TABLE OF CONTENTS - AZBluepages.azblue.com/rs/054-SSC-705/images/contractual-roles...providers. The secure provider portal (BlueNet) gives providers access to a wide range of online

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Section 4 Contractual Roles and Responsibilities

Contents

Provider Participation Agreement Information 4-1

Provider Consultant (and/or Billing Company) Negotiation Guidelines 4-3

Communication of Provider Changes 4-4

BCBSAZ Resources and Education 4-5

Use of the BCBSAZ Name or Logo (Brands) 4-7

National Provider Identifier (NPI) 4-9

Health Care Fraud 4-10

Access to Service and Availability Guidelines: Provider Offices 4-11

Transitional Period for Continuing Physician Care 4-14

Follow-up Care for Discharged Behavioral Health Patients 4-16

Provider Administrative and Operational Requirements 4-17

Primary Care Physician (PCP) and Specialist Roles and Responsibilities 4-19

Revision date:1/01/15 Section 4: Contractual Roles and Responsibilities

Provider Participation Agreement Information

4 - 1

Standard Participation Agreements: All BCBSAZ participating providers are required to sign a written agreement. These agreements can be signed by the individual provider, or the appropriate designee of a group practice, an ancillary provider or institutional provider.

The agreements will, at the least, contain the following elements:

A listing of all individuals or entities that are covered under the agreement

Conditions for participation

Obligations and responsibilities of BCBSAZ and the provider including any obligations to participate any BCBSAZ programs

Events that may result in the reduction, suspension, or termination of network participation privileges

Requirements for access to medical records as part of BCBSAZ programs or health benefits

Health care services to be provided and any related restrictions

Claims submission requirements and any restrictions on billing of consumers

Reimbursement methodology

Mechanisms for dispute resolution by participating providers

Term of the contract and conditions for terminating the contract

Requirements with respect to preserving the confidentiality of patient health information

Prohibitions regarding discrimination against consumers Reimbursement Terms Reimbursement amounts to providers vary by provider type and specific contract arrangement. The fee and price terms and conditions of a provider’s BCBSAZ contract are confidential and proprietary, and the provider may not disclose the reimbursement terms and conditions without BCBSAZ’s prior written consent. This confidentiality requirement extends to the provider’s employees and agents, including any third party billing service. However, providers may disclose information regarding their BCBSAZ contract to their patients to the extent necessary to explain the terms and conditions (including reimbursement terms) to their patients. Violation of confidentiality requirements may result in exclusion from the BCBSAZ network.

Note: A provider may obtain reimbursement only for covered services. Please see Section 1, page 1-4 for the definition of Covered Service. Subcontracting

Professional Providers: - Providers that are subcontracted by a group entity that is contracted with BCBSAZ,

must be subject to, and abide by, the same provisions in the BCBSAZ Standard Participation Agreement for professional services.

Ancillary and Institutional Providers - Subcontracting is not permitted under ancillary or institutional agreements. A separate

agreement for professional services must be executed for this purpose.

Mental Health Parity Providers must comply with and maintain parity between the behavioral and mental health and medical benefits covered under BCBSAZ benefit plans, pursuant to applicable federal and/or state law and regulations and any related regulatory or sub-regulatory guidance.


Provider Participation Agreement Information

4 - 2

Ongoing Monitoring of Participating Providers To ensure and evaluate the accessibility to services and compliance with other participation obligations, BCBSAZ may periodically perform telephonic or on-site reviews of PCP and specialist offices. These visits consist of a check list of items that address BCBSAZ and office policies and procedures, and are completed by the provider’s assigned Network Contract Specialist (NCS) with the office manager or physician in the practice.

We review the BCBSAZ policies and procedures, along with your office practice policies and procedures that are in place, such as those to schedule appointments, handle emergencies, and ensure patient confidentiality. BCBSAZ considers these reviews educational and will work with the office to improve areas in which the office is deficient.

The Credentialing Department also reserves the right to perform site visits, usually related to questions or concerns.

01/01/15 Section 4: Contractual Roles and Responsibilities

Provider Consultant (and/or Billing Company) Negotiation Guidelines

4 - 3

The provider consultant negotiation guidelines define how provider negotiations are structured when a Consultant (and /or Billing Company) is representing the interests of the provider.

BCBSAZ’s preference is to communicate directly with providers during a negotiation for contractual reimbursement rates. The benefits of direct communication include:

Builds effective and improved communication

Increases timeliness of responses between BCBSAZ and the provider,

Advances the implementation time of approved rates between BCBSAZ and the provider. Definitions

Consultant: In this context, a Consultant is a person or entity hired to provide consulting services to a provider with regard to provider contract negotiations, and is not a direct employee of the provider or an attorney representing the provider. These guidelines apply to Consultants based both within and outside of the State of Arizona.

Billing Companies: Billing companies provide third party services to a provider and are not direct employees. The provider pays for services rendered by the billing company which may include, but are not limited to, billing of claims and negotiating contractual reimbursement rates.

Guidelines for Provider Use of a Consultant or Billing Company

The provider must submit a Letter of Permission allowing BCBSAZ to communicate with a Consultant or Billing Company. In the event the provider gives negotiating authority to a Consultant or Billing Company, the following conditions must be met:

- The Consultant or Billing Company must execute a BCBSAZ confidentiality agreement

- The provider must be present at the initial negotiating meeting with BCBSAZ (including the initial negotiating meeting in relation to any renewal), and should also be present for at least 50% of all subsequent meetings with BCBSAZ wherein reimbursement rates are addressed. Telephonic participation constitutes “presence” for purposes of this policy.

If the provider is a group, then presence of the provider is satisfied with presence of the lead physician.

If the provider is a hospital, then presence of the provider is satisfied with presence of an officer with full negotiating authority.

Provider Agreements (draft and final) will not be sent to the Consultant or Billing Company directly and will be forwarded only to the provider. Consultants or Billing Companies must obtain copies of Provider Agreements from the provider.

BCBSAZ requires written approval from the provider that agreed-upon rates have been accepted by the provider, allowing BCBSAZ to proceed in finalizing the Provider Agreement

The Consultant and/or Billing Company may not represent more than one provider within the same specialty at the same time or within six (6) months of each other. This helps reduce the potential for conflicts of interest and also reduces the risk of confidential information being shared between providers of the same specialty.

BCBSAZ reserves the right to refuse interaction with a specific Consultant or Billing Company for previous non-compliance with these guidelines.


Communication of Provider Changes

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Provider Changes Participating providers must inform BCBSAZ of any changes to name, Tax ID, NPI, address, etc.1

You can use the BCBSAZ Provider Change Form to communicate changes for a provider who is already approved by the BCBSAZ Credentials Committee. Types of changes include adding a group practice, updating an address for written correspondence, or other required information.

The Provider Change Form is available on the BCBSAZ website at www.azblue.com/Forms.

Fillable PDF format: www.azblue.com/ChangeForm

Questions and Instructions on Use of the Provider Change Form This form is used to notify BCBSAZ of changes or information regarding:

Tax ID number

Name change

National Provider Identifier (NPI)

Hospital privileges

Opening and closing patient panels

Address, phone numbers and other demographic changes

If BCBSAZ does not receive written notice of a provider's change of address, BCBSAZ will continue sending correspondence, including claim payments, to the address currently listed in our systems.

The most current version of the Provider Change Form (fillable PDF) is available on our internet site at www.azblue.com/Forms.

This fillable PDF format allows you to enter the data, then save and email the form to [email protected], or print and fax it to the Network Management Department at (602) 864-3142.

If you do not have internet access, call Provider Relations at (602) 864-4231 or (800) 232-2345, ext. 4231, to request a copy of the form.

1 NOTE: If BCBSAZ does not receive a new address from the provider in writing, BCBSAZ will continue sending correspondence, including claims payments, to the address currently listed in BCBSAZ’s system. BCBSAZ will not be responsible for lost or returned mail if we do not receive this form from the provider sixty (60) days prior to the effective date of the change. In addition, we recommend that the provider submit a change of address form through the post office.

http://www.azblue.com/ChangeFormhttp://www.azblue.com/ChangeFormhttp://www.azblue.com/Formshttp://www.azblue.com/ChangeFormhttp://www.azblue.com/ChangeFormhttp://www.azblue.com/Formsmailto:[email protected]

Revision date: 01/01/15 Section 4: Contractual Roles and Responsibilities

BCBSAZ Resources and Education

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BCBSAZ is committed to building a strong partnership with providers that includes effective communication as well as relevant resources and education to support ongoing quality and value in healthcare for our members. Provider Communication A primary source of communication for providers is the assigned Network Contract Specialists (NCSs) who work on a one-on-one basis with each provider. Additional communication channels include the Provider Relations team at (602) 864-4231 or (800) 232-2345, ext. 4231, the Provider Assistance team at (602) 864-4320 or (800) 232-2345, option 4, and the eSolutions team at (602) 864-4844 or (800) 650-5656.

Written communications are sent via mailed letters, emails, newsletters and the provider portal. Provider Office Staff Advisory Council BCBSAZ has formed the Medical Office Staff Advisory Council (MOSAC) to provide updates and receive feedback and suggestions from provider office managers. The council meets twice a year in both Phoenix and Tucson and serves as a forum for communication, education and the exchange of ideas between providers and BCBSAZ. Providers interested in participating may contact their NCS for more information. Provider Resources In addition to the Provider Operating Guide, BCBSAZ offers many resources and tools for providers. The secure provider portal (BlueNet) gives providers access to a wide range of online transaction tools, forms, lists, guides and information. We are continuously striving to make it easy and efficient to business with us. Provider Education Educational seminars and workshops for BCBSAZ contracted providers are available free of charge. BCBSAZ offers these programs to continually improve communication and partnership with contracted providers.

Provider Office Staff Introductory Seminar Our office staff introductory seminar is a basic introduction to doing business with BCBSAZ, designed for staff of newly contracted providers and new staff members of existing providers who have not previously attended. Specific specialties and coding are not addressed in this seminar.

The presentation is based on relevant content from the Provider Operating Guide. These periodic in-person seminars are offered at no cost at various locations. For more information or to register, visit www.azblue.com/ProviderEducation .

Covered topics include:

- BCBSAZ products and networks

- BCBSAZ identification cards

- BlueCard (out-of-area) members

- Eligibility and precertification

- Claims

- Online tools for providers

http://www.azblue.com/ProviderEducation


BCBSAZ Resources and Education

4 - 6

An online version of the Introductory Seminar is available by logging into azblue.com and accessing the “Education & Training” section. Click on the “Introductory Seminar – Virtual” link to view the presentation at your convenience.

Staff in-services on BCBSAZ policies and procedures. In-service sessions may be

requested through the provider’s designated NCS (Network Contract Specialist).

Electronic Workshops and Lunch and Learn The eSolutions department offers training to providers on conducting business electronically with BCBSAZ. We also offer providers technical assistance for standard transactions through the BCBSAZ APN Clearinghouse, BlueNet, and through a third-party clearinghouse.

Topics for the eWorkshop and Lunch and Learn sessions include:

- Electronic Claims – comprehensive workshop on electronic claims, covering topics such as:

Electronic claims filing basics

BCBSAZ electronic solutions

Reading reports

- HIPAA Standard Transactions – overview of the HIPAA Standard Transactions, covering topics such as:

837 Professional, Institutional and Dental Claims

835 Electronic Remittance Advice

276/277 Claim Status Inquiry and Response

270/271 Eligibility & Benefit Inquiry and Response

- Provider Internet Services – overview of Internet services available through the

secure BlueNet Provider portal, covering topics such as:

Eligibility and Benefits

Claims Status

CHS

Electronic Communication


Use of the BCBSAZ Name or Logo (Brands)

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Permission to use Blue Cross Blue Shield of Arizona name or logo (Brands) The Blue Cross® and Blue Shield® Brands (Brands) are the intellectual property of the Blue Cross and Blue Association (BCBSA) who has licensed these marks to Blue Cross® Blue Shield® of Arizona (BCBSAZ). The BCBSA Brand Regulations provide the standards and guidelines for use of the Brands by all Licensees.

Provider guidelines:

Signs and Communications within Arizona:

BCBSAZ contracted providers may place small signs on their premises, and issue

communications within Arizona, to indicate their participation in the BCBSAZ provider

network.

Website:

A contracted provider may also display the BCBSAZ name/logo on its Internet site,

provided that such site does not advertise or promote provider locations outside of Arizona

and use complies with all other regulations.

Joint Communications (any public communication in which the Brands and the name or

brand(s) of an unlicensed entity appear – e.g. the name or brands of a contracted provider):

With prior written approval, BCBSAZ may permit the use of the BCBSAZ name/logo in other types of joint communications with a provider in connection with BCBSAZ programs or services, subject to the regulations.

Blue Symbols:

When the Blue symbols are used, the BCBSAZ name and Independent Licensee Tag Line must appear to the right or below the symbols.

Narrative Text:

When used in narrative text, the BCBSAZ name must be spelled out (Blue Cross® Blue

Shield® of Arizona) and include the BCBSA Independent Licensee Tag Line (An

Independent Licensee of the Blue Cross and Blue Shield Association).

Examples of Narrative Text:

Correct examples:

Contracted with Blue Cross Blue Shield of Arizona, an Independent Licensee of the Blue Cross and Blue Shield Association.

We accept Blue Cross Blue Shield of Arizona, an Independent Licensee of the Blue Cross and Blue Shield Association.

Incorrect examples:

Contracted with Blue Cross/Blue Shield

Contracted with BC/BS or BCBS.

We accept Blue.

We accept Blue Cross.


Use of the BCBSAZ Name or Logo (Brands)

4 - 8

Prohibited Use:

A provider may not use the Brands in yellow pages or similar telephone directories, and in

communications or activities outside of Arizona.

A provider may not use the words “blue,” “cross,” or “shield” in reference to its name, office

location, internet URLs, email, Facebook, Twitter, YouTube, or other social media accounts.

Please contact your BCBSAZ Network Contract Specialist for BCBSAZ prior approval of

Brand use in communications or, if you have questions about Brand use.


National Provider Identifier (NPI)

4 - 9

The NPI is a unique identification number for providers to use, regardless of health plan affiliation. The NPI is a lifetime number that follows an individual health care provider anywhere he or she practices, and an organizational health care provider for as long as the organization exists.

Except in limited, temporary locum tenens situations, no physician-level provider (which includes, but is not limited to, medical doctors, doctors of osteopathy, podiatrists, dentists, and chiropractors) may bill for services provided by another physician-level provider, or use another physician-level provider’s NPI number. No mid-level provider (which includes, but is not limited to, nurse practitioners, certified registered nurse anesthetists, physician assistants, and certified nurse midwives) may bill for services rendered by a physician-level provider. Electronic HIPAA transactions Use your NPI number on all HIPAA transactions, including electronic claims; otherwise the transaction will be rejected. For detailed instructions on using the NPI in HIPAA transactions, please refer to the HIPAA Transaction Technical Report Type 3 (TR3), which is available electronically from the Washington Publishing Company’s website at www.wpc-edi.com. Paper claims For paper claims submissions, BCBSAZ has designated the NPI as the provider identification number. Except for atypical providers2, all providers must use the NPI on all paper claims. Lack of an NPI may delay claim processing and could result in a returned claim.

ADA Dental Claim Form (2012 version) – Refer to the Dental Claim Form information on pages 16-10 to 16-15 for instructions on completing the dental claim form.

CMS 1500 (02/12) – Refer to the Professional Claim Form information on pages 16-16 to 16-20 for instructions on completing the professional claim form.

UB-04 – Refer to the Institutional Claim Form information on pages 16-21 to 16-26 for instructions on completing the institutional claim form.

BlueNet Your BlueNet account will display the NPIs associated with your tax ID numbers. Interactive Voice Response (IVR) system You must use your NPI number to access information on the IVR. For fee schedule requests through the IVR, you will also be required to submit your tax ID number. Tax Identification Number (TIN) Edits TIN edits are in place to reject claims in the BCBSAZ front end system with one or more of the following errors:

Billing provider tax ID not on file.

Billing Tax ID not valid for date of service. Contact provider network at (602) 864-4321.

Tax ID/NPI combination not on file.

To update our systems with your current information, go to www.azblue.com/providers and access the Provider Change Form at www.azblue.com/forms. Note: The SY (SSN) and EI (EIN) qualifiers are both used in determining the TIN. 2 Atypical providers, as defined by HIPAA, cannot obtain an NPI. Therefore, BCBSAZ will assign a proprietary provider ID. This proprietary ID must be used when submitting claims. (Refer to the CMS 1500 (02/12) claim form detail on pages 16-17 to 16-20 for instructions on completing the paper professional claim form.)

http://www.wpc-edi.com/http://www.azblue.com/providershttp://www.azblue.com/ChangeFormhttp://www.azblue.com/forms


Health Care Fraud

4 - 10

The BCBSAZ Special Investigations Unit investigates potential fraud, waste and abuse. According to the National Health Care Anti-Fraud Association, billions of dollars of the nation's annual health care outlay are lost to outright fraud. Everyone is ultimately affected through higher health insurance premiums, higher copays and fewer benefits. Protecting your practice

Keep your provider ID and DEA numbers confidential and never allow other providers to bill their services under your number.

Keep prescription pads in a secured location to prevent theft and be alert for forgeries.

If you have delegated billing functions to an employee or billing service, have a process in place to ensure billing reflects services provided.

Establish a process to keep up with benefit and policy changes.

Do not waive deductibles and/or coinsurance.

Conduct internal audits to promptly detect billing inaccuracies.

Watch out for patients who are “doctor shopping” to obtain controlled substances.

Check insurance cards and verify identity with a picture ID. How to report suspected health care fraud BCBSAZ’s Special Investigations Unit maintains a confidential hotline to report suspected fraud, waste and abuse. You may request to remain anonymous. Business hours are Monday through Friday from 8:00 a.m. to 4:30 p.m. Messages can be left outside business hours. Call (602) 864-4875 or (800) 232-2345, ext. 4875.

You can also report suspected fraud, waste and abuse online at www.azblue.com/FraudAbuse by selecting “Resources” in the “Resource Center” dropdown menu at www.azblue.com/Providers and then scrolling to the “Fraud & Abuse” page.

http://www.azblue.com/FraudAbusehttp://www.azblue.com/Providershttps://www.azblue.com/fraud


Access to Service and Availability Guidelines: Provider Offices

4 - 11

BCBSAZ has developed guidelines for accessibility and availability that contracted providers are responsible for maintaining. Some of these guidelines are based on access requirements prescribed by the Arizona Department of Insurance in the Arizona Administrative Code (R20-6-1914.)

BCBSAZ recommends network providers have policies and procedures consistent with these guidelines. In addition, we require providers to adopt mechanisms to furnish accessible service to individuals with limited English proficiency or reading skills and those with physical or mental disabilities. Scheduling patient services is a medical decision to be made by the provider, using the provider’s independent medical judgment, based on the circumstances presented.

BCBSAZ performs periodic re-assessment of the standards, with changes communicated to providers through updates in the Provider Operating Guide.

To ensure the BCBSAZ members have timely access to medically necessary health care services, the following are to be considered maximum appointment availability and wait times:


Type of Care Acceptable Time Frame

Preventive care visits: Includes services that promote good health, reduce the likelihood of disease or provide early detection of a disease or illness. Examples may include routine physicals, immunizations, and screening tests.

Within 60 days

Routine care visits: (Non-urgent, but in need of attention.) Includes services for the evaluation and treatment of a non-urgent symptomatic condition. Examples may include non-acute symptoms of new or recent onset.

Within 15 days

Specialty care visits: Includes services by a physician or practitioner who has education, training or qualifications in a specialty, other than primary care, beyond the education or qualifications required for the license. Examples may include visits to a cardiologist, orthopedic surgeon, ophthalmologist, or dermatologist.

Within 60 days

Urgent care visits: Includes services for unforeseen medical conditions that require prompt medical attention to prevent physical deterioration or complications. Examples may include fractures, bladder infections, and earaches.

Within 24 hours

Emergency care visits: Includes services for severe medical conditions that a person with average knowledge of health and medicine could consider life threatening or result in permanent physical impairment if not immediately diagnosed and treated. Examples may include difficulty breathing and chest pain.

Immediately

After-hours coverage: Includes services in response to the patient’s medical needs outside of regular office hours. Examples may include an answering service, pager or answering machine.

24 hours/day 7 days/week

Office wait time: Wait time is measured from the scheduled appointment time until the patient is seen by a healthcare professional, barring unforeseen emergencies.

Within 30 Minutes

Telephone wait time during office hours: Wait time is measured from the time the telephone call is answered until the patient is given an opportunity to discuss the purpose of their call.

Within 3 minutes

Medical telephone triage: A healthcare professional shall triage patient telephone messages and return calls.

Emergent Calls Urgent Calls Non-Urgent calls

Immediately 2 business hours 4 business hours



4 - 12

Availability All primary care physicians (internal medicine, family medicine, general practice and pediatrics) and specialists contracted with BCBSAZ must provide or arrange for medical care 24 hours a day, seven days a week for all of our members. The provider or the designated covering physician or health care professional must be available to provide care personally, or to direct the member to the most appropriate treatment setting. Referring in network

Contracted providers must refer members only to Network Providers for covered services. Exceptions: - Type of service not available in network - Timely access to care - Sound medical practice dictates otherwise

If a Network Provider is not available: - The referring provider must obtain precertification from BCBSAZ (except in emergency

situations) - The referring provider must advise the member of non-network status (except in

emergency situations) After-Hours Answering Systems In order for members to access their physician after regular office hours, all primary care physicians and specialists (listed in the directory) must have a telephone answering system or service available. Providers who use answering machines for after-hour services are required to include:

Urgent/emergent instructions (as the first point of instruction)

Information on contacting a covering provider

Telephone number for after-hours physician access Member Access to Emergency Services BCBSAZ does not require authorization/precertification for urgent or emergent care, whether in or out of the service area. Members should call 911 or go to the nearest hospital in case of an emergency. (Refer to page 12-2 for notification process of ER admissions for local business within one 48 hours.) Note: FEP does require notification of emergency inpatient admissions within 2 business days. BCBSAZ has contracted with certain free-standing urgent care providers to render urgent care services to its members. These providers are listed in the BCBSAZ provider directory at www.azblue.com/Directory, under “Urgent Care Centers.” PPO members with access to the BlueCard Program can view the Blue National Doctor and Hospital Finder to locate out-of-state or out-of-country providers. (Providers listed in this online directory also include hospitals and urgent care centers.) This directory can be accessed from www.azblue.com/Directory, by selecting one of the “Out-of-Arizona Providers” options. Assistance with locating an out-of-state provider can also be accessed by calling BlueCard at (800) 810-BLUE (2583). For FEP, go to www.fepblue.org to access the nation-wide provider directory.

http://www.azblue.com/Directoryhttp://www.azblue.com/Directoryhttp://www.fepblue.org/



4 - 13

Network Exceptions (non-emergent) - Out-of-Network referrals Precertification is required if the member (or referring provider) cannot find timely access to care or for a specific specialty that is not available within the BCBSAZ provider network. Call the precertification phone numbers listed on page 12-8, depending on the line of business, to initiate this process. If BCBSAZ authorizes an exception:

HMO network exceptions: The member is held harmless against any balance billing.

PPO network exceptions: PPO benefit plans have an out-of-network benefit, however, when a PPO network specialist or facility is not available, BCBSAZ may, prior to delivery of services, pre-certify the member for the in-network coinsurance and deductible. The member is still responsible for any balance bill. The referring or treating provider may initiate this request, which is separate from any preauthorization that may be required for the service.

FEP network exceptions: The Service Benefit Plan recognizes that situations may arise where the member has little, or no, choice in selecting a provider. As a result, the Service Benefit Plan includes specific provisions to provide benefits for certain types of services at preferred levels when provided by non-participating professionals. Examples include non-participating providers, such as hospital-based providers, when the care is provided at a preferred facility other than the emergency room.

Continuing Physician Care - Transitional Care (out-of-network providers) - Precertification is required. Refer to pages 4-14 through 4-15 (“Transitional Period for Continuing Physician Care”) for additional details and requirements that need to be met for this benefit.

Monitoring Procedures Compliance with Blue Cross Blue Shield of Arizona's Access to Service and Availability Guidelines will be monitored through surveys and periodic audits. Non-compliance with these standards will be addressed when credentialing and re-credentialing its providers.


Transitional Period for Continuing Physician Care

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Transitional Care from an Out-of-Network Physician for BCBSAZ Members Members may be able to receive benefits at the in-network level for services provided by an out-of-network Arizona physician, under the circumstances described below. Continuity of care benefits are subject to all other applicable provisions of a member’s benefit plan.

Continuity of care only applies to otherwise covered services rendered by doctors of medicine and osteopathy who are located in Arizona. Continuity of care is not available for facility services. If the hospital or other facility at which a physician practices is not an in-network facility, the out-of-network provisions of coverage will apply to covered facility services. BCBSAZ will not cover the out-of-network hospital charges for HMO or EPO benefit plans.

New Members Current Members

A new member may continue an active course of treatment with an out-of-network Arizona physician during the transitional period after the member’s effective date if:

The member has:

A life-threatening disease or condition, in which case the transitional period is not more than thirty (30) days from the effective date of coverage; or

Entered the third trimester of pregnancy on the effective date of coverage, in which case the transitional period includes the covered physician services for the delivery and any care related to the delivery for up to six (6) weeks from the delivery date; and

A current member may continue an active course of treatment with an out-of-network Arizona physician if BCBSAZ terminates the physician from the network for reasons other than medical incompetence or unprofessional conduct if:

The member has:

A life-threatening disease or condition, in which case the transitional period is not more than thirty (30) days from the effective date of the physician’s termination; or

Entered the third trimester of pregnancy on the effective date of the physician’s termination, in which case the transitional period includes the covered physician services for the delivery and any care related to the delivery for up to six (6) weeks from the delivery date; and

The member’s physician adheres to all of the following:

Accepts the BCBSAZ allowed amount applicable to covered services as if provided by an in-network physician, subject to the deductible, coinsurance and copay requirements of the member’s benefit plan;

Provides BCBSAZ with any necessary medical information related to the patient’s care; and

Complies with BCBSAZ’s policies and procedures, as applicable, including precertification, network referral, claims processing, quality assurance and utilization review.

To request continuity of care during a transitional period as described above, please contact BCBSAZ at (602) 864-4320 or (800) 232-2345, option 4.


Transitional Period for Continuing Physician Care

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Transitional Care for FEP Members In certain circumstances, federal employees who are Service Benefit Plan members are entitled to continue seeing their in-network providers (including ancillary providers) and receiving in-network benefits for a temporary period, if:

Blue Cross and Blue Shield terminates its contract to administer the Blue Cross and Blue Shield Service Benefit Plan with the Association or OPM; or

The provider’s network participation contract with BCBSAZ is terminated FEP provides transitional care:

For up to 90 days for members who are undergoing treatment for chronic or disabling conditions; and

Through the postpartum period for members who are in the second or third trimester of pregnancy.

To request continuity of care during a transitional period as described above, please contact BCBSAZ at (602) 864-4102 or (800) 345-7562.

01/01/15 Section 4: Contractual Roles and Responsibilities

Follow-up Care for Discharged Behavioral Health Patients

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BCBSAZ requires behavioral health inpatient facilities to adhere to patient discharge follow-up procedures to reduce readmission rates:

1. Assist patients in scheduling a 7-day follow-up appointment with a behavioral health practitioner* at the time of discharge.

2. Provide education to patients at the time of discharge on the importance of keeping their follow-up appointments.

The behavioral health practitioner* responsible for the follow-up appointment is required to:

1. Ensure the patient receives a reminder of the scheduled appointment one to two days in advance.

2. If unable to reach the patient directly with the reminder, leave a message and make another attempt to reach them at a different time.

* Provider specialties that qualify as a “Behavioral Health Practitioner” include:

Addiction Medicine and/or Psychiatry

Board Certified Behavioral Analyst

Developmental/Behavioral Pediatrics

Licensed Associate Counselor, Clinical Social Worker, Independent Substance Abuse

Counselor, Marriage & Family Therapist, or Professional Counselor

MFCC Marriage / Family / Child Counselor

Psychologist - Child / Adolescent / Adult

Neuropsychology - used for PhDs (Psychologist)

Psychiatric Nurse Practitioner

Psychiatrist - Child / Adolescent / Adult / Geriatric

Neuropsychiatry


Provider Administrative and Operational Requirements

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BCBSAZ providers are responsible for a safe and professional environment for the treatment of patients. Providers are expected to meet the following office/facility environment criteria:

State and federal regulations: Comply with all state and federal laws, rules and regulations including, but not limited to:

- The Clinical Laboratory Improvement Amendment (CLIA) requirements

- Fire safety regulations

- Americans with Disabilities Act (ADA) requirements

- Applicable Health Insurance Portability and Accountability Act-Administrative Simplification (HIPAA) regulations

- Mental Health Parity

- Drug Enforcement Agency (DEA) requirements.

Review procedures on an annual basis and update as needed. Review with all staff annually.

OSHA: Comply with all OSHA requirements including a written exposure control plan and appropriate handling of bio-hazardous waste.

Policies and procedures: Maintain written administrative policies and procedures including but not limited to:

- Confidentiality of patient information and medical records release guidelines

- Handling of emergency situations such as a fire/disaster plan and medical emergency procedures

- Handling of patient grievances and tracking of pending diagnostic services.

Update procedures as needed and review with all staff.

Physicians’ office hours: Make office hours information and after hours instructions easily accessible to the patient.

Customer service: Satisfy the BCBSAZ Provider Office Access to Service Guidelines for physicians (Refer to pages 4-11 to 4-13). Exercise of a provider’s independent medical judgment may require services to be provided sooner.

Drug procedures: Develop a procedure to ensure that drug expiration dates, including samples, are checked at least monthly. Ensure drugs, including samples, are stored in areas inaccessible to patients. Secure controlled substances in a locked cabinet and maintain a log book.

Training: Provide opportunities for staff in-service and training.

CPR certification: Maintain current CPR certification so that at least one CPR certified person is available when patients are present in the office.

Patient confidentiality: Maintain policies and procedures to assure patient confidentiality in compliance with applicable federal and state laws, including proper storage, retention and destruction of records to prevent access by non-authorized individuals.


Provider Administrative and Operational Requirements

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Imaging equipment*

- Accreditation requirements: BCBSAZ requires that all CT, MRI and PET scanners located in freestanding radiology facilities are accredited either by the American College of Radiology (ACR)3 or Intersocietal Accreditation Commission (IAC)4.

- Ionizing equipment: Ionizing equipment must comply with all applicable laws and safety standards contained in Arizona Administrative Code Title 12, Chapters 1 and 2, Radiation Regulatory Agency, including administration by an appropriately licensed or certified technician.

* Over time, BCBSAZ expects to include other modalities in the list of equipment requiring accreditation.

Sleep Lab Accreditation: BCBSAZ requires accreditation of existing and all new sleep labs coming into the network by one of the following entities:

- American Academy of Sleep Medicine (AASM)

- Accreditation Commission for Health Care (ACHC)

- The Joint Commission (TJC).

3 American College of Radiology (ACR), www.acr.org, (800) 770-0145.

4 Intersocietal Accreditation Commission (IAC), www.intersocietal.org, (800) 838-2110.

http://www.acr.org/http://www.intersocietal.org/


Primary Care Physician (PCP) and Specialist Requirements

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PCPs include those physicians in family medicine, pediatrics, internal medicine or general practice. (BCBSAZ does not require notification of members’ PCP changes.)

Specialists are physicians who practice in a specific area other than those practiced by primary care providers.

Requirements

PCPs and Specialists are expected to:

Provide coverage and services 24 hours a day, 7 days per week, 365 days per year

Post office hours clearly and visibly

Coordinate services with other network providers

Ensure continuity of care

Manage medical problems within the scope of the provider’s specialty (Specialists)

Communicate evaluations and recommendations to the PCP. Provide a written response to the referring physician within 14 days of the initial visit (Specialists)

Comply with medical record documentation requirements

Cooperate with utilization management and performance measures reporting activities, including but not limited to HEDIS, risk adjustment and government required programs related to the Affordable Care Act.

Comply with BCBSAZ Provider Office Access to Service Guidelines (refer to pages 4-11 through 4-13)

Submit claims within the timely filing guidelines

Meet ADA (Americans with Disabilities Act) established requirements

Preserve confidentiality of patient health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA), and take precautions to prevent the unauthorized disclosure of any and all medical records

Maintain all BCBSAZ credentialing standards

Refrain from discrimination against any member in the provision of covered services, whether on the basis of the member’s coverage under a benefit plan, age, sex, marital status, sexual orientation, race, color, religion, ancestry, national origin, disability, handicap, health status as required by law, source of payment, utilization of medical or mental health services or supplies, or any unlawful basis

Collect applicable deductible, coinsurance and/or copayments from the member. BCBSAZ provider contracts obligate providers to collect member cost share amounts. If the copay amount collected is greater than the BCBSAZ allowed amount for the services rendered, the provider must refund the difference to the member or credit the member’s account

Obtain/coordinate precertification requests. (Refer to precert requirements in Section 12.)


Primary Care Physician (PCP) and Specialist Requirements

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PCPs and Specialists are expected to:

Coordinate medical/surgical care with contracted providers: When the member requires surgery or other medical procedures or services, coordinate the selection of other contracted providers; for example, a home health agency, facility, assistant surgeon, anesthesiologist, or pathologist, within the member’s network.

Your BCBSAZ provider contract generally requires you to refer patients to other BCBSAZ providers in the patient’s plan network. For PPO members, make sure the provider is contracted with the PPO network. PPO members have lower out of pocket costs with PPO providers. For HMO members enrolled in Blue Select or Blue Choice, choose providers who are contracted within the HMO network. In most circumstances other than emergencies, HMO members will not have coverage unless they receive services from an HMO network provider.

If it is necessary to refer a member to a non-contracted or out-of-network provider, you must request precertification for in-network member coinsurance and deductibles in order to minimize out-of-pocket expenses for the member. Even if BCBSAZ issues the precertification, the member will still be responsible for the difference between the provider’s billed charges and the BCBSAZ allowed amount. This difference may be substantial. Because using an out-of-network provider will affect a member’s benefits and potentially result in higher out of pocket costs, you should advise the member of the other provider's non-network status and discuss this with the member.

Comply with and maintain parity between the behavioral and mental health and medical benefits covered under BCBSAZ benefit plans, pursuant to applicable federal and/or state law and regulations and any related regulatory or sub-regulatory guidance.

Information on Professional Courtesy and Services Rendered to Family Members

Professional courtesy: Providers sometimes choose to waive fees as a matter of “professional courtesy” to another provider. If a provider wishes to extend professional courtesy to another provider, the provider rendering services should not submit a claim to BCBSAZ. Under the BCBSAZ provider contract, a provider cannot waive the member responsibility amount as a professional courtesy while still submitting a claim to BCBSAZ for the balance of the claim.

Services rendered to family members: A contracted provider may not bill BCBSAZ for covered services rendered to members of the provider’s immediate family. “Immediate family” members are: parents, siblings, children, stepparents, stepchildren, spouses, grandparents, grandchildren, and anyone related to the provider by marriage to the same degree as any of the preceding individuals. When a provider is also the covered person, services rendered by that provider for himself or herself, are also excluded from coverage. If BCBSAZ pays the claim in error, and later discovers the family relationship, BCBSAZ will recover the payments.

Documents

TABLE OF CONTENTS - AZBluepages.azblue.com/rs/054-SSC-705/images/contractual-roles...providers. The secure provider portal (BlueNet) gives providers access to a wide range of online