calls to the hot line are confidential. Each call to the hot line is investigated and tracked for an accurate outcome.
10
BCBSVT Audit
The complete Audit, Sampling and Extrapolation Policy is available on our provider website at www.bcbsvt.com. Here is a high level overview:
For the purpose of the audit investigation, the contemporaneous records will be the basis for the Plan's determination. If the provider modifies the medical record later, it will not affect the audit results. Audit findings are based on documentation available at the time of the audit. Audit findings will not be modified by entry of additional information subsequent to initiation of the audit, for example to support a higher level of coding. Additional clinical information pertinent to the continuum of care that affects the treatment of the patient and to clarify health information may be accepted prior to the closure of the audit and will be reviewed (e.g. patient intake form, lab/radiology reports). The Plan reserves the right to conduct audits on any provider and/ or facility to ensure compliance with the guidelines stated in Plan policies, provider contracts or provider manual. If an audit identifies instances of non‑compliance with this payment policy, the Plan reserves the right to recoup all non‑compliant payments.
Provider Initiated Audit
Written notification needs to be sent to assigned Provider Relations Consultant 30 days prior to the audit being initiated. The Provider Relations Consultant will contact the provider group and coordinate the detail specific to completing the audit, such as when, required information and format of document.
Access Standards
Primary Care and OBGYN Services
BCBSVT/TVHP include the specialties of general practice, family practice, internal medicine and pediatrics in their definitions of Primary Care Providers. BCBSVT/TVHP monitors compliance with the standards described below. We use member complaints, dis enrollments, appeals, member satisfaction surveys and after‑hours telephone surveys to monitor compliance. If a provider does not meet one of the below listed standards, we will work with the provider
to develop and implement an improvement plan. The following standards for access applies to care provided in an office setting: • Access to medical care must be provided
24 hours a day, seven days a week.
• Appointments for routine preventive examinations, such as health maintenance exams, must be available within
90 days with the first available provider in a group practice.
• Appointments for routine primary care (primary care for non‑urgent symptomatic conditions) must be available within two weeks. • Appointments for urgent care must be available within 24 hours
(urgent care is defined as services for a condition that causes symptoms of sufficient severity, including severe pain, that the absence of medical attention within 24 hours could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in: placing the member’s physical or mental health in serious jeopardy; or serious impairment to bodily functions; or serious dysfunction of any bodily organ or part).
• Appointments for non-urgent care needs, a member must be seen within two weeks of a request (excluding routine preventive care).
• Emergency care must be available immediately.
• Routine laboratory and other routine care
must be available within 30 days.
If a provider does not meet one of the above standards, we work with the provider to develop and implement a plan of correction. The BCBSVT/TVHP administrative services standards
for PCP and OB/GYN offices are as follows:
• Wait time in the waiting room shall not exceed 15 minutes beyond the scheduled appointment. If wait is expected to exceed 15 minutes beyond the scheduled appointment, the office notifies the patient and offers to schedule an alternate appointment. • Waiting to get a routine prescription renewal (paper or call
in to patient’s pharmacy) shall not exceed three days.
• Call back to patient for a non‑urgent problem shall not exceed 24 hours.
Specialty Care Services
BCBSVT and TVHP define specialty care as services provided by specialists (including obstetricians). The Department of Financial Regulation (DOFR) require BCBSVT and TVHP to monitor specialists’ compliance with the standards described below. We use member complaints, dis enrollments, appeals, member satisfaction surveys and
11
after‑hours telephone surveys to monitor compliance. The following standards for access apply to care provided in an office setting: • Appointments for non‑urgent symptomatic office
visits must be available within two weeks.
• Appointments for emergency care (i.e., for accidental injury or a medical emergency) must be available immediately in the providers office or referred to an emergency facility.
If a provider does not meet one of the above standards, we work with the provider to develop and implement an improvement plan.
Availability of Network Providers
The BCBSVT Quality Improvement Policy, Availability of Network Practitioners provides the definition of the policy, including geographic access, performance goals, travel time specifications, number of practitioners, linguistic and cultural needs and preferences and how the program is monitored. The policy is located on the secure provider portal at www.bcbsvt.com under BCBSVT Policies then the Quality Improvement link. Or, you can call your provider consultant for a paper copy.
Opening/Closing of Primary Care
Provider Patient Panels
Primary Care Services
Opening of a Closed Physician Panel: A PCP may open his or her patient panel by sending a completed Provider Enrollment/Change Form (PECF). If opening your patient panel, be sure to include the date you wish to open your panel, otherwise, we will use the date we received the form.
Closing of an Open Physician Panel: BCBSVT and TVHP require 60 days notice to close a patient panel. You must submit a Provider Enrollment/Change Form. The effective date will be 60 days from our receipt of the form. BCBSVT and/or TVHP will send confirmation of our receipt of your request, including the effective date of the change. A PCP may not close his or her panel to BCBSVT/TVHP members unless the panel is closed to all new patients.
PCPs with closed patient panels: It is the PCP’s responsibility to review the monthly managed care membership report. If a member appears as an addition and is not an existing patient, notify your provider relations consultant immediately. The notification
should contain the member ID number and name. We will notify the member and ask him or her to select a new PCP. If notification from the PCP does not occur within 30 days, the PCP will be expected to provide health care until the member is removed from the provider’s patient panel. We will send confirmation to the provider that the member has been removed and the effective date.
PCP Initiated Member Transfer
A Primary Care Provider may request to remove a BCBSVT, TVHP and/or NEHP member from his or her practice due to:
• Repeated failure to pay co‑payments, deductibles or other out‑of‑pocket costs.
• Repeated missed scheduled appointments. • Rude behavior or verbal abuse of office staff.
• Repeated and inappropriate requests for prior approval; or • Irreconcilable deterioration of the physician/patient relationship. The PCP must submit a written request to his or her provider relations consultant clearly defining the reason, and documenting concerns, regarding the deterioration of the patient/physician relationship, and any steps that have been taken to resolve this problem. The PCP should mail the letter to:
Attn: (your provider relations consultant’s name) BCBSVT/TVHP
PO Box 186
Montpelier, VT 05601‑0186
The provider relations consultant and the director of provider relations will review each case, considering provider and member rights and responsibilities.
If the transfer is approved, we will send a letter to the member with a copy to the PCP. The member will be instructed to select a new PCP who is not in the current PCP’s office. The current PCP is expected to provide health care to the departing patient, as medically necessary, until the new PCP selection becomes effective.
If we do not approve the transfer, we send the PCP a letter of explanation.
Transitioning Pediatric Patients
We know that transitioning your pediatric patient (of a certain age) to their future provider for adult care, can be an emotional and sensitive issue. We offer the following advice and tools to assist you:
• Talk with your patients who are approaching adulthood
about the need to select a primary care provider (PCP). Help them to take the next step by recommending several providers. You
12
may even be able to provider some inisght into who may be a good fit for them.
• Our Find a Doctor tool can help you or your patient identify appropriate providers who are accepting new patients. To access the Find a Doctor tool, go to the Blue Cross and Blue Shield of Vermont website at www.bcbsvt.com and select the Find a Doctor link. Once you accept the terms you can search by name, location, specialty or specific gender of provider.
• Send a letter to your patients with a list of PCPs accepting
new patients. We offer a customizable letter you can use to help highlight the importance of selecting a new provider and walk the patient through the process. This template is available on our provider webiste at www.bcbsvt.com.
• Encourage the patients to call BCBSVT directly at the
customer service number listed on the back of their identification card for assistance in adding the new PCP to their member profile. We also offer an online option they can use to update their PCP by logging into our secure member portal at www.bcbsvt.com.
Notification of Change In Provider
and/or Group Information
Please complete a Provider Enrollment/Change Form (PECF) for each of the following changes:
• Patient panel change (for managed care providers only) • Physical, mailing or correspondence address
• Termination of a provider ‑ or in place of a PECF, we will accept an email for termination of a provider. Please see details below in "Deleting/Terminating a Provider" section. • Provider name (include copy of new license with new name) • Provider specialty
• Change in rendering national provider identification number Please complete a Group Practice Enrollment Change Form (GPECF) for each of the following changes: • Tax identification number (include updated W‑9) • Billing national provider identifier
• Physical, mailing or correspondence address • Group Name
Mental Health and Substance Abuse Clinicians will need to provide an updated Area of Expertise form if there is a change in the type of conditions they are treating. We cannot accept requests for changes by telephone.
If you have a change that is not on the list above, please provide written notification on practice letterhead. Include with your written documentation to BCBSVT and/or TVHP and the full names and NPI numbers for the group and all providers affected by the change. The forms (PECF, GPECF and Area of Expertise) are available our provider website at www.bcbsvt.com under Forms, Enrollment and Credentialing. If you are not able to access the web, contact provider enrollment at (888) 449‑0443 option 2 and a supply will be mailed out to you. Mail your request to:
Provider File Specialist BCBSVT
PO Box 186
Montpelier, VT 05601‑0186 Or fax to: (802) 371‑3489.
We appreciate your assistance in keeping our records up‑to‑date. Notifying us of changes ensures that we continue to accurately process claims.
13 Taxpayer Identification Number
If your Taxpayer Identification Number changes, you must provide a copy of your updated W‑9. We may need to update your provider contract if your W‑9 changes. For more information, please contact your provider relations consultant at (888) 449‑0443.
Provider Going on Sabbatical
Providers going on sabbatical for an indefinite time period should suspend his/her network status.
Providers will notify their assigned Provider Relations Consultant of when they are leaving and expected date of return. During the sabbatical time period the provider will not be marketed in any directories and will have members temporarily reassigned to another in‑Plan provider if a covering provider within their own practice is not identified. Recredentialing will occur during the providers’ normal recredentialing cycle. The provider should make arrangements to ensure that the CAQH application and other information needed for recredentialing is available and timely. If recredentialing is not timely, the provider risks network termination.
Adding a Provider to a Group Vendor
Providers joining a group vendor must provide advance notice to BCBSVT and/or TVHP. If the provider does not have an active National Provider Identifier with BCBSVT/TVHP, we need the following documents to add the provider: • Provider Enrollment Change Form (PECF)
• Copy of current state licensure
• Any applicable Drug Enforcement Agency certificate (Please note that the DEA for the state in which providers will be conducting business must be supplied when dispensing, storing medications in that location.) • Any applicable board certification
• Copy of a liability insurance
• Credentialing via the CAQH process, please see Enrollment of Providers • Mental Health and Substance Abuse Clinicians must
complete the Area of Expertise form and attach
When we receive the required documentation, we will activate your provider profile for both BCBSVT and TVHP. We will send a letter notifying the provider of his or her addition to the group vendor file. The letter will clarify the provider’s status with each network and effective date. Provider Enrollment Change and/or Area of Expertise Forms are available our provider website at www.bcbsvt.com under Forms, Enrollment and Credentialing. If you are not able to
access the web, contact provider enrollment at (888) 449‑0443 option 2 and a supply will be mailed out to you.
Deleting/Terminating a Provider
A provider who leaves a group or private practice must provide advance notice to BCBSVT. Notice can be provided through email to
providerfiles@bcbsvt.com or by completing the "terminate provider" section of the Provider Enrollment and Change Form (PECF). If you are sending through email, you will want to include the provider's full name, rendering national provider identifier (NPI), and if a group setting, the NPI of the billing group, reason for termination (such as moved out of state, went to another practice, going into private practice, etc.) and termination date. If the terminating provider is a primary care provider, we will need to know if there is another provider taking on those patients. If submitting a PECF, follow the instruction on the form. We appreciate your help in keeping our records up‑to‑date. Notifying us in a timely manner of provider termination ensures access and continuity of care for BCBSVT/TVHP members. BCBSVT notifies affected members of a provider termination 30 days in advance of the effective date of termination.
You can download a Provider Enrollment/Change Form by logging onto our provider site at www.bcbsvt.com. If you do not have internet access, please contact your provider relations consultant for a copy of the form.
Utilization Management Denial
Notices: Reviewer Availability
We notify providers of utilization management (UM) denials by letter. Providers are given the opportunity to discuss any utilization management (UM) denial decision with a Plan physician or pharmacist reviewer. All UM denial letters include the telephone number for the administrative coordinator in our integrated health management department. Providers may call this number if they desire to discuss a UM denial with a Plan physician or pharmacist. The telephone number is 1‑800‑922‑8778 (option 4) or 1‑802‑371‑3508. The administrative coordinator will schedule a time for the requesting provider to speak with the appropriate reviewer.
Complaint and Grievance Process
Provider on Behalf of Member Appeal Process
An Appeal may only be filed by a provider on behalf of a Member when there has been a denial of services which are benefit related for reasons such as: non‑covered services pursuant to the Member Certificate; services are not medically necessary or investigational;
14
lack of eligibility; or, reduction of benefits. Before a provider on behalf of member appeal is submitted, we recommend you contact the BCBSVT Customer Service Department first, as most issues may be able to be resolved, without an appeal. If you proceed with an Appeal there are three levels to the Provider on behalf of Member Appeal process.
Level 1—A First Level Provider on behalf of Member Appeal:
A first level Provider on behalf of Member Appeal must be filed in writing to:
Blue Cross and Blue Shield of Vermont Attn: Appeals
P.O. Box 186
Montpelier, VT 05601‑0186
The appeal request may also be faxed to (802) 229‑0511, Attn: Appeals. The appeal request should include all supporting clinical information along with the Member certificate number, Member name, date of service in question (if applicable), and the reason for appeal. Assuming you have provided all information necessary to decide your grievance, the appeal will be decided within the time frames shown below, based on the type of service that is the subject of your appeal (grievance): • Grievances related to “urgent concurrent” services (services that are part of
an ongoing course of treatment involving urgent care and that have been approved by us) will be decided within twenty‑four (24) hours of receipt; • Grievances related to urgent services that have not yet been provided
will be decided within seventy‑two (72) hours of receipt;
• Grievances related to non‑urgent mental health and substance abuse services and prescription drugs that have not yet been provided will be decided within seventy‑two (72) hours of receipt; • Grievances related to non‑urgent services that have not yet been
provided (other than mental health and substance abuse services and prescription drugs) will be decided within thirty (30) days of receipt; and • Grievances related to services that have already been provided
will be decided within sixty (60) days of receipt.
If the Provider on behalf Member Appeal is urgent, as described above, you and the member will be notified by telephone and in writing of the outcome. If the appeal is not urgent, as described above, you and the member will be notified in writing of the outcome. If you are not satisfied with the First Level Appeal decision you may pursue the options below, if applicable.
Level 2—Voluntary Second Level Appeal (not applicable to non group):
A Voluntary Second Level Appeal must be requested no later than ninety (90) days after receipt of our first level denial notice. If we have denied your request to cover a health care service, in whole or in part, you as the provider on behalf of member, may request a Voluntary Second Level Appeal at no cost to you or the member.
Level 1 outlines the information that should be included with your appeal, review time frames, and where the appeal should be sent. You and the member or the member’s authorized representative have the opportunity to participate in a telephone meeting or an in‑person meeting with the reviewer(s) for your second level appeal, if you wish. If the scheduled meeting date does not work for you, or the member, you may request that the meeting be postponed and rescheduled.
Level 3—Independent External Appeal:
A provider on behalf of member may contact the External Appeals Program through the Vermont Department of Banking, Insurance, Securities and Health Care Administration to submit an Independent External Appeal no later than one hundred twenty (120) days after receipt of our first level or voluntary second level, if applicable, denial notice. If you wish to extend coverage for ongoing treatment for urgent care services (“urgent concurrent” services) without interruption beyond what we have approved, you must request the review within twenty‑four (24) hours after you receive our first level or voluntary second level denial notice. To make a request, contact the Vermont Department of Banking, Insurance, Securities and Health Care Administration during business hours (7:45 a.m. to 4:30 p.m., EST, Monday through Friday) at External Appeals Program, Vermont Department of Banking, Insurance, Securities and Health Care Administration, 89 Main Street, Montpelier, VT 05620‑3101, telephone: (800) 631‑7788 (toll‑free) or (802) 828‑2900. If your request is urgent or an emergency, you may call twenty‑four (24) hours a day, seven (7) days a week, including holidays. A recording will tell you how to reach the person on call. If your request is not urgent, the Department will provide you with a form to submit your request.
BlueCard Member Claim Appeal
An appeal request for a BlueCard member must be submitted in writing using the BlueCard Provider Claim Appeal Form located on the Provider Website under resources/forms/BlueCard Claim Appeal. If the form is not submitted, the request will not be considered an Appeal. The request will not be filed with the home plan but rather returned to you. You will be informed of the decision in writing from BCBSVT. Please note, the form requires the member’s consent prior to submission. Some Blue Plans may also require the member to sign an additional form, specific to their Plan, before starting the appeal process.
When a Member Has to Pay
If a member’s appeal is denied, they must pay for services we didn’t cover.
Health Insurance Portability and
Accountability Act (HIPAA) Responsibilities
BCBSVT, TVHP, and its contracted providers are each individually considered “Covered Entities” under the Health Insurance Portability and
15
Accountability Act Administrative Simplification Regulations (HIPAA‑ AS) issued by the U.S. Department of Health and Human Services (45 C.F.R. Parts 160‑164). BCBSVT, TVHP and contracted providers shall, by the compliance date of each of the HIPAA‑AS regulations,
have implemented the necessary policies and procedures to comply. For the purposes of this Section, the terms “Business Associate,”
“Covered Entity,” “Health Care Operations,” “Payment,” and “Protected Health Information” have the same meaning as in 45 C.F.R. 160 and 164.
Disclosure of Protected Health Information
From time to time, BCBSVT or TVHP may request Protected Health Information from a provider for the purpose of BCBSVT and/or TVHP Payment and Health Care Operations functions, including but not limited to the collection of HEDIS data. Upon receipt of the request, the provider shall disclose, or authorize its Business Associate who maintains Protected Health Information on its behalf to disclose the requested information to BCBSVT/TVHP as permitted by the HIPAA‑AS at § 164.506.
The provider is not required to disclose Protected Health Information unless
A: BCBSVT and/or TVHP has or had a relationship with the individual who is the subject of such information; and
B: The Protected Health Information pertains to that relationship; and
C: The disclosure is for the purposes of:
• The Payment activities of BCBSVT and/or TVHP • Conducting quality assessment or quality improvement
activities, including outcomes evaluation and development of clinical guidelines
• Population‑based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, contacting health care providers and patients with information about treatment alternatives, and related activities that do not include treatment
• Reviewing competence or qualifications of health care professionals, evaluating practitioner and provider performance, health plan performance
• Accreditation, certification, licensing, or credentialing activities BCBSVT and/or TVHP will limit such requests for Protected Health Information to the minimum amount of Protected Health Information necessary to achieve the purpose of the disclosure.
Business Associates
Providers are required to provide written notice to BCBSVT or TVHP of the existence of any agreement with a Business Associate, including, but not limited to, a billing service to which Provider discloses Protected Health Information for the purposes of obtaining Payment from BCBSVT and/or TVHP.
The notice to BCBSVT/TVHP regarding such agreement shall, at a minimum, include: • the name of the Business Associate • the address of the Business Associate
• the address to which the BCBSVT and/or TVHP should remit payment (if different than the Provider’s office)
• the contact person, if applicable
Upon receipt of notice, BCBSVT and/or TVHP will communicate directly with Business Associate regarding Payment due to Provider. Provider must notify BCBSVT and/or TVHP of the termination of the Business Associate agreement in writing within ten (10) business days of termination of the Business Associate agreement. BCBSVT/TVHP shall not be liable for payment remitted to Provider’s Business Associate prior to receipt of such notification. Notifications should be sent to: Blue Cross and Blue Shield of Vermont
Attn: Privacy Officer PO Box 186
Montpelier, VT 05601‑0186
Standard Transactions
The provider and BCBSVT/TVHP shall exchange electronic transactions in the standard format required by HIPAA‑AS. Questions regarding the status of HIPAA Transactions with BCBSVT/TVHP should be directed to the E‑Commerce Support Team at (800) 334‑3441.
Member Rights and Responsibilities
Click here for full details and link to the URL:
http://www.bcbsvt.com/member/member-rights-responsibilities
Blue Cross and Blue Shield of Vermont and
The Vermont Health Plan Privacy Practices
We are required by law to maintain the privacy of our members’ health information by using or disclosing it only with the member’s authorization or as otherwise allowed by law. Members have the right to information about our privacy practices. A complete copy of our Notice of Privacy Practices is available at www.bcbsvt.com, or to request a paper copy, contact the Provider Relations Department at (888) 449‑0443.
17
Section 2
Blue Cross and Blue Shield of Vermont
Web Site
The Blue Cross and Blue Shield of Vermont (BCBSVT) web site located at www.bcbsvt.com/provider uses 128‑bit encryption as well as firewalls with built‑in intrusion detection software. In addition we maintain security logs that include security events and administrative activity. These logs are reviewed daily.
Our provider website it broken out into two areas; a general area that anyone can access and a secure area that only registered users can access. The general area of the provider website contains information about doing business with BCBSVT, such as recent provider mailing, news from BCBSVT, forms, medical policies, provider manual, tools and resources.
The secure area of the provider website can only be accessed by registered users and contains information such as eligibility, benefits and claim status for BCBSVT, FEP and BlueCard members. To become a registered user, you will need to work with your local administrator (this is a person in your organization who has already agreed to oversee the activities related to adding/deleting staff and assigning roles and responsibilities for your organization). If your organization does not already have a local administrator, click on the secure area of the provider website and follow the instructions to register as a new user.
A complete demo on the BCBSVT provider website is available by clicking this link:
www.bcbsvt.com/export/sites/BCBSVT/provider/ ProviderResourceCenter/bcbs_demo_2011.swf
Questions related to the website can be direct to the provider relations team at (888) 449‑0443.
18
Section 3
Member Eligibility
Member eligiblity can be verified by using our Provider Resource Center located at www.bcbsvt.com/provider. You must have a user name and password to view the information. Full details on requirements and how to obtain password are available on the “log in” page.
There are two web based options available; Eligibility Search and Realtime Eligibility Search. The Eligibility Search feature will provide information on members covered by BCBSVT. The Realtime Eligibility Search will provide information on all Blue Plan members, including BCBSVT and Federal Employee Program. Full details on the BlueCard (Blue Plan members) program are available in Section 8 of the provider manual.
We also have customer service teams that will be able to assist you over the phone if you are not able to utilize the web based searches. Click here for a listing of contacts and number(s) to call for assistance.
Regardless of which method you use to verify member eligibility you will need to have key information available:
• Patient Name (First and Last)
• Patient Date of Birth (month, day and year)
• Patient identification number. For BCBSVT
