Chapter 5: Clinical, care, and quality management
Referrals
As a PCP, when you refer Members to Participating Providers, specialists, and facilities, you will need to issue a referral. Our commercial products (POS, CareConnect GPPO, and HMO (including CHIP)) require services to be coordinated by a PCP in order for services to be paid at the higher benefit level. Referral requirements do not apply to Traditional, Comprehensive, PPO or EPO, or MA products.
As a PCP, you may sometimes need to submit referrals on behalf of your patient.
There are two types of referrals:
- Medical Care – Consult and Treat
- This covers evaluation and management with a specialist. Specialists may extend this referral to a facility by initiating referral to the facility but may not refer the patient to another specialist.
- If a Member needs to be referred on to another Provider by the PCP for additional services, a new referral must be entered.
- Specified services
- Consult only.
- Durable Medical Equipment (DME), prosthetics and orthotics that do not require preauthorization.
- Sleep studies.
- Endoscopy.
- Outpatient surgery and facility services that do not require preauthorization.
Referrals are required when:
- Your patient is covered by Commercial POS, CareConnect GPPO, and HMO (including CHIP). and
- The Member needs to see any Provider or specialist other than his or her PCP.
Please Note: A referral is not needed for the following services when care is given by a provider in our network; OB/GYN, Mammogram, and Behavioral Health Care.
Members must be referred to a Participating Provider. It is the specialty Provider’s responsibility to make sure services are provided only after the referral is confirmed.
Referrals must be submitted online using Our referral application on Our Provider Portal.
In order to receive faxback notifications, it is imperative that We have your correct fax number on file. Providers and facilities can use the Provider and Facility Maintenance applications located on Payer Spaces on Our Provider Portal.
Length of Time for Referral
Referrals are valid for 90 days after the anticipated date of service or to the end of Our Member’s Certificate of Coverage term, whichever comes first. Referrals expire when a Member is no longer covered by Us or the Member changes their plan year.
Please Note: When a referral is submitted with both Today’s Date and the Anticipated Date of Service, the 90-day referral period begins from the Anticipated Date of Service. Any date of service prior to Today’s Date will not be covered by the referral.
Standing referrals and designation of specialist as a PCP
Our HMO and POS Members with life-threatening, degenerative, or disabling diseases or conditions can obtain a standing referral to a participating specialty Provider for up to one year for services related to that diagnosis. This is a process initiated by Our Members. All treatments by non-Participating Providers require preauthorization. A standing referral, in this instance, is not applicable.
In addition to standing referrals, Our Members may request that a specialist be designated as his/her PCP, provided the specialist meets Our requirements to serve as PCP. Either Our Member or their Provider may initiate a request for a standing referral or designation of a specialist as the Member’s PCP by completing the Designation of Specialist as PCP request form. This form is located in the Forms section of the Provider Library on the “Resources” tab on Our Provider Portal.
Plan directed care
Plan-directed care is care Our Member believes they were instructed to obtain or authorized to receive, and such instruction and/or authorization was provided by a health plan representative. A representative of the health plan includes plan-contracted Providers. CMS considers plan-directed care to be the financial responsibility of the health plan and/or Our contracted network but, in either case, not the responsibility of Our Capital Blue Cross Medicare Advantage Member.
Our Medicare Advantage HMO Members are required to select a PCP who can serve as their care coordinator. As a PCP, you can oversee all medical care and services provided to the Member and may also serve to help ensure access to medically necessary specialty care services when appropriate. Any referrals to out-of-network Providers require plan notification and preauthorization.
For services requiring preauthorization, it is extremely important that Our preauthorization procedures are followed. If Our Member proceeds to receive care at the direction of his/her PCP or network specialist, the Member cannot be held financially responsible. In such instances where the performing network Provider fails to obtain a preauthorization, the performing Provider will be held financially responsible for the services received by the Member. CMS prohibits holding Our Member financially responsible for the services received by Our Member when a provider fails to obtain preauthorization.
Preauthorization requests (including all inpatient elective admissions and any outpatient service requiring preauthorization) are required to be entered via Our preauthorization function on Our Provider Portal for Participating Providers.
Our Capital Blue Cross Medicare Advantage PPO Members are not required to select a PCP or obtain a referral for specialty care services. They are encouraged; however, to coordinate their care through a family physician or internal medicine physician and they can utilize both in and out-of-network Providers. Plan directed Care requirements are still applicable.
Clinical management overview
Clinical management includes programs and activities to promote the delivery of high quality, medically necessary, and appropriate care for Our Members and to monitor the potential instances of over or underutilization. Our various programs are designed to ensure that care and services provide maximum benefits to Members and are high quality, Medically Necessary and Appropriate, and provided in an efficient and effective manner at the appropriate level of care.
Clinical Medical Necessity determinations are based solely on the appropriateness of care, service, and existence of coverage. We do not reward, pay, or provide a bonus to Practitioners, Providers, or their clinical management staff on the basis of utilization, issuance of coverage denials, or provision of financial incentives of any kind to encourage decisions resulting in underutilization or negatively impact the provision of health care services. We do not use incentives to encourage barriers to care and services and We do not make decisions regarding hiring, promoting, or terminating Practitioners or other staff based on the likelihood, or perceived likelihood, the Practitioner or staff Member supports or tends to support denial of benefits.
Our clinical management program is designed to meet Our quality improvement goals. Program goals are supported through monitoring, tracking, and trending of plan wide, product specific, and Practitioner specific utilization measures. Consistency in the program is supported through the development and application of clinically based industry standards as well as internally developed clinical policies. Clinical management criteria are used for the preauthorization of services, concurrent and retrospective review of inpatient care, outpatient care, and certain drugs under the medical benefit. These processes enhance care coordination and continuity of services for Our Members.
Detailed information regarding the clinical management program can be obtained by contacting your Provider Engagement Consultant or by calling Our clinical management team: 1.800.471.2242
Program Components
Our clinical management program includes utilization management, population health management, health education and wellness, and quality improvement.
Utilization management
Verifying Eligibility
Providers are expected to confirm eligibility and benefits prior to rendering services to one of our Members. You can do this by using the “Eligibility and Benefits” function available via our Provider Portal or by calling Provider Services at 1.866.688.2242.
Medically Necessary and Appropriate
Services or supplies provided by a Provider that Capital Blue Cross or its designee determines are: (i) necessary and appropriate for the diagnosis and/or the direct care and treatment of the Member’s medical or behavioral health condition, disease, illness, or injury; (ii) in accordance with generally accepted standards of good medical practice; (iii) consistent with Capital Blue Cross’ or its designee’s clinical protocols and utilization guidelines; (iv) not primarily for the convenience of the Member, the Member’s family, the Member’s physician or other health care Provider; and (v) provided at the most appropriate level of service, supply, or setting to safely diagnose or treat the Member. When applied to hospital services and/or higher levels of care, this means that the Member requires care in an emergency department or as an inpatient or within a higher level of care due to the symptoms presented or the Member’s condition, and the Member cannot receive safe or adequate care as an outpatient in another setting.
Review Criteria
We employ industry standard clinical management criteria for review of medical and behavioral health care delivered to Our Members. Clinical criteria sets are reviewed and approved annually. The application of clinical criteria facilitates clinical management decisions that are based on scientific evidence and achieves consistency in clinical management decisions. Specific criteria used in rendering a Medical Necessity decision can be obtained by calling Our clinical management team: 1.800.471.2242.
Medicare Advantage Review Criteria
Medicare provides policies guiding coverage of many medical services and interventions. These Medicare policies include statutes, regulations, national coverage determinations, local coverage determinations, and general coverage and benefit conditions in traditional Medicare (collectively referred to as "Medicare criteria").
When Medicare criteria are not fully established, as that term is defined in Medicare rules, Capital Blue Cross and/or our contracted third-party vendors, may develop and/or adopt additional policies and coverage criteria based on current evidence in widely used treatment guidelines or clinical literature, as permitted by law. Specific criteria used in rendering a medical necessity decision can be obtained by calling Our clinical management team: 1.800.471.2242.
Medical and Behavioral Health Claims Review
We conduct medical and behavioral health claims review to evaluate the Medical Necessity and appropriateness of Covered Services submitted for payment. Medical and behavioral health claim review is performed on a retrospective basis. Our clinicians use nationally recognized criteria and/or medical policies to make Medical Necessity and appropriateness determinations. Any case potentially not meeting Our criteria is referred to a medical director for evaluation and subsequent approval or denial.
Please Note: We may contact you if additional information is needed to determine whether the services submitted for payment are Medically Necessary and Appropriate.
Medical Policies
Our medical policies are available on Our website at CapitalBlueCross.com and in the Resource Center via Our Provider Portal.
Medical Policy Product Variation
Not all products cover the same services. See specific products for coverage.
Application of Criteria
The application of criteria includes an assessment of the Member’s individual needs, age, comorbidities, complications, home environment, and psychosocial situation. Community factors, such as availability of facilities, home care services, and benefit coverage are also considered. In Pennsylvania, minors between the ages of 14 and 18 can consent to inpatient or outpatient mental health and/or substance use disorder treatment without parental consent.
Our medical director reviews the requests for authorization not meeting clinical criteria and, as necessary, discusses cases with other board-certified specialists.
All denials based on Medical Necessity are made by a medical director or designated physician reviewer. Verbal notification and/or written confirmation of denials are provided to the requesting Provider, Member’s PCP (if applicable), Member, as well as to the inpatient facility in the case of an inpatient denial. The written confirmation will contain the detailed reason for the denial and information on how to file an appeal or grievance to dispute any adverse or denial decision.
In the case of a denied authorization request other than an administrative denial, Capital shall make available to the requesting provider a licensed health care professional for a peer-to-peer review discussion. The peer-to-peer reviewer provided by Capital shall meet the standards specified in subsection (d) and have authority to modify or overturn the prior authorization decision. The peer-to-peer discussion following an adverse determination may result in a decision to uphold, overturn, or partially overturn a denial based on additional information or clarification of originally provided information regarding the Members’ unique medical condition.
There is no peer-to-peer option available for Medicare Advantage lines of business once an adverse determination has been rendered. Outreach is attempted in advance of an adverse determination for Medicare Advantage.
Technology Assessment
We utilize scientific and evidence-based analysis to evaluate new technology. New technology excluded from coverage may be evaluated internally and considered for future coverage.
This applies to the evaluation of new technology and the application of existing technology for:
- Medical interventions.
- Behavioral health interventions.
- Pharmaceuticals.
- Devices.
Changes in medical procedures, behavioral health procedures, drugs, and devices occur at a rapid rate. We strive to remain knowledgeable about recent medical developments and best practice standards to facilitate processes that keep our medical policies up-to-date. Capital’s Medical Policy and Coding department coordinates the adoption of new medical necessity policies and the annual review of Capital’s existing medical necessity policies. Various Capital committees evaluate the use of new medical technologies and new applications of existing technologies and provide opportunity for multidisciplinary group review, discussion, and final approval. These committees may include internal Capital staff, including Capital clinicians, pharmacists, and medical directors of various specialties, and external physicians who can act as subject matter experts and provide clinical input on medical necessity policy position. External independent physician reviewers may also be used.
Through these committees, Capital reviews topics such as the effectiveness and safety of new technology in treating various conditions, along with any associated risks. Five criteria are used to evaluate new technology, including:
- The technology should have final approval from the appropriate governmental regulatory bodies.
- The scientific evidence should permit conclusions concerning the effect of the technology on health outcomes.
- The benefits of the technology should outweigh any likely harmful effects, such that the net health outcome is improved.
- The technology should be as beneficial as any established alternatives.
- The improvement in net health outcomes should be attainable outside an investigational setting.
A variety of sources are referenced, including technology evaluation bodies, current medical literature, national medical associations, specialists and professionals with expertise in the technology, and governmental agencies such as the Food and Drug Administration (FDA), the National Institutes of Health (NIH), and the Centers for Disease Control and Prevention (CDC).
Following comprehensive review, evaluation, and discussion on the new technology and after assessing member and provider impact, final determinations on medical necessity policies are made.
Our medical policies are developed to assist us in administering benefits and do not constitute medical advice. Although the medical policies may assist you and your provider in making informed healthcare decisions, you and your treating providers are solely responsible for treatment decisions. Benefits for all services are subject to the terms of this coverage.
Scientific evidence and other resources reviewed include, but are not limited to:
- Decisions and recommendations of appropriate governmental regulatory bodies, such as the FDA, National Institutes of Health (NIH), Centers for disease Control (CDC), Centers for Medicare and Medicaid Services (CMS), Health and Human Services (HHS), Agency for Health care Research and Quality (AHRQ), and the United States Preventive Services Task Force (USPSTF).
- The opinions and evaluations of national medical organizations; professional specialty societies; clinical panels, task forces, and other technology evaluation bodies.
- Available clinical evidence in published scientific literature.
- External reviews from physicians or other professionals who have expertise in the technology.
The designation “medically necessary” indicates that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities, or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing and/or treating an illness, injury, disease, or their symptoms, are:
- In accordance with generally accepted standards of medical practice; and
- Clinically appropriate in terms of type, frequency, extent, site, and duration and considered effective for the patient’s illness, injury, or disease.
- Not primarily for the convenience of the patient, physician, or other health care Provider, and
- Not more costly than an alternative service or sequence of services at least as likely to product equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the patient’s illness, injury, or disease.
For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical and behavioral health literature generally recognized by the relevant medical and behavioral health community, physician specialty society recommendations, and the views of physicians practicing in relevant clinical areas, and other relevant factors.
Medical Necessity is established in medical policies after assessment of the scientific evidence. All Commercial (including CHIP) medical policies are reviewed and updated at least annually by Capital and evaluated by the Internal Utilization Management Committee (IUMC). Capital medical policies for Medicare Advantage medical necessity determinations are updated at least annually and reviewed/approved by Capital’s Medicare Advantage Utilization Management Committee (MAUMC).
The framework outlined in Table 1 generates recommendations from the very strong (benefit/risk tradeoff unequivocal, high quality evidence, 1A) to the very weak (benefit/risk questionable, low quality evidence, 2C).
Table 1: Grading recommendations
Grade of recommendation
|
Clarity of risk/benefit
|
Quality of supporting evidence
|
Implications
|
|
1A.
Strong recommendation, high quality evidence.
|
Benefits clearly outweigh risk and burdens, or vice versa.
|
Consistent evidence from well performed randomized, controlled trials or overwhelming evidence of some other form. Further research is unlikely to change our confidence in the estimate of benefit and risk.
|
Strong recommendations, can apply to most patients in most circumstances without reservation. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
|
|
1B.
Strong recommendation, moderate quality evidence.
|
Benefits clearly outweigh risks and burdens, or vice versa.
|
Evidence from randomized, controlled trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise), or very strong evidence of some other research design. Further research (if performed) is likely to have an impact on our confidence in the estimate of benefit and risk and may change the estimate.
|
Strong recommendation and applies to most patients. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
|
|
1C.
Strong recommendation, low quality evidence.
|
Benefits appear to outweigh risk and burdens, or vice versa.
|
Evidence from observational studies, unsystematic clinical experience, or from randomized, controlled trials with serious flaws. Any estimate of effect is uncertain.
|
Strong recommendation, and applies to most patients. Some of the evidence base supporting the recommendation is, however, of low quality.
|
|
2A.
Weak recommendation, high quality evidence.
|
Benefits closely balanced with risks and burdens.
|
Consistent evidence from well performed randomized, controlled trials or overwhelming evidence of some other form. Further research is unlikely to change our confidence in the estimate of benefit and risk.
|
Weak recommendation, best action may differ depending on circumstances or patients or societal values.
|
|
2B.
Weak recommendation, moderate quality evidence.
|
Benefits closely balanced with risks and burdens, some uncertainly in the estimates of benefits, risks, and burdens.
|
Evidence from randomized, controlled trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise), or very strong evidence of some other research design. Further research (if performed) is likely to have an impact on our confidence in the estimate of benefit and risk and may change the estimate.
|
Weak recommendation, alternative approaches likely to be better for some patients under some circumstances.
|
|
2C.
Weak recommendation, low quality evidence.
|
Uncertainty in the estimates of benefits, risks, and burdens; benefits may be closely balanced with risks and burdens.
|
Evidence from observational studies, unsystematic clinical experience, or from randomized, controlled trials with serious flaws. Any estimate of effect is uncertain.
|
Very weak recommendation; other alternatives may be equally reasonable.
|
In accordance with Commonwealth of Pennsylvania 2022 Act 146, clinical review criteria adopted at the time of medical policy development or review shall:
- Be based on application nationally recognized medical standards.
- Be consistent with applicable governmental guidelines.
- Provide for delivery of health care service in a clinically appropriate type, frequency, setting, and duration; and reflect current medical/scientific evidence re: emerging procedures, clinical guidelines, and best practices from independent, peer reviewed medical literature.
Preauthorization overview
Participating Providers are responsible for obtaining preauthorization for services provided to Members when those services require preauthorization. Some employer groups do not have preauthorization requirements. Therefore, it is imperative that you verify eligibility, benefits, and any preauthorization requirements prior to rendering services to Our Members. Medical Necessity and appropriateness remain a requirement for benefit coverage whether or not preauthorization is required. All services for which preauthorization has been approved remain subject to post-service Medical Necessity and appropriateness review. A preauthorization is not a guarantee of benefits for payment.
In accordance with PA Act 146 – Prior Authorization (Senate Bill 225), if an insurer or CHIP managed care plan needs medical records, and Provider can transmit them electronically, Provider should ensure electronic access, with the ability to print, subject to applicable law and corporate policies. However, inability to provide electronic access by a Provider shall not constitute a reason to deny prior auth request.
Substance Use Disorder treatment services are addressed in Pennsylvania’s Act 106; however, only certain Members are covered. Per Act 106, preauthorization is not required for the first forty-five (45) days IF a physician certification/notification is received within fourteen (14) days of treatment initiation/admission. After day forty-five (45), medical necessity criteria is applied.
- Act 106 is not applicable to:
- Medicare Advantage, FEP, and individual commercial policies.
- Employer groups that have elected another behavioral health vendor.
To find out which Members are covered under Act 106 and/or how to submit the required certification, please see the contact information below:
In accordance with PA Act 146, for Capital to consider payment of a closely related service(s), Capital Blue Cross providers must notify Capital or our appropriate vendor(s) within fifteen (15) calendar days of the completion of the closely related service(s) AND in advance of submitting the claim. This notification should follow standard UM submission processes and must include all relevant clinical information to allow review for medical necessity. A closely related service is a healthcare service that is closely related in purpose, diagnostic utility, or designated healthcare billing code, and is provided on the same date as an authorized service.
It is extremely important that Our preauthorization procedures are followed. If a Member proceeds to receive care at the direction of his/her PCP or network specialist, Our Member must be held harmless and cannot be held financially liable for more than the applicable cost-sharing for that service. In such instances where the performing Participating Provider fails to follow plan rules, such as obtaining a preauthorization, the performing Participating Provider will be held financially responsible for the services received by the Member. CMS prohibits holding the Member financially responsible in these instances.
You can verify preauthorization requirements:
- Online via Our preauthorization single source code list available via Our Provider Portal or Our website (Capital Blue Cross).
- By calling Provider Services: 1.866.688.2242.
How to request a preauthorization
You can initiate a preauthorization request by accessing the Preauthorization application via Our Provider Portal. Here you will be able to perform a preauthorization inquiry, request preauthorization for Inpatient and Outpatient medical and behavioral health services, request a preauthorization for a Member to see a non-Participating Provider and perform a pre-service review for out-of-area Members.
To initiate an urgent preauthorization request during weekends or holidays, call Our clinical management team at 1.800.471.2242. Urgent requests include, but are not limited to, situations where delay in care could endanger the life or health of a Member. A response will be provided within 24 hours of receipt of the call.
ABA services – authorization & reviews
Applied Behavior Analysis treatment services require a preauthorization prior to beginning treatment. You can initiate a preauthorization request by accessing the Preauthorization application via Our Provider Portal. You will need to submit all applicable clinical documentation (plan of care, clinical notes, etc.) with the preauthorization or concurrent review request. Should you choose to use our standard ABA Progress Report, it can be found on Capital Blue Cross under Provider forms.
ACT 62 requires ASD diagnosed individuals have access to Autism services. This includes diagnosis and treatment. Copay, deductible and coinsurance exclusions and limitations still apply.
Cardiac preauthorizations
Preauthorization services for the following cardiac surgeries and procedures are delegated to TurningPoint:
Cardiac surgeries and procedures
|
- Coronary Angioplasty/Stenting
- Coronary Artery Bypass Grafting
- Implantable Cardioverter Defibrillator
- Internal Cardiac Monitoring
- Leadless Pacemaker
- Non-Coronary Angioplasty/Stenting
- Pacemaker
- Percutaneous Left Atrial Appendage Occluder
|
- Peripheral Revascularization
- Revision or Replacement of Implanted Cardiac Devices
- Valve Replacement
- Cardiac Catheterization
- Wearable Cardiac Defibrillator
- Cardiac Contractility Modulation
- Diagnostic Coronary Angiography
- Peripheral Diagnostic Angiogram & Venogram
|
TurningPoint Healthcare Solutions is an independent company providing preauthorization services for cardiac surgeries and procedures.
TurningPoint provides various methods to request preauthorization from their Utilization management and Precertification area including:
Clinical Policies are available by contacting TurningPoint at 866.422.0800 or by emailing Provider Relations at providersupport@tpshealth.com
The TurningPoint Authorization Request Form is available in the Provider Library section of Our Provider Portal under Forms.
Appeals:
First-level pre-service medical necessity appeals for Commercial Fully Insured, ASO, and CHIP will be delegated to TurningPoint. Submit appeals to: TurningPoint via fax at 717.412.1001 or by mail at:
TurningPoint Healthcare Attention: Appeals Unit 744 Primera Blvd Suite 2100 Lake Mary, FL 32746
First-level medical necessity appeals for Medicare should be submitted to Capital via fax at 888.456.2449 or by mail at:
Medicare Advantage Appeals PO Box 779970 Harrisburg, PA 17177-9970
Note: All post-service claim appeals should be submitted in accordance with the TurningPoint Post Service Review Process below.
Hip, knee, shoulder, & spine preauthorizations
Preauthorization services for hip, knee, shoulder, and spine surgical procedures in both inpatient and outpatient settings are delegated to TurningPoint.
TurningPoint Healthcare Solutions is an independent company providing preauthorization services for musculoskeletal inpatient and outpatient surgical procedures.
TurningPoint provides various methods to request preauthorization from their Utilization management and Precertification area including:
Web Portal Intake: myturningpoint-healthcare.com Telephone: 1.844.540.3705 | 717.370.6450 Fax: 717.412.1001
The TurningPoint Authorization Request Form is available in the Provider Library section of Our Provider Portal under Forms.
TurningPoint clinical guidelines
The following information is applicable to Orthopedic and Neurosurgery procedures only.
TurningPoint reviews preauthorization requests for designated hip, knee, shoulder, cervical, and spinal procedures. The specific procedure codes are available in the Capital Blue Cross Single Source Preauthorization list.
Yearly, TurningPoint updates the Clinical Guidelines for Musculoskeletal procedures. The guidelines are located on the Web Portal Intake at myturningpoint-healthcare.com. Click on Policies in the right upper corner. Please review the specific guidelines for your specialty.
TurningPoint post service review process
TurningPoint Healthcare Solutions performs preauthorization reviews for musculoskeletal surgical procedures and certain cardiac surgical procedures identified on Our Single Source Preauthorization list. A link to the Single Source Preauthorization list is located under “Authorizations and Referrals” and on the “Resources” tab on the Capital Blue Cross Payer Spaces page of Our Provider web portal and on Our website (Capital Blue Cross).
When the review is complete, the preauthorization determination letter outlines the approved surgical procedure code(s). After the surgery, the Provider may determine a more appropriate procedure code should be billed or may have needed to perform an additional procedure during the surgery. A closely related service is a healthcare service that is closely related in purpose, diagnostic utility, or designated healthcare billing code and is provided on the same date an authorized service. When this occurs, Providers can request a Post Service Review for the new code(s).
To request a Post Service Review, the Provider will need to complete a Post Service Review form located in the Forms section of the Provider Library on the “Resources” tab on Our Provider Portal. The completed form, cover sheet, and applicable surgical operative note can then be faxed to TurningPoint at 717.412.1001.
In accordance with PA Act 146, Capital will consider payment of a closely related service (s) IF the provider notifies TurningPoint of the performance of the closely related service no later than 15 calendar days following completion of the service but prior to submitting the claim.
Medical specialty injectable drugs prior authorization – commercial products
Prior authorization services for select medical specialty injectable drugs are delegated to Prime Medical Pharmacy Solutions (MPS). Prior authorization should be requested using the Prime MPS Gateway PA portal.
If prior authorization cannot be performed online, Prime MPS will be accepting requests via phone or fax:
Telephone: (800) 424.1710 Fax: (888) 656.6671
*Please refer to Capital Blue Cross’ Single Source Preauthorization list for a complete listing of prior authorization codes.
Medical specialty injectable drugs policies and a list of pharmaceuticals included in each policy are located on the Prime MPS Gateway PA portal.
Medical specialty injectable drugs – prior authorization and site of service for commercial products
Prior authorization services for select medical specialty injectable drugs to meet site of service criteria are delegated to Prime Medical Pharmacy Solutions (MPS) for commercial Members. Please use Prime MPS’ site of service policy and other medical policies in the Specialty Medical Injectable Policies section on the Prime MPS provider Portal.
Medical specialty injectable drugs must meet applicable Medical Necessity criteria, including appropriate site of service, for coverage.
Prior authorization for these medical specialty injectable drugs can be completed using Prime MPS online prior authorization application on the Prime MPS Gateway PA provider portal.
If preprior authorization cannot be performed online, Prime MPS will be accepting requests via phone or fax:
Telephone: (800) 424.1710 Fax: (888) 656.6671
*Please refer to Capital Blue Cross’ Single Source Preauthorization list for a complete listing of prior authorization codes.
During the prior authorization process, if a site of service other than one of the options listed below is selected, the request may be denied unless the Member is receiving these medications for the first time*. These alternative sites of service include:
- Provider office, not located in a hospital setting.
- Home infusion.
- Free-standing infusion center, not located in a hospital setting.
*Members being prescribed these medications for the first time will have the option to receive their initiation therapy in a hospital or facility setting. Initiation therapy varies by drug and may include multiple doses depending on the validity period as described within the drug specific medical policies. In the absence of any adverse reactions, subsequent doses should be arranged at one of the alternative sites of care listed above. If the Member receives their initiation therapy in a hospital or facility setting, an initial preauthorization is assigned. Should the Member then be transitioned to an alternative site of care, a new prior authorization should be requested.
Members already receiving their medications at an alternative site of service as described above will not be impacted. Additionally, Members may receive their medications in a hospital outpatient setting when medically appropriate.
Specific infusion therapy Providers can be located using “Find a Doctor” on Our website at CapitalBlueCross.com.
Medical specialty injectable drugs – prior authorization for Capital Blue Cross Medicare Advantage
Prior authorization requests for certain medications covered under a Capital Blue Cross Medicare Advantage Member’s medical benefit are delegated to Prime Medical Pharmacy Solutions (MPS).
*Please refer to Capital Blue Cross’ Single Source Preauthorization list for a complete listing of prior authorization codes.
Prior authorization for these medical specialty injectable drugs can be completed using Prime MPS’ online prior authorization application on the Prime MPS Gateway PA provider portal.
If preprior authorization cannot be performed online, Prime MPS will be accepting requests via phone or fax:
Telephone: (800) 424.1710 Fax: (888) 656.6671
High-tech imaging and radiation oncology services – preauthorization
Preauthorization services for certain “high-tech” outpatient and select cardiac imaging services are delegated to Evolent Specialty Services, Inc. You can locate Current Procedural Terminology (CPT) codes managed by Evolent in the Resource Center on Our Provider Portal.
Providers will be asked to submit certain aspects of medical records for review by Evolent clinicians as part of the preauthorization for studies requiring a clinical record review.
*Please refer to Our Single Source Preauthorization list for a complete listing of preauthorization codes.
You may obtain Evolent preauthorization via:
Evolent’s secure web application, RADMD at RadMD.com Telephone: 1.888.203.1423
To ensure that the most accurate preauthorization requirements for the Members group benefits are returned during the preauthorization process, Providers should check the procedure code requirements for each Member using the following process:
- Using the CPT-4 Procedure Code/Keyword Lookup – Enter the Name of the study being preauthorized in the Evolent Portal.
- A response will be returned specific to that Member’s benefits.
Tips:
- Please do not schedule testing prior to receipt of preauthorization. Allow enough time if Medical Director review is necessary.
- If Evolent sends a fax request for additional information, please use the cover sheet when returning the requested information for faster document attachment.
- If the Provider receives a denial for a Commercial account, and in review of the denial, language has the missing clinical information, you may submit the request again as a brand-new request, engage in a peer to peer discussion, or submit an appeal.
- When a denial is received for a Medicare Member and the denial language states missing clinical information which is in your possession, a new request cannot be submitted via RadMD for 60 days. The Provider can appeal the decision if you elect not to wait for the new submission timeframe.
- For Medicare Members, a Peer to Peer can be conducted in advance of the authorization requested being finalized.
- Evolent has a RadMD document guide to assist with online authorization process. Request a guide by either calling Evolent at 877.807.2363 or contacting your Capital Blue Cross Provider Engagement Consultant.
- Clinical guidelines for each procedure code are located on www.RadMD.com under More Online Tools.
In order to expedite your request, please utilize the “upload of clinical information” feature on RadMD or use the fax coversheet received from Evolent, to ensure the information is automatically attached to the case and forwarded to Evolent’s clinician for review.
For additional RadMD resources, visit RADMD|Clinical Guidelines and Other Resources.
Molecular laboratory management services preauthorization
Preauthorization services for the following outpatient molecular and genomic tests are delegated to EviCore:
Molecular lab management services
|
- Hereditary Cancer Syndromes
- Carrier Screening Tests
- Tumor Marker/Molecular Profiling
- Immunohistochemistry (IHC)
- Hereditary Cardiac Disorders
- Neurologic Disorders
|
- Cardiovascular Disease and Thrombosis Risk Variant Testing
- Pharmacogenomics Testing
- Mitochondrial Disease Testing
- Intellectual Disability/Developmental Disorders
|
EviCore is an independent company providing preauthorization services for Molecular Laboratory Management Services for Commercial Fully-Insured, select ASO, Medicare, and CHIP members.
EviCore provides various methods to request preauthorization from their Utilization Management and Precertification area including:
Web Portal Intake: EviCore.com Telephone: 877.282.2510 Fax: 844.545.9213
Clinical Policies are accessible through the web portal at EviCore.com. From the Resources drop down menu, select Clinical Guidelines, and scroll down to select Laboratory Management.
A closely related service is a healthcare service that is closely related in purpose, diagnostic utility, or designated healthcare billing code and is provided on the same date as the authorized service. When this occurs, Providers can request a Post Service Review for the new code(s).
In accordance with PA Act 146, Capital will consider payment of a closely related service (s) IF the provider notifies EviCore of the performance of the closely related service no later than 15 calendar days following completion of the service but prior to submitting the claim.
Peer-to-peer (P2P):
Log-in to EviCore.com to perform a Clinical Review Lookup to determine the status of your request.
Select P2P Availability to determine if your case is eligible for a P2P. In some instances, a P2P consultation is allowed, but the decision cannot be changed. In such cases, you can still request a Consultative-Only P2P. You can also click on the All Post Decision Options button to learn what other action can be taken.
Once the Request Peer-to-Peer Consultation link is selected, you will be transferred to EviCore’s scheduling software to schedule a date/time for your P2P discussion. You may also cancel or reschedule a P2P from this link.
Appeals:
First-level pre-service medical necessity appeals for Commercial Fully Insured, Select ASO, and CHIP will be delegated to EviCore. Submit appeals to: EviCore via telephone at 800.792.8744 or fax at 866.699.8128 or by mail at:
EviCore Healthcare Attention: Clinical Appeals PO Box 5620 Hartford, CT 06102
First-level medical necessity appeals for Medicare should be submitted to Capital via fax at 888.456.2449 or by mail at:
Medicare Advantage Appeals PO Box 779970 Harrisburg, PA 17177-9970
EviCore clinical guidelines
The following information is applicable for Molecular Laboratory Management Services for Commercial Fully Insured, select ASO, CHIP, and Medicare Advantage.
EviCore reviews preauthorization requests for Molecular Laboratory Management Services. The specific procedure codes are available in the Capital Blue Cross Single Source Preauthorization list.
Minimally annually, EviCore updates the Clinical Guidelines for Molecular Laboratory Management Services. The guidelines are located on the web portal EviCore.com. From the Resources drop down menu, select Clinical Guidelines, and scroll down to select Laboratory Management. Please review the specific guidelines for your services.
EviCore retrospective review process
EviCore performs preauthorization reviews for Molecular Laboratory Management Services identified on our Single Source Preauthorization list. A link to the Single Source Preauthorization list is located under “Authorizations and Referrals” and on the “Resources” tab on the Capital Blue Cross Payer Spaces page of Our Provider web portal and on our website (CapitalBlueCross.com).
When the review is complete, the preauthorization determination letter outlines the approved Molecular Laboratory Management Services procedure code(s). Following the procedure, the Provider may determine that a different procedure code is more appropriate or that additional testing is necessary.
To request a Retrospective Review, the Provider may contact EviCore by telephone at 877.282.2510 within 30 calendar days. The Provider should have all clinical information relevant to the request available when contacting EviCore.
Clinical trials
Preauthorization for clinical trials is not required. Providers should refer to Our Clinical Trial medical policy. Providers are required to submit the claim for routine patient costs for services associated with a Clinical Trial with the appropriate modifier along with providing the approved Clinical Trial number.
Letters of medical necessity
Letters of Medical Necessity are obtained via Our Provider Portal, the “Provider Forms” page on the “Resources” tab in Our Payer Space. Correspondence and supporting information should be submitted with the request. If unable to fax the number on the form, providers may submit to:
Capital Blue Cross Attn: Preauthorization Unit PO Box 773733 Harrisburg, PA 17177-3733
Expedited preauthorization
Our Capital Blue Cross Medicare Advantage Members or their Providers may request an expedited review of a preauthorization involving situations where applying the standard timeframe for making a determination could:
- Seriously jeopardize the life, health, or safety of the Member or the Member's ability to regain maximum function.
- The Member would be subject to severe pain that cannot be adequately managed without the care or treatment.
To request an expedited determination, a Member or a physician acting on behalf of the Member, may request electronically or submit a verbal or written request directly to us. Once received, the request must meet the definition of a service requiring expedited determination.
Any request received from Members will be processed under the same standard as requests received from a Provider. Under these circumstances, We will attempt to contact the Member’s Provider to obtain their opinion regarding the need for an expedited determination or will base the decision on information obtained from the Member.
If a request for expedited determination is denied, the request will be transferred to the standard timeframes for a determination. Our Member and their Provider, will be notified verbally of:
- The decision and a written notice with the reasons for the denial.
- Instructions for filing an expedited grievance.
- The opportunity to discuss the decision with one of Our physician reviewers.
If a request for an expedited review is approved, a determination will be made and their Provider will be verbally notified of the decision as expeditiously as the Member’s health condition requires.
For Our Capital Blue Cross Medicare Advantage Members, in compliance with CMS, a 14-calendar day extension will be permitted if the Member requests the extension or if We justify the need for additional information and how the delay is in the interest of the Member. A written notice to the Member and Provider will follow within 24 hours from the decision date. If the determination is not completely favorable to the Member, the notice will inform Our Member of their right to a reconsideration (both standard and expedited).
Medicare Outpatient Observation Notice (MOON) requirement
The Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act requires hospitals and critical access hospitals (CAH) provide the MOON to Medicare beneficiaries, including Members covered by Capital Blue Cross Medicare Advantage receiving observation services as outpatients for more than 24 hours.
The MOON describes the status of the individual as an outpatient as opposed to an inpatient, along with the implications of observation services on cost sharing and coverage for post-hospitalization skilled nursing facility (SNF) services.
A verbal explanation of the MOON must be provided, ideally in conjunction with the delivery of the notice, no later than 36 hours after observation services are initiated or, sooner if the member is transferred discharged or admitted. Additionally, a signature must be obtained from the Member, or an individual qualified to act on the Member’s behalf, to acknowledge receipt and understanding of the notice. In cases where the Member or qualified individual acting on behalf of the Member refuses to sign the MOON, the staff Member of the hospital or CAH providing the notice must sign the notice to certify that notification was presented. The staff Member’s signature must include the name and title of the staff Member, a certification that the notification was presented, and the date and time the notification was presented. The staff Member annotates the “Additional Information” section of the MOON to include the staff Member’s signature and certification of delivery. The date and time of refusal is considered to be the date of notice receipt.
The MOON and instructions can be found at: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html.
Preservice request notification, Capital Blue Cross Medicare Advantage
- We will verbally notify Capital Blue Cross Medicare Advantage Members of an expedited preservice determination.
- Capital Blue Cross Medicare Advantage Members must receive a Notice of Medicare Non-Coverage (NOMNC) when We determine that ongoing care is no longer medically necessary or when clinical information is not received to support continued approval for Members receiving the following Covered Services:
- Skilled nursing care in a facility.
- Home health services (including psychiatric care).
- Comprehensive outpatient rehabilitation facility care.
It is the responsibility of the Provider to provide this notice to the Member at least two calendar days prior to the coverage end date.
Providers must explain the purpose and contents of the NOMNC to the Member. The Provider must obtain a signature from the Member acknowledging receipt of the information. The Provider must provide Us with a copy of the notice signed by the Member.
- Capital Blue Cross Medicare Advantage Members must receive a Detailed Explanation of Non-Coverage (DENC) only if a Member requests an expedited determination from a Quality Improvement Organization (QIO). The DENC explains the specific reasons when the ongoing care is no longer medically necessary for Members receiving the following Covered Services:
- Skilled nursing care in a facility.
- Home health services (including psychiatric care).
- Comprehensive outpatient rehabilitation facility care.
Predetermination: Capital Blue Cross Medicare Advantage
Providers may request a predetermination review to determine if a proposed treatment or service is covered under a Capital Blue Cross Medicare Advantage Member’s health plan. Predetermination requests are not required and are voluntary. These are performed as a courtesy review and do not take the place of any preauthorization requirements. Failure to obtain any necessary preauthorization may result in a denial.
A predetermination review of a service or treatment is not a guarantee of payment. Payment will be determined once a claim is received and based upon Our Member’s eligibility at the time of the service, Medical Necessity, Provider network status, applicable Member copayments, Coinsurance, Deductibles, Certificate of Coverage exclusions, preauthorization or referral requirements, National Coverage Determination (NCD) or Local Coverage Determination (LCD), and Our medical policy.
Completion of Our predetermination form is required when requesting predetermination review for a specific procedure or service.
Capital Blue Cross Medicare Advantage member liability
In the event a Capital Blue Cross Medicare Advantage Member wishes to receive a service not covered in their Evidence of Coverage, the Provider may, under certain circumstances, seek payment from the Member. The Provider must submit a preservice determination to Us for review and a preservice determination will be issued to Our Member advising the service is not covered. Providers who render services without pursuing preservice determination will be held liable for the charges for these denied services and may not bill the Member.
Concurrent review
Urgent and/or emergent inpatient admissions are not subject to initial medical necessity and appropriateness evaluation but require notification to Capital within 2 business days of admission. Failure to notify Capital may result in an administrative denial. Admission medical necessity and concurrent review will be performed following admission and notification.
Concurrent review is conducted to evaluate and monitor quality of medical and/or behavioral health care provided in the inpatient setting, including higher levels of care, and for select outpatient services. For inpatient or higher levels of care the concurrent review process is used to assist the facility or provider in the coordination of medical or behavioral health services for the Member and to facilitate a level of care appropriate to the Member’s needs. This assessment includes Medical Necessity and appropriateness of ongoing care and services.
Additionally, discharge planning (discussed below), beginning at the time of admission, occurs as a component of concurrent review. Our Utilization Management (UM) Clinicians(s) use nationally recognized clinical criteria to perform concurrent review. The objectives of concurrent review are to:
- Work collaboratively with physicians and hospital staff to facilitate discharge planning and document such plans.
- Work collaboratively with facility medical and behavioral health professionals to facilitate treatment plans.
- Coordinate continuity of care post discharge.
- Identify and refer Members requiring care management services.
- Monitor adherence to treatment plans.
- Monitor and facilitate any medically necessary continued stays or services.
- Identify potential Member quality of care issues.
Concurrent review is performed upon initiation of care through discharge. Clinical review with the facility’s utilization review/quality improvement department or rendering provider is conducted. Concurrent review is initiated for:
- All admissions to an acute care hospital, acute psychiatric hospital/unit, intensive outpatient programs/ mental health and substance use disorders, long-term acute care hospital (LTACH), partial hospitalization/Mental health and substance use disorders, rehabilitation hospital, residential treatment center (RTC) or skilled nursing facility.
- Services that require submission of a treatment plan and selected ongoing outpatient services.
A UM clinician will review the Member’s medical record or treatment plan to evaluate the continued Medical Necessity and appropriateness of treatment as well as the Member’s treatment response. Subsequent reviews are performed periodically to evaluate the Medical Necessity and appropriateness of continuation of the higher level of care and/or ongoing services.
Discharge planning
Discharge planning is performed for inpatient services and/or higher levels of care and begins with the initial review. Our UM Clinicians(s) will coordinate the Member’s discharge from a facility, or higher level of care, arrange for alternative services, and discuss treatment options with the Member and Member’s physician as appropriate. Areas of assessment include:
- The Member’s living arrangements prior to admission to an inpatient facility.
- The expected living arrangements/home environment after discharge.
- Others available to assist at home.
- Psychosocial/financial status of patient.
- Assessment of local delivery system.
- Benefit coverage.
- Comorbidities.
- Member’s physical disabilities.
- Need for special medication, equipment, and other ancillary supports.
- Level of skill required.
- Aftercare and/or alternative treatment services.
If a Member has discharge planning needs and the Provider has not already been contacted by a UM Clinician, please call Our clinical management team at 1.800.471.2242 and a member of our team will be available to assist the Provider or the facility staff.
Utilization management timeframes
Review type
|
Product
|
Decision and notification
|
|
Non-urgent preservice
- Standard Outpatient PA (medical and behavioral health, i.e., TMS, ABA services)
- IP Elective Standard
- Standard Medical Specialty Drug
- Standard Subsequent Medical Specialty Drug
- Standard Outpatient Subsequent
|
Commercial, Exchange, Managed Care Medical Specialty Drug
|
Notification to provider of missing information ASAP, but no later than 48 hours from receipt of the request.
Decision within 2 business days, but not more than 72 hours of receiving the request.
Verbal notification to provider of denials within 2 business days, but not more than 72 hours of receiving the request.
Written notification within 2 business days, but not more than 72 hours.
|
|
CHIP Medical Specialty Drug
|
Notification to provider of missing information ASAP, in advance of decision time frame.
Decision within twenty-four (24) hours of receiving the request.
Verbal notification within twenty-four hours (24) hours of receiving the request.
>Written notification within twenty-four (24) hours.
|
|
Medicare Medical Specialty Drug
|
Decision for medical injectables within seventy-two (72) hours of the request.
Verbal notification for medical injectables to member and provider for denials within seventy-two (72) hours.
Written notification within seventy-two (72) hours.
|
|
CHIP
|
Notification to provider about missing information must occur ASAP but no later than 48 hours from the receipt of the PA request.
Decision must occur within two (2) business days.
Verbal notification to provider of approvals and denials within two (2) business days of receipt of the request.
Written notification within two (2) business days.
|
|
Commercial, FEP, Exchange, and Managed Care
|
Notification to provider about missing information must occur ASAP but no later than forty-eight (48) hours from the receipt of the PA request.
Decision within fifteen (15) calendar days.
Verbal notification to provider of denials within fifteen (15) calendar days.
Written notification within fifteen (15) calendar days.
|
|
Medicare Advantage
|
Decision within seven (7) calendar days.
Verbal notification to member and Provider of denials within seven (7) calendar days.
Written notification within seven (7) calendar days.
|
| |
|
Urgent preservice
- Expedited Outpatient PA (medical and behavioral health, i.e., TMS, ABA services)
- IP Elective Expedited
- Expedited Medical Specialty Drug
- Expedited Subsequent Medical Specialty Drug
- Expedited outpatient subsequent
|
CHIP, Commercial, Exchange, FEP, Managed Care and Medicare Advantage Specialty Injectable Medication.
|
Notification to provider of missing information ASAP, in advance of decision time frame.
Decision within twenty-four (24) hours of receiving the request.
Verbal notification within twenty-four (24) hours.
Written notification to member and provider within twenty-four (24) hours.
|
|
CHIP
|
Notification to provider about missing information must occur ASAP but no later than forty-eight (48) hours from the receipt of the PA request.
Decision within two (2) business days.
Verbal notification to provider of all decisions within two (2) business days.
Written notification within two (2) business days.
|
|
Commercial, Exchange, and Managed Care
|
Notification to provider about missing information must occur ASAP but no later than forty-eight (48) hours from the receipt of the PA request.
Decision ASAP but within seventy-two (72) hours.
Verbal notification to provider of all decisions within seventy-two (72) hours.
Written notification of approvals and denials within seventy-two (72) hours.
|
|
Medicare
|
Decision for within seventy-two (72) hours of request.
Verbal notification to member and provider for all decisions within seventy-two (72) hours.
Written notification within three (3) days from the verbal notification.
|
| |
|
Concurrent
- Emergent-admission
- Continued Stay
**For inpatient stays, Provider notifies the member.
|
CHIP
|
Notification to provider about missing information must occur ASAP but no later than 48 hours from the receipt of the request.
Decision within two (2) business days of receipt of the request.
Verbal notification to provider of all decisions within two (2) business days.
Written notification within two (2) business days.
|
|
Commercial, Exchange, and Managed Care
|
Notification to provider of missing information ASAP, in advance of decision time frame.
Decision within twenty-four (24) hours of receipt of the request.
Verbal notification to provider of all decisions within twenty-four (24) hours.
Written notification of approvals and denials within 3 calendar days following verbal, IF we spoke to a live person for verbal. If no live person, due within twenty-four (24) hours.
|
|
Medicare
|
Decision within seventy-two (72) hours.
Verbal notification to member and provider for all decisions within seventy-two (72) hours.
|
| |
|
Post Service
- Post Service
- Retrospective
|
All products
|
Decision within thirty (30) days.
Verbal notification not required.
Written notification within thirty (30) days.
|
Population health management
Capital Blue Cross’ Population Health Management (PHM) program/strategy is a model for care that addresses the health and social needs of individuals at all points during the continuum of care. This continuum includes the community setting, through participation, engagement, and targeted interventions for a defined population. The program is structured on the Institute for Health care Improvement (IHI) Triple Aim concept, which has three main objectives: improve patient experience of care, improve the health of the population, and reduce per capita cost of health care. The goal of Capital’s PHM strategy is to maintain or improve the physical and psychosocial well-being of individuals and address health disparities through cost-effective and tailored health solutions that address social determinants of health (SDoH). Capital Blue Cross’ PHM program identifies and stratifies Members into one of four categories – healthy, rising risk, multi-chronic, or catastrophically ill. At each stage, We provide appropriate educational and clinical services to improve the Members’ health and quality of life.
Care management programs
Our care management programs are proactive and designed to provide a whole person approach that addresses unstable chronic, and/or complex/catastrophic medical and behavioral health needs and Members who could benefit from additional support with coordinating their care.
Programs include, but are not limited to:
- Complex care management.
- Chronic condition/disease management.
- Maternity management.
- Oncology care management.
- Outreach programs.
- Social Work programs to support complex Social Determinants of Health.
- Transitions of care.
- Transplant care management.
- Behavioral Health, including Substance Use Disorders.
Complex care management
The complex care management program is an interdisciplinary service encompassing a wide variety of resources, information, and specialized assistance for Members:
- With complex medical and behavioral health needs.
- At risk for future adverse health events.
The complex care management resources help Members manage complex health needs through whole person care coordination of care and services to improve Member quality of life.
Chronic condition/disease management
The chronic condition/disease management program is an interdisciplinary, collaborative program that assesses the health needs of chronic conditions using a whole person care model. Capital Blue Cross Care Managers utilize Milliman care guidelines and preventative guidelines, providing customized Member education, counseling, and support to increase the Member’s ability to self-manage their condition(s).
The program has many areas of concentration, however whole person care, self-management action plans, education, knowledge enhancement, and medication optimization and adherence are of particular importance.
Conditions addressed in the program may include, conditions related to the following systems: Cardiovascular, Pulmonary, Diabetes, Renal, Musculoskeletal, Gastroenterology and Behavioral Health conditions, along with pediatric condition management.
Maternity management
We offer a comprehensive maternity management program which provides education, care coordination, materials, and support to pregnant women. Registered nurses, experienced in all phases of pregnancy and delivery, provide assessment, education, and support to Members identified with high-risk pregnancies.
The focus of the maternity management program is to help pregnant Members have a healthy pregnancy and baby through a variety of interventions, based upon population and individual needs.
Oncology care management
Registered nurses, experienced in cancer care and advanced care planning, provide assessment and support to Members at all stages of adjustment to a cancer diagnosis.
Transplant care management
Registered nurses experienced in transplant care provide assessment, education, and support during the transplant process. Core goals of this program include education and support regarding treatments, medical benefit plan, and Blue Distinction® Centers for Transplants.
Behavioral health
The behavioral health program helps Members with behavioral health and substance use disorder care needs obtain the right services, skills, and support needed to achieve optimal health and life functioning in the community.
Transitions of Care (TOC)
The transitions of care program assist Members in understanding their post-discharge treatment plan and thereby helps prevent avoidable complications and readmissions.
Capital Blue Cross’ comprehensive transition of care program includes:
- Capital Blue Cross Transitions of Care Management Program: Every discharge from any level of in patient setting, will receive a TOC referral (exclusions: Member is discharged to a custodial/extended care setting) and receive a care management telephonic visit weekly for four weeks. This visit addresses whole person care by assessing various issues, such as:
- Medication reconciliation.
- Health literacy.
- Social Determinants of Health (SDoH) assessment.
- Care Coordination.
- Screening for resource concerns, etc.
- Capital Blue Cross Partnering with Health Systems: Includes outreach to health systems, as appropriate, to review quality indicators and collaborate with health care systems to innovate ways in which Capital Blue Cross and hospital systems can unite in one common goal, the health and well-being of Our Members and patients.
- As part of the care management program, we offer assistance with:
- Discharge planning.
- Assessment and integration of service for ongoing needs.
- Coordination with medical and behavioral health services.
- Collaboration with healthcare Providers and caregivers.
- Providing information about what benefits might be available.
- Medication education and monitoring.
- These initiatives are additional investments by Capital Blue Cross designed to:
- Ensure whole person care.
- Support the Provider’s quality and financial performance in Our value-based programs.
- Allow for goal-based care – which may include asking Providers to support Member engagement into one of Our clinical programs.
- Augment Our commitment to prevent avoidable readmissions, thus improving the Member’s health and minimizing the financial impact of Our avoidable readmission reimbursement policy that applies to Our Providers.
Additional information can be found in the Member resources section on Our website at CapitalBlueCross.com.
Providers may refer a Member that may be a candidate for care management by calling 1.888.545.4512. Referrals can also be made via the Health Program Information page on Our website at CapitalBlueCross.com or by email at CareMgmt@capluecross.com.
Behavioral health initiatives
Our Behavioral Health Initiatives are driven by nationally recognized quality standards. To evaluate clinical quality, Capital Blue Cross relies on the NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®). Some of the Behavioral Health measures include:
- Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics.
- Follow-Up After Emergency Department Visit for Mental Illness.
- Follow-Up After Emergency Department Visit for Substance Use.
- Follow-Up After Hospitalization for Mental Illness.
- Initiation and Engagement of Substance Use Disorder Treatment, Engagement of SUD Treatment.
- Follow-Up After High Intensity Care for Substance Use Disorder.
These initiatives aim to educate Members and Providers about the benefits of medication adherence and follow-up for behavioral health medications, which can be sent as targeted reminders encouraging patients to follow Provider recommendations for medications and have appropriate follow-up visits. Education also focuses on, but is not limited to, follow-up after hospitalization for mental illnesses and improving insight and access to treatment services. Initiatives are primarily shared via digital platforms for privacy reasons.
For additional quality initiatives, see Chapter 5: Clinical, Care and Quality Management, Unit 4: Quality Improvement.
Continuity and coordination between behavioral and medical health care
As part of care coordination activities, Providers must identify all Providers involved in the medical and/or behavioral health care and treatment of a Member to improve the coordination between medical care and behavioral health care. The following guidance specifies when an exchange of information is expected to occur between behavioral health Providers (with Member’s written consent) and Our Member’s personal Provider:
- After initial evaluation
- When significant change in patient status, treatment, or diagnosis occurs
- When medications are initiated or changed
- No less than annually for Members receiving ongoing treatment with no change in treatment or medications
Evidence of communication between the behavioral health Provider and Our Member’s personal Provider is expected to exist in the behavioral health Providers’ chart.
Subject to any required consent or authorization from the Member, Providers are expected to coordinate the delivery of care to the Member with other identified Providers but AT LEAST the primary care physician. All coordination, including PCP coordination, must be documented in the Member treatment record including, but not limited to, the following:
- Exchange of information.
- Appropriate diagnosis, treatment, and referral of behavioral disorders.
- Use of psychotropic medications.
- Management of treatment access and follow-up for Members with coexisting medical and behavioral disorders.
- Primary or secondary preventive behavioral health care program referral or participation, if known.
- Needs of Members with serious mental illness or serious emotional disturbance.
Member authorization consent forms are available through the website.
Behavioral health care management system
Members and participating Capital Blue Cross Providers may access the care management system through any of the following avenues:
- 24-hour toll-free emergency care/clinical referral line.
- Direct authorization of care through Provider Connect for Providers.
- Direct authorization of all levels of care through referral by a care manager.
- Emergency services through freestanding psychiatric hospitals, medical hospitals with psychiatric units, emergency rooms, or crisis response teams.
If a call is received from a Member requesting a referral and/or information about Providers in the Member’s location, care managers may conduct a brief screening to assess whether there is a need for urgent or emergent care. Referrals are made to Providers, through the care manager taking into account Member preferences such as geographic location, hours of service, cultural or language requirements, ethnicity, type of degree the Provider holds and gender. Additionally, the Member may require a clinician with a specialty (such as treatment of eating disorders). In all cases, where available, the care manager will assist in arranging care for the Member. The name, location, and phone number will be given to the Member.
Provider dispute resolution
Your Provider Agreement supersedes the below information if it contains specific dispute resolution or appeals language.
Commercial products overview
We maintain appeal and grievance processes in accordance with the provisions of, as applicable:
- Pennsylvania Act 68 of 1998, and
- Pennsylvania Act 146 of 2022.
Our Point-of-Service and Commercial HMO products are managed care products subject to provisions of Act 68. Act 68 distinguishes between disputes regarding Medical Necessity and appropriateness determinations (referred to as “grievances”) and disputes regarding Participating Providers, coverage, operations, or management policies of a managed care plan (referred to as “complaints”). We comply with Act 68, as well as the claim regulations of ERISA, (Employee Retirement Income Security Act, Department of Labor), when considering Member complaints and grievances.
- Department of Health Regulations for Managed Care.
- Patient Protection and Affordable Care Act.
- Capital Blue Cross Medicare Advantage regulations.
- Department of Labor’s Employee Retirement Income Security Act (ERISA) claims regulations and National Committee for Quality Assurance (NCQA) standards.
A Provider or a Member may request an appeal of an adverse benefit determination for which they disagree with the outcome. If the Provider is appealing on behalf of a Member they must provide a completed Authorization of Designated Appeal Representative (ADAR) form. The ADAR form can be found in the Provider Library under Provider forms via Our Provider Portal. The ADAR form is explained in more detail later in this chapter. If an appeal is submitted by both the Provider and the Member, the Member’s appeal rights will take precedence over those of the Provider. We will not process duplicative Member and Provider appeals arising from a single benefit determination.
An ADAR form from the member’s HOME plan must be used for a BlueCard claim when submitting on the Member’s behalf.
CHIP products overview
A completed CHIP consent form and the reason for the appeal are required when the CHIP member/head of household or a Provider acts on behalf of the CHIP member. Please see the CHIP Consent form
Administrative claim reviews
Administrative Claim Review Definition: A dispute of a claim adjudication not able to be submitted as a claim adjustment, and unrelated to Our Medical Necessity criteria. For example, untimely claim filing, failed preauthorization reviews, contractual pricing, or billing disputes.
Administrative Denial Definition: A denial of preauthorization, coverage or payment based on a lack of eligibility, failure to submit complete information or other failure to comply with an administrative policy.
Medical necessity appeals
Medical Necessity Appeal Definition: A dispute of a service or item that failed to meet Medical Necessity criteria within Our medical policies.
In some circumstances, We will determine that a service fails to satisfy Our Medical Necessity criteria. In advance of submitting an appeal, providers can request a Peer to Peer Review after Capital Blue Cross's initial authorization adverse determination. These reviews involve a telephone conversation with the attending or primary care provider and a Capital Medical Director.
To request a Peer to Peer Review, the provider should complete the Peer to Peer form located in the Forms section of the Provider Library on the “Resources” tab on Our Provider Portal.
- For Commercial, Exchange, Managed Care members – request should be made within 180 days of receiving an adverse determination and in advance of submission of an appeal.
- For CHIP members – requests should be made within 60 days of receiving an adverse determination and in advance of submission of an appeal.
When determinations are made that a service fails to satisfy Our Medical Necessity criteria, a Provider may submit an appeal; however, the following condition must be met:
- Members must be held harmless for any services that were the subject of the adverse determination of Medical Necessity. The only exception to this Member hold harmless requirement is if the Member acknowledged and accepted financial responsibility in writing prior to receiving the non-Medically Necessary service in accordance with Our policies.
External Review for Post Services – The right for an external review is available to Medical Necessity appeals only after the first level review has been completed. To file a request for an external review, you must submit the request for external review no later than 60 calendar days after We have notified you of its final decision. Additionally, you must remit payment of a filing fee in the amount of the greater of $250 or five percent of the amount in dispute, up to a maximum filing fee of $500. We will refund the filing fee if the external review decision is in favor of the Provider.
- The Provider External Review Form must be completed and filed along with the appeal, documentation for consideration and a check for the filing fee upon submission. Requests received without the appropriate documentation will be returned without a review. The form is available in the Forms section of the Resource Center on Our health plan home page on Our Provider Portal.
Preauthorization disputes
Failure to Request Preauthorization – For services that require preauthorization, if a Provider fails to request preauthorization or fails to follow Capital Blue Cross’ procedures for requesting preauthorization, a Participating Provider may not file an appeal and must hold the Member harmless.
In accordance with PA Act 146, in order for Capital to consider payment of a closely related services(s), Capital Blue Cross providers must notify Capital or our appropriate vendor(s) within 15 calendar days of the completion of the closely related service(s) AND in advance of submitting the claim. This notification should follow standard UM submission processes and must include all relevant clinical information to allow review for Medical Necessity.
What qualifies as a “closely related service(s)”?
A Health care service that is closely related in purpose, diagnostic utility, or designated health care billing code is provided on the same date as an authorized service.
Of note: All hip, knee, shoulder & spine surgical, and limited scope cardiac surgical Post Service Reviews must be submitted to TurningPoint. To request a Post Service Review, the Provider will need to complete a Post Service Review form. The completed form, cover sheet, and applicable surgical operative note can then be faxed to TurningPoint at 1.717.412.1001.
There are few instances where Capital Blue Cross will continue to review a claims adjudication showing preauthorization was not obtained. These instances include:
- Services performed in an emergency situation.
- Incorrect benefits provided via web-tools or Provider Services.
- Inability to obtain preauthorization due to Other Party Liability.
- No coverage at the time of service but was retroactively reinstated prior to the date of service.
Dispute submission timeframes
Provider administrative claim reviews and Medical Necessity appeals must be submitted in writing within 180 calendar days following the date the Provider is given notice via a Statement of Remittance (SOR) that a claim was reduced or denied payment.
If disputing a claim timeframe’s possible exceptions could be as listed below:
For Coordination of Benefit situations when the claim is filed to another carrier as primary, we will review to determine if good cause for not disputing within 180 days from when the Provider is given notice.
If the claim is submitted to us as secondary, it must be filed no later than 180/365 days from the other carriers notice. See claim filing guidelines in Chapter 6, Unit 1 to determine applicable timeframes based on provider type.
The timely filing dispute must be received within 180 days from when the Provider receives our timely filing denial and as long as proof is supplied showing the other carriers notice, we will review for good cause consideration.
Dispute review timeframe
We will review your dispute within 60 calendar days following the date of receipt of a complete written Medical Necessity appeal or administrative claim review. A written request will be “complete” only when the documentation includes all the information necessary for Us to meaningfully review its prior decision. If you fail to supply additional information within 14 days of Our request, We will deem your dispute withdrawn and it will be dismissed.
Upon receipt of all required information, We will review Our prior decision. We will send the written decision to you within 60 calendar days of Our receipt of a complete written appeal.
How to submit a dispute/appeal
A Provider Dispute Form or the Provider BlueCard Claim Appeal Form is required to be submitted with all administrative claim reviews and Medical Necessity appeals requests for Capital Blue Cross members and members of other Blue Plans. Any dispute submitted without either of the required forms will be returned with no review actions completed. Both the Provider Dispute Form and the Provider BlueCard Claim Appeal Form can be found on the Capbluecross.com provider page.
The request must include the following information:
- A Provider Dispute Form or the Provider BlueCard Claim Appeal Form with all fields completed.
- An explanation of the issue being disputed.
- Documentation to support the dispute:
- Medical records (performing or referring Provider as appropriate).
- Other insurance Explanation of Benefits.
- Any other documentation to support the dispute.
Mail or Fax Appeals to:
AGR Dept – Provider Unit Capital Blue Cross PO Box 779518 Harrisburg, PA 17177-9518 Fax: 717.541.6915 (fax appeals Monday - Friday only).
Note: If an appeal is being faxed and it contains 1-250 pages it must be faxed in increments of 50 pages each. Include either the Provider Dispute Form or the Provider BlueCard Claim Appeal Form and appeal letter with each fax. On the fax cover sheet, indicate 1 of 3, 2 of 3, etc.
An Appeal containing over 250 pages must be mailed via a CD (please include any security passcodes in the package with the CD).
Member appeals
When We make an adverse benefit determination, We will provide the Member with a Notice of Adverse Benefit Determination. For a complete description of the appeal rights available to the Member, please see the Notice of Adverse Benefit Determination.
A Provider may dispute adverse benefit determinations on behalf of a Member. In order for a Provider to appeal on behalf of a Member, the Provider and the Member must complete—in its entirety—the Authorization of Designated Appeals Representative (ADAR) Form, available in the Resource Center on Our Provider Portal. A Provider Claim Appeal is not needed when the ADAR form is submitted.
The ADAR form must be signed correctly by both the Provider and the Member. Supporting documentation should be included, if necessary.
The written appeal should be submitted using the Member Appeal Form, which has an ADAR form attached for convenience. Both forms are available in the Resource Center on Our Provider Portal.
Please note: A completed CHIP consent form is required when the CHIP member/head of household selects an appeals representative to act on their behalf. The CHIP Consent form along with the Dispute form must be completed when a Provider submits their CHIP appeal. Please see the CHIP Consent form located in Our Provider Library under Forms.
Expedited member appeal
An expedited appeal is available only under emergency situations. In cases of preservice denials, the Provider may request an expedited appeal when application of a standard appeal review period could place the Member’s life, health, or ability to regain maximum function in jeopardy. The identification of the emergency medical circumstances necessitating an expedited appeal must be submitted in writing or verbally by the Provider submitting the appeal.
Internal member appeal process
If a Member disagrees with Our adverse benefit determination, the Member, or authorized representative, may seek internal review of that determination by submitting a written appeal. The appeal should include the reason(s) the Member disagrees with the adverse benefit determination, and be submitted on the Member Appeal Form, available in the Resource Center on Our Provider Portal.
The appeal must be received by Us within 180 days after the Member received notice of the adverse benefit determination.
The Member may submit written comments, documents, records, and other information relating to the appeal of the Notice of Adverse Benefit Determination. Upon receipt of the appeal, We will provide the Member with a full and fair internal review. The Member may receive information on the internal review process, and is entitled to receive additional information including copies, free of charge, of any internal policy, rule, guideline, criteria, or protocol which We relied upon in making the adverse benefit determination.
External member appeal process
A Member may request an external review by an Independent Review Organization (IRO) of a Final Internal Adverse Benefit Determination that involves an issue of Medical Necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, as well as any rescission of coverage.
For members of a group health plan subject to ERISA. In order to request an external review, the Member must submit the Member Appeal Form within 120 days from receipt of the Notice of Final Internal Adverse Benefit Determination. We will forward the documentation pertaining to the denial to the IRO assigned.
Members who do not agree with the Final Internal Adverse Benefit Determination have the right to bring a civil action under Section 502(a) of ERISA.
For Commercial, Exchange, and Managed Care: Within four (4) months of receipt of Notice of Final Internal Adverse Benefit Determination, the Member may file a request for external review through the Bureau of Health Coverage Access, Administration, and Appeals (HCA3) online at https://www.insurance.pa.gov/externalreview.
A Member may also complete a Request Form and submit it via Fax: 717.231.7960 or Email: RA-IN-ExternalReview@pa.gov, or by mail at:
Pennsylvania Insurance Department Attn: Bureau of Health Coverage Access, Administration and Appeals (HCA3) 1311 Strawberry Square Harrisburg, PA 17120
If the request is determined eligible for external review, HCA3 will assign an Independent Review Organization (IRO) to review the case.
Member may request an expedited review if any of the following situations apply:
- Member has a medical condition for which the time frame for completion of a standard external review would seriously jeopardize their life or health or would jeopardize their ability to regain maximum function.
- The denial concerns an admission, availability of care, or continued stay or healthcare service for which they received emergency services but have not been discharged from the facility in which they received emergency services.
- The denial is based on a determination that the recommended or requested healthcare services are experimental or investigational and the treating healthcare provider certifies in writing that the recommended or requested healthcare services would be significantly less effective if not promptly initiated.
Capital Blue Cross Medicare Advantage: Disputes
We established grievance and appeals procedures in accordance with applicable federal laws and regulations. Our grievance and appeals procedures do not create any contract rights, whether expressed or implied, in favor of a Provider who is not a signatory to the Provider Agreement. In addition to the dispute resolution and Provider appeals provisions in this section, specific provisions relating to Capital Blue Cross Medicare Advantage Members are described below.
We provide Capital Blue Cross Medicare Advantage Members with written information about the grievance and appeals procedures. We are ultimately responsible to ensure Our Participating Providers cooperate with and abide by Our grievance and appeals procedures including, upon request, the Provider’s gathering and forwarding of information to Us within required timeframes.
Capital Blue Cross Medicare Advantage: Definition of an appeal
An appeal is a request for reconsideration of an adverse organizational determination (defined by CMS as a health plan’s decision to deny, discontinue, or reduce services or payment, in whole or in part). A Member may file an appeal regarding any decision such as Our failure to approve, furnish, arrange for, continue, or pay for health care services that the Member believes he or she is entitled to receive under Capital Blue Cross Medicare Advantage.
An expedited appeal process is available to Members for time-sensitive situations. If a Member requests an expedited appeal, We must provide an expedited reconsideration if it is determined that applying the standard timeframes could seriously jeopardize the life, health, or safety of the Member or the Member's ability to regain maximum function or if the Member would be subject to severe pain that cannot be adequately managed without the care or treatment. For a request made by or supported by a physician (participating or non-participating), We must provide an expedited reconsideration if the physician requests it and/or indicates that applying the standard timeframe could seriously jeopardize the life, health, or safety of the Member or the Member's ability to regain maximum function or if the Member would be subject to severe pain that cannot be adequately managed without the care or treatment.
A Member must request an appeal within 60 calendar days of the adverse determination. Any of the procedures that deal with the review of adverse organization determinations on the health care services an enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the enrollee), or on any amounts the enrollee must pay for a service as defined in 42 CFR 422.566(b). These procedures include reconsiderations by the Medicare health plan and, if necessary, an independent review entity, hearings before Administrative Law Judges (ALJs), reviews by the Medicare Appeals Council (MAC), and judicial review.
Capital Blue Cross Medicare Advantage: Appeal processing
We process all appeals regarding requests for service as expeditiously as the Member’s health requires, but no later than 30 calendar days after receipt of a Part C appeal. We process preservice Part B drug appeals and preservice appeals under Medicare Part D Prescription Drug Coverage (Part D) regarding requests for service as expeditiously as the Member’s health requires, but no later than seven calendar days after receipt of the appeal for pre-service requests. Appeals regarding requests for payment are processed within 60 calendar days of receipt of a Part C appeal and/or Part B drug appeals. Part D appeals involving payment are processed within 14 calendar days of receipt. All redeterminations are made by one or more people not involved in the original decision. Reconsideration of an adverse determination based on Medical Necessity will include a review by a licensed physician or licensed psychologist with appropriate expertise in the field of medicine appropriate for the service at issue. When a favorable decision is made on an appeal request, the requested service is provided or authorized within 30 calendar days of receipt of the Part C appeal for a service appeal or is paid within 60 calendar days of receipt of a Part C payment appeal.
When a favorable decision is made on a Part D standard pre-service appeal request, the requested service is provided or authorized as expeditiously as the Member’s health requires, but no later than seven calendar days after receipt of the appeal request. For expedited Part D appeal requests, the requested service is provided or authorized as expeditiously as the Member’s health requires, but no later than 72 hours after receipt of the appeal request. In regard to Part D payment requests, We must authorize payment no later than 30 days after the date of the receipt of the appeal request.
If We uphold the original adverse decision, either in whole or in part, or if a decision is not provided within the required timeframes, the appeal is automatically forwarded by Us to the Independent Review Entity (IRE) contracted by CMS to provide independent second-level reviews.
Please Note: If We uphold the original adverse decision in a Part D prescription drug coverage appeal, the appeal is not automatically forwarded to the IRE; a request must be initiated by the Member or the Member’s authorized representative.
If the IRE decides in favor of the Member, We must comply with the decision. Service requests must be authorized within 72 hours of the IRE’s decision or provided as expeditiously as the Member’s health condition requires. Payment requests must be paid no later than 30 calendar days after notification of the IRE’s decision. If the IRE does not rule in favor of the Member, the IRE notifies the Member of the further levels of appeal.
Capital Blue Cross Medicare Advantage: Expedited appeal process – IRE
An expedited appeal process is available to Members for time-sensitive situations.
Expedited appeal decisions are made as quickly as the Member’s health condition requires, but no later than 72 hours after receiving the request. If We uphold the initial denial, the case is forwarded to the IRE for an independent second review within 24 hours of the decision. The IRE notifies all appropriate parties with its determination.
- Please Note: If We uphold the original adverse decision in a Part D prescription drug coverage appeal, the appeal is not automatically forwarded to the IRE; a request must be initiated by the Member or the Member’s authorized representative.
Expedited appeals may be filed verbally; however, We encourage the submission of written appeals with supporting clinical documentation.
Capital Blue Cross Medicare Advantage: Expedited review of termination of inpatient care
A Member and/or Member’s authorized representative may request an immediate review by the Quality Improvement Organization (QIO), contracted by CMS to provide independent reviews, in the event of Member liability for termination of coverage of inpatient hospital care (including psychiatric and rehabilitation) and the Member decides to stay in the hospital. The QIO will return a decision within one business day after all information is received.
We must provide payment for continued services until the decision is made. If the Member misses the deadline for this review, the beneficiary may remain in the hospital past the discharge date; however, the beneficiary may be charged for any services provided after the discharge date. If the QIO agrees the beneficiary should not have been discharged, any funds collected will be refunded. Beneficiaries who miss the deadline and leave the hospital continue to have the right to request a QIO review within 30 calendar days of the date of discharge.
Capital Blue Cross Medicare Advantage: Expedited review of termination of home health, SNF, or OP rehab
The Member and/or Member’s authorized representative have the right to a “fast-track” appeal of a Participating Provider’s decision to terminate services provided by home health agencies, skilled nursing facilities, and comprehensive outpatient rehabilitation facilities. The Member or Member’s representative must contact the designated QIO by noon of the first day after delivery of the termination notice from the Provider or no later than two days before the termination of services. The QIO will contact Us to provide information to assist in the decision making process. If the appeal request is not made to the QIO within the required timeframe, an expedited reconsideration can be requested.
Capital Blue Cross Medicare Advantage: Rules of participation changes
Capital Blue Cross Medicare Advantage participating physicians have the right to appeal changes to Capital Blue Cross Medicare Advantage Rules of Participation that are deemed as having an adverse effect on the physician. We define Capital Blue Cross Medicare Advantage Rules of Participation as credentialing criteria and terms of payment. Should you wish to appeal changes to Capital Blue Cross Medicare Advantage Rules of Participation, please contact your assigned Provider Engagement Consultant or contact Provider Services.
Blue Cross and Blue Shield Federal Employee Program®: Provider appeals
A Provider Appeal may only be filed by the Provider who is liable for the charge or service.
Provider administrative claim reviews and medical necessity appeals must be submitted in writing within 180 calendar days following the date the Provider is given notice via a Statement of Remittance (SOR) that a claim was reduced or denied payment.
Provider Appeals must be in writing on either Provider Dispute Form or the Provider BlueCard Claim Appeal Form and may be mailed or faxed to:
FEP Capital Blue CrossPO Box 773736Harrisburg, PA 17177-3736 Fax: 717.651.1824 (fax appeals M-F only)
Note: If an appeal is being faxed and it contains 1-250 pages it must be faxed in increments of 50 pages each. Include either the Provider Dispute Form or the Provider BlueCard Claim Appeal Form and appeal letter with each fax. On the fax cover sheet, indicate 1 of 3, 2 of 3, etc.
An Appeal containing over 250 pages must be mailed via a CD (please include any security passcodes in the package with the CD.
Note: Exception – under certain circumstances a provider may file an urgent, expedited, or priority appeal. There must be an urgent or emergency situation that requires immediate attention, i.e., it is the doctor’s belief that the patient’s health is in jeopardy and cannot wait for the standard appeal time frames.
Members cannot appeal Provider liable charges. Providers cannot appeal Member liable charges without the Member’s express written consent. When a Member has a power of attorney or custodial arrangement, the Provider must obtain written authorization from that entity.
- The Member or Provider can print FEP’s Authorized Designation of Representative (ADR) form from FEP’s website: Authorized_Representative_Designation Form_2018.pdf (fepblue.org).
- FEP only accepts the ADR form when it has been completed and signed by both:
- The person filing the reconsideration on the Member’s behalf, i.e., provider, spouse, other family Member, etc., and
- The Member or the power of attorney.
An ADR form is only valid for the current reconsideration. It may not be used again for future reconsiderations. A new ADR must be obtained for each and every reconsideration request filed on the Member’s behalf.
Quality Improvement Program (QIP) overview
Our Quality Improvement Program (QIP) provides a formal structure and process to monitor and evaluate the quality and safety of care and services provided to Our Members. Capital implements a continuous quality improvement cycle where designated staff conduct measure and analysis of key performance indicators; assess and prioritize the indicators; and plan, implement, and subsequently evaluate those interventions to further improve and enhance the quality of care, quality of service, patient safety, and Member experience. Participating Providers have an important role in Our QIP. Providers must cooperate with Capital’s quality improvement activities to improve the quality of care and services and Member experience.
Providers furnish valuable input to QIP design and other activities both through participation in quality improvement committees and through suggestions from individual Providers and staff. Providers with suggestions for quality improvement activities or who are willing to participate in Our quality committees should contact Our Population Health Management Department at 717.703.8401. Providers may also obtain additional information about Our QIP and may request a report on Our progress in meeting Our QIP goals by contacting Our Population Health Management Department at the above telephone number.
Performance data use
Capital Blue Cross relies on its provider’s cooperation as part of Our ongoing NCQA accreditation process. As a condition of Capital’s accreditation status, Capital must be able to use provider and facility performance data in activities including quality improvement, population health management, public reporting to consumers, and network designation. Examples may include Health care Effectiveness Data and Information Set (HEDIS®) data reporting, Consumer Assessment of Health care Providers and Systems (CAHPS®), transparency reporting, and provider incentive programs. All data are managed in accordance with state and federal requirements for protected health information (PHI).
QIP goals and objectives
Capital’s Quality Improvement Program (QIP) encompasses all aspects of care and service provided to Capital’s Members. It is based on the principles of continuous quality improvement and is implemented to improve the quality, safety, and cost effectiveness of clinical care and services, as well as Member and provider experience in care delivery. Performance is designed with Members, providers, employers, and vendors in mind. Capital Blue Cross’ QIP promotes objective and systematic monitoring, evaluation, and improvement of health care services while taking into consideration the cultural, linguistic, and complex health needs of the population. In addition, Capital is committed to improving the Member’s health equity, reduce disparity, and will take necessary actions to promote equity in health management for the Member. The focus of this framework is on motivating and building the will for change; identifying and testing new models of care; working with Members, vendors, and health care professionals; and ensuring the broadest possible adoption of best practices and effective interventions.
The goals of the QIP are:
- Improving Member health and experience of care while providing the best value for the population through processes that support ongoing quality improvement.
- Assessing social determinants of health of Our Members, i.e., economic and social conditions that affect a wide range of health, functioning, and quality of life outcomes and risks.
- Measuring quality and outcomes through trending and analysis of quality improvement activities compared to performance goals and/or recognized benchmarks.
- Focusing on population health management that addresses all Members’ health needs across the continuum of care.
- Maintaining NCQA accreditation.
- Identifying improvement opportunities using the Plan, Do, Study, Act (PDSA) cycle.
- Coordinating Member programs and services across all levels of care.
- Facilitating of appropriate accessibility and availability of care and services, including the cultural, racial, ethnic, and linguistic needs and preferences of our membership; assessment of the availability of high-volume and high-impact Providers and web access to health plan services.
- Improving Member experience; implementing of effective interventions to address areas of dissatisfaction through processes including, but not limited to, conducting and analyzing Member surveys and analyzing and trending Member complaint and appeal data.
- Achieving and maintaining compliance with all Federal and State regulatory requirements as well as appropriate accrediting bodies; i.e., National Committee for Quality Assurance (NCQA), Affordable Care Act (ACA), Centers for Medicare & Medicaid Services (CMS), Pennsylvania Department of Health (DOH), PA Department of Health and Human Services (DHS), Pennsylvania Insurance Department (PID), FEP, and Employee Retirement Income Security Act of 1974 (ERISA).
- Monitoring of vendors and delegated activities for compliance with State and Federal regulations, NCQA, and Capital’s standards. Reduction in unwarranted readmissions through improving continuity and coordination of transitions of care and addressing Members’ complex health needs.
- Integration of quality strategy and communication feedback loops into appropriate functional areas, including, but not limited to population health management, behavioral health, utilization management, pharmacy, Member services, and network management.
Quality improvement information available on our website
Capital houses the quality information listed below in Our Resource Center via the provider portal:
- Clinical Practice Guidelines.
- Health Maintenance Guidelines.
- Medical Record Documentation Guidelines.
- Access to Care Standards.
- Notice of Privacy Practices at CapitalBlueCross.com/HIPAA/.
- Care management program information including how to use the services and how We work with provider’s patients in the program.
You may request a paper copy of any information included on our website by calling 1.866.688.2242.
Committees
Providers can assist Us by, for example, reviewing standards for care, analyzing data, and evaluating Provider participation in the network. Providers also serve on committees to offer input based on clinical and regional practice. The following clinical management committees have Participating Provider representation:
- Quality Improvement Committee (QIC)
- The Quality Improvement Committee (QIC) provides directions and continuous monitoring of the Quality Improvement (QI) initiatives in the areas of clinical care, service, patient safety, and Member and provider experience. The QIC continually strives for excellence and quality in health care delivery and services to the Members, customers, and the community. The participating providers are representatives of specialists in Capital’s network. The viewpoint of these providers who practice in the community can assist Capital with continuous quality improvement efforts to identify opportunities and implement programs that will improve Member safety as well as care and service delivered to the Members. The provider’s background, expertise, and knowledge of the local health delivery system and the characteristics of the population make the local provider an improvement Member of the quality improvement team.
- Utilization Management Committee (UMC)
- The Utilization Management Committee (UMC) is responsible for oversight of Capital’s Utilization Management (UM) Program. This is accomplished through review of UM activities and UM Program outcomes, review of key performance indicators for compliance with regulatory requirements, and oversight of approved medical necessity criteria and medical policies and the services subject to utilization management for both Capital and delegated UM vendors. The UMC also reviews and analyzes member and provider satisfaction with UM programs and processes and trended utilization data.
- Medicare Advantage Utilization Management Committee (MAUMC)
- Specific to Capital’s Medicare Advantage population, the Medicare Advantage Utilization Management Committees (MAUMC) review and approve all coverage criteria used in Utilization Management (UM) determinations by Capital and all delegated UM vendors and/or Capital subsidiaries. Similarly, the MAUMCs are responsible for review and approval of the services to which UM applies. These oversight and approval activities ensure compliance with all applicable CMS requirements.
- Pharmacy and Therapeutics Committee (P&T)
- The P&T Committee is responsible for assessing that Our drug formulary systems and pharmaceutical management programs are based on sound clinical evidence, including objective clinical perspectives from practicing Practitioners, and that there is regular review/update to remain responsive to the needs of Our Members and Providers.
- Credentialing Committee
- The credentialing committee reviews and determines Provider participation in Our networks.
Conflict of interest provisions
No Provider or other individual involved in quality improvement activities will be permitted to review any case in which he/she is professionally involved or has any personal or financial interest.
Safety monitoring
Member safety program
Capital’s Member Safety Program provides a framework to allow swift and appropriate action to be taken when a potential safety event involving one of our members is identified. Additional program components include follow-up on confirmed member safety concerns, interventions and monitoring of provider performance issues, and tracking and trending of data. A cross-functional Member Safety Committee is tasked with oversight of Capital’s Member Safety Program and meets on a monthly basis, or ad hoc for urgent/emergent Potential Member Safety Concerns (PMSC). The Member Safety Committee (MSC) is co-led by a Capital Medical Director and Network Leadership.
Capital is committed to ensuring patient safety. As part of the organization’s commitment to improving safe clinical practice, patient safety is integrated into many of the routine activities Capital performs, such as credentialing and recredentialing and review and monitoring of potential quality issues. Data is analyzed routinely through the Member Safety Committee.
In alignment with regulatory requirements, providers in Capital’s networks should self-report events or incidents regarding Potential Member Safety Concerns (PMSCs), especially Serious Reportable Events (SREs), directly to Capital Blue Cross.
To report PMSCs, a PMSC Reporting Form must be completed. The form is available in the following locations:
- From capbluecross.com, select “Providers” at the top right, then “Out-of-area/network provider resources.”
- On Our provider web portal, from the Capital Blue Cross payer space page, click on the “Resources” tab, then “Provider Forms.
Capital works with Our providers to build action plans to improve the quality of care Our Members receive and avoid future serious events and incidents.
A PMSC is any clinical or system variance warranting further review and investigation to determine the provider's: 1) contribution to a safety or quality issue; or 2) deviation from the standard of care or service. PMSCs include (but are not necessarily limited to):
- Quality of Care (QOC) complaints from a Member or Member advocate.
- Potential Quality Issues (PQIs) that are identified by Internal Capital staff or self-reported by Our providers.
- Initial reports of a Serious Reportable Event prior to the conclusion of an investigation.
The National Quality Forum (NQF) defines a SRE as:
- “Unambiguous, largely, if not entirely, preventable, serious, and any of the following: adverse; indicative of a problem in a health care setting’s safety system; and important for public credibility or public accountability. Additionally, SREs are events that are: of concern to both the public and health care professionals and providers; clearly identifiable and measurable; feasible to including in a reporting system; and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures of the health care facility.”
NQF’s list of SREs includes both injuries occurring during care management (rather than underlying disease) and errors occurring from failure to follow standard care or institutional policies and procedures. A link to the most current list of SREs is below.
NQF: List of SREs (qualityforum.org)
Performance measurement and customer satisfaction
Capital initiates and takes part in numerous vehicles for measuring health plan performance and Member satisfaction with the experience of care.
HEDIS®
HEDIS, developed by NCQA, is a set of more than 90 standardized performance measures used to annually evaluate and compare the performance of health plans. HEDIS is regularly updated to reflect advancements in the science of performance measurement and information systems technology, as well as changes in the health care industry. Data for these measures are collected using administrative/claims information and also Member medical record information. Medical records providing HEDIS data will be collected prospectively during the measurement year and retrospectively in the spring, closing out the previous measurement year. HEDIS results are used to identify opportunities for improving health care.
Using Current Procedural Terminology (CPT II) when submitting claims can:
- Optimize proper documentation and monitoring care outcomes effectively.
- Minimize medical record request and maximize gaps in care closure and interventions.
- Improve communication and data capture across different settings of care.
A HEDIS CPT II quick reference guide is located in the Education and Manuals section of Our Provider Library.
Capital Blue Cross risk adjustment
- What is Risk Adjustment?
- Risk Adjustment is a method used in health insurance programs to account for the overall health and expected medical costs of individuals enrolled in a health plan.
- Risk Adjustment is a payment methodology that uses diagnosis and demographic data to appropriately reimburse health plans for the cost to care for the population. There are different models of risk adjustment used by the federal government to support Medicare Advantage, Medicaid, and the Affordable Care Act. At Capital, risk adjustment applies to Our Medicare Advantage line of business as well as the Individual and Small groups under the Patient Protection and Affordable Care Act (PPACA).
- What can you do?
- Encourage all Members to have their annual wellness exam/annual physical exam to capture the most current health status, active diagnosis and appropriate treatment plan.
- Ensure that the documentation in the medical records supports the assignment of ICD10 codes on the claims.
- Always code to the highest level of specificity as warranted by the Member’s health status.
- Ensure your staff is using the most up-to-date coding tools/codebooks and EMR functionality for appropriate ICD10 code assignment.
- Remember, code all documented conditions that coexist at the time of the encounter/visit AND that require or affect patient care, treatment, or management.
- Educate providers that the coding/billing team cannot assign an ICD10 code unless the provider/clinician explicitly documents that the condition is active.
Risk adjustment data validation audits
CMS conducts annual validation audits on an ongoing basis.
- Capital must meet the aggressive deadlines set by CMS. Therefore, Capital requires a very rapid response from providers, whether the record is available or not. Therefore, Capital expects providers to respond to a record request by either promptly providing the requisite records or by notifying Capital immediately if the requested records are not available.
- Providers must follow CMS’ 10-year record retention requirements to ensure that they are able to provide the required records for the relevant audit periods prescribed by CMS.
For additional information, or if you have any questions, please contact your Provider Engagement Consultant.
Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is administered by an external vendor to a random sample of Members.
- Per NCQA requirements, Capital annually administers surveys for our Commercial lines of business, On Exchange business, and FEP members.
- Per NCQA and DHS requirements, Capital administers a survey to our CHIP members as well.
- Per CMS requirements, Capital annually administers a similar Capital Blue Cross Medicare Advantage survey, MA-CAHPS, to Capital Blue Cross Medicare Advantage Members.
The CAHPS Member Satisfaction Survey is used to measure satisfaction with the following areas:
- Getting care quickly.
- Getting needed care.
- How well providers communicate.
- Member services.
- Claims processing.
- Plan information on costs.
- Shared decision-making.
- Overall ratings of personal doctor, specialist, health plan, and health care.
- Doctor discussed illness prevention.
- Personal doctor informed about care from specialist.
- Coordination of care.
- Assistance with smoking and tobacco use cessation.
- Percentage of Members who receive flu shots (age 18-64 for Commercial plan Members and all Capital Blue Cross Medicare Advantage plan Members).
The survey results are used to develop improvements in the areas of service and care.
CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
Overview
Outpacing Our competitors, Capital Blue Cross was the first health care insurer to introduce value-based programs to the marketplace with the 2011 launch of the QualityFirst Accountable Care ArrangementSM (ACA). With the health care market focused on outcomes-based care models, Capital Blue Cross continues to set Ourselves apart from the competition.
Our QualityFirst programs recognize and reward health care Providers for improving outcomes, reducing costs, and enhancing patient satisfaction. Our efforts are paying off. Analysis shows that Our QualityFirst ACA and Medical Neighborhood programs consistently outperform the peer group by lowering acute inpatient hospital admissions, hospital readmissions, and emergency department visits. Also, medical and pharmacy costs associated with QualityFirst programs are growing at a lower rate than Our total book of business and compare favorably against similar arrangements established by Blue plans across the country.
All three of Our QualityFirst programs are designated Total Care programs. Of note: Only (QualityFirst Accountable Care ArrangementSM (ACA), QualityFirst Medical Neighborhood ProgramSM, and QualityFirst Primary Care Recognition ProgramSM Performance Levels 2 and 3) are designated Total Care. QFPCRP performance level 1 is not Total Care.
The Blue Cross Blue Shield Association’s Total Care program is based on patient-centered and data-driven practices that lead to better coordinated care and improved quality, safety, and affordability. Providers in Total Care (TC) programs are paid with value-based payment instead of traditional fee-for-service, so they must reach quality and cost outcome targets in order to receive incentives and rewards for better health outcomes.
To receive a TC designation from the Blue Cross Blue Shield Association (BCBSA), the local value-based program must meet the following criteria:
- Provider is responsible for managing care for a population of BCBS Members.
- BCBS Members are attributed to the Provider responsible for managing their care.
- Provider Agreements contain value-based incentives tied to both cost and quality outcomes.
- Data and analytics are used to support quality and affordability improvements.
- Available to BCBS national account employees through a PPO-based product.
- Available to BCBS national account employees through administrative services only (ASO) and fully insured products.
Member cost share differential for value based programs
Capital Blue Cross offers a unique PPO health insurance benefit differential that is focused on Capital Blue Cross’ patient centered partnerships and the strength of the Blue Cross Blue Shield Association’s (BCBSA) Preferred Provider Organization (PPO) network.
Capital Blue Cross customers, can select a benefit option that lowers cost share for employees who utilize select patient-centered Providers. To qualify for the lower benefit, Providers must be recognized as a primary care physician that is part of a Capital Blue Cross value-based program (QualityFirst Accountable Care ArrangementSM (ACA), QualityFirst Medical Neighborhood ProgramSM , and QualityFirst Primary Care Recognition ProgramSM Performance Levels 2 and 3).
Members that have the cost share differential will receive a new ID card (see below) that shows a copay amount under Office Visit. If they have this benefit, it will be noted as “Office Visit Plus – Total Care” on the card. Moreover, Members who live outside the 21-county service area are able to use a Total Care (TC) Provider to benefit from the reduced copay.
How it works:
- Member presents their ID card that shows copay amounts. If you are designated in one of the above programs, your practice can collect the “Office Visit Plus – Total Care” copay from the Member.
- Provider offices not part of a Capital Blue Cross value based program should collect the standard “Office Visit” copay.
QualityFirst Accountable Care ProgramSM
Capital designed this program to link Provider payment to the improvement of health care quality while reducing the total cost of care for an attributed patient population. Through Provider relationships, the ACA program delivers holistic care to Our Members through dedicated care management resources and technology for a patient-centered approach. The ACA program works to enhance access to care, remind Members of needed prevention and chronic care services, and increase satisfaction with the care experience.
Introduction to the ACA Quality Program
Capital tailors the ACA quality program to the unique characteristics of the health care organization, taking into consideration environmental context, demographics, and concurrent quality improvement initiatives. The quality program uses nationally recognized HEDIS measures that focus on prevention, chronic care management, and acute care services. Moreover, the quality program includes patient satisfaction measures, typically through the Clinician and Group Consumer Assessment of Health care Providers and Systems (CG CAHPS) survey.
Providers are encouraged to manage open care gaps and submit supplemental data through Theon™ Care Collaborator™ and Care Optimizer™. Our online reporting solutions are designed to enhance value-based arrangements. The Theon™ platform assists ACAs in understanding total cost-of-care, population health, as well as cost and utilization trends. Theon™ makes actionable information available to aid decision-making, including:
- Attributed Member lists.
- Quality opportunities for closing gaps in care.
- Medical and pharmacy financial information.
- Prescribing patterns.
- Admissions, discharge, and emergency department encounters.
Program evaluation criteria
In order to receive performance year quality incentive payments, the ACA must demonstrate success in positively impacting performance. Examples of quality measures include:
Quality measures
|
Measure
|
|
Antidepressant medication management – Continuation phase
|
Blood pressure control for patients with Diabetes (BPD)
|
|
Appropriate testing for Pharyngitis
|
Eye exam for patients with Diabetes (EED)
|
|
Appropriate treatment for upper respiratory infection
|
Comprehensive Diabetes care – HbA1C control (<8%)
|
|
Asthma medication ratio
|
Controlling high blood pressure (<140/90)* (CBP)
|
|
Avoidance of antibiotic treatment for acute Bronchitis/Bronchiolitis
|
Immunizations for adolescents – Combination #2
|
|
Breast cancer screening*
|
Statin therapy for patients with cardiovascular disease – Received therapy*
|
|
Cervical cancer screening
|
Statin therapy for patients with Diabetes – Adherence 80%
|
|
Childhood immunization status – Combination #10
|
Use of imaging studies for low back pain
|
|
Chlamydia screening in women
|
Weight assessment and counseling for children/adolescents – BMI percentile
|
|
Colorectal cancer screening*
|
Medicare annual wellness visit**
|
|
Eye exam for patients with Diabetes (EED)**
|
Transition of care – Medication reconciliation**
|
|
Glycemic status assessment for patients with Diabetes(GSD)**
|
Osteoporosis management in women who had a fracture**
|
|
Kidney health evaluation for patients with Diabetes(KED)**
|
|
* = Commercial and Medicare measures
** = Medicare only measures
QualityFirst Medical Neighborhood ProgramSM
We recognize the value added by improved communication and coordination across all health care Providers. One approach to decreasing fragmentation, improving care coordination, and placing a greater emphasis on patient needs is the Patient Centered Medical Home (PCMH). Our PCPs lead many of the efforts to improve communication and coordination that are integral to the goals of a PCMH. To be successful, a PCMH requires a high-functioning medical neighborhood that encourages the flow of information across clinicians and patients and accountability to ensure clinician engagement.
Participation in Our QualityFirst Medical Neighborhood Program requires:
- A minimum threshold of attributed Capital Blue Cross Members.
- Electronic Medical Record (EMR) capability.
Introduction to the Medical Neighborhood Quality Program
Our QualityFirst Medical Neighborhood Program (the “Program”) is designed for independent Provider practices and/or hospital-based (health system) Provider practices to work as and be evaluated as a single organization similar to an ACA. The Provider will work toward a common goal of increasing quality while lowering overall medical spend. We support collaboration among participants and provide assistance through a dedicated team and custom reporting tools, the Theon™ platform, Care Collaborator, and Care Optimizer modules. Care Collaborator and Care Optimizer are designed to enhance value-based arrangements.
The Theon™ platform assists organizations in understanding total-cost-of-care, patient population health, and cost and utilization trends. This includes providing organizations with actionable information to assist in decision-making, such as:
- Attributed Member lists.
- Quality opportunities for closing gaps in care.
- Medical and pharmacy financial information.
- Prescribing patterns.
- Admissions, discharge, and emergency department encounters.
The Program’s success will be measured annually by evaluating both quality and trend performance. Quality is measured using HEDIS* quality measures and patient satisfaction.
*Healthcare Effectiveness Data and Information Set® (HEDIS) is a registered trademark of the National Committee for Quality Assurance (NCQA).
Trend is measured by comparing the year-over-year overall health care spend of your attributed Members. The trend is compared to that of other health care Providers and their attributed Members with aligned specialty types within Our 21-county market that are not participating in the Program (“peer”) to develop a final savings or loss amount based on the difference between the two trend statistics. Quality and trend performance are measured via a quality scorecard, containing HEDIS and patient satisfaction measures. Our team supports this part of the program through ongoing evaluation of the quality scorecard.
Examples of quality measures include:
Quality measures
|
Measure
|
|
Antidepressant medication management – Continuation phase
|
Blood pressure control for patients with Diabetes (BPD)
|
|
Appropriate testing for Pharyngitis
|
Eye exam for patients with Diabetes (EED)
|
|
Appropriate treatment for upper respiratory infection
|
Comprehensive Diabetes care – HbA1C control (<8%)
|
|
Asthma medication ratio
|
Controlling high blood pressure (<140/90)*
|
|
Avoidance of antibiotic treatment for acute Bronchitis/Bronchiolitis
|
Immunizations for adolescents – Combination #2
|
|
Breast cancer screening*
|
Statin therapy for patients with cardiovascular disease – Received therapy*
|
|
Cervical cancer screening
|
Statin therapy for patients with Diabetes – Adherence 80%
|
|
Childhood immunization status – Combination #10
|
Use of imaging studies for low back pain
|
|
Chlamydia screening in women
|
Weight assessment and counseling for children/adolescents – BMI percentile
|
|
Colorectal cancer screening*
|
Medicare annual wellness visit**
|
|
Eye exam for patients with Diabetes (EED)**
|
Transition of care – Medication reconciliation**
|
|
Glycemic status assessment for patients with Diabetes(GSD)**
|
Osteoporosis management in women who had a fracture**
|
|
Kidney health evaluation for patients with Diabetes(KED)**
|
|
* = Commercial and Medicare measures
** = Medicare only measures
Reporting
As a participant, you have access to Our online reporting solution. Designed to enhance value-based arrangements, the Theon™ platform Care Collaborator and Care Optimizer modules assist you in understanding total-cost-of-care, the health of your patient population, and cost and utilization trends. It provides you with the following actionable information to assist in decision-making:
- Attributed Member lists.
- Quality opportunities for closing gaps in care.
- Medical and pharmacy financial information.
- Prescribing patterns.
- Admissions, discharge, and ED encounters.
QualityFirst Primary Care Recognition ProgramSM
The QualityFirst Primary Care Recognition Program (QFPCRP) is a value-based program that rewards eligible Primary Care Providers (PCPs) for achieving high quality, patient-centered, and affordable health care to our Members. Eligible PCPs are evaluated on nationally recognized quality measures and the efficiency in which care is delivered to Our Members.
To evaluate performance in terms of clinical quality, Capital Blue Cross relies on the nationally recognized and utilized Healthcare Effectiveness Data and Information Set (HEDIS®). HEDIS is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare health care quality. Altogether, HEDIS includes more than 90 measures across six (6) domains of care. Because so many plans collect HEDIS data and the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans in a uniform fashion.
Participation in Our Primary Care Recognition Program requires:
- Have an attribution threshold of greater than or equal to 250 Capital Blue Cross commercial Members.
- If you do not meet the threshold number, you may still qualify for participation in Our Opportunities in Care Program. Please contact your Provider Engagement Consultant for more details.
- Access and active utilization of Our Provider Portal for:
- Eligibility and Benefits.
- News and Announcements.
- Claims Coding and Lookup.
- Accept/Reject Reports.
- Secure File Transfer.
- eClaims View and Resubmission.
- Provider Information Maintenance (group profile modifications).
- Provider Library (preauthorization single source code list and more).
- Access and active utilization of the Theon™ platform for:
- All clinical information on your patient panel.
- Identifying and closing care gaps.
- Not being enrolled in Our QualityFirst Accountable Care Program or Our QualityFirst Medical Neighborhood Program.
Additional information is located in Our Program Details document located in the Program Information section in Our Resource Center.
Program evaluation criteria
The program year will run from January 1 through December 31. In the second quarter of the year following the performance year, eligible Providers will receive their scorecards. These scorecards will notify Providers of their new corresponding performance-based tiered reimbursement for the Primary Code Set that will be effective August 1.
Quality measures - 60%
- Appropriate testing for pharyngitis
- Appropriate treatment for upper respiratory infection
- Asthma medication ratio
- Avoidance of antibiotic treatment for acute bronchitis/bronchiolitis
- Blood pressure control for patients with screening diabetes
- Breast cancer
- Cervical cancer screening*
- Child and adolescent well-care visits
- Childhood immunization status – combination #10
- Chlamydia screening*
- Colorectal cancer screening
- Controlling high blood pressure
- Eye exam for patients with diabetes**
- Glycemic assessment for patients with diabetes
- Immunizations for adolescents – combination #2
- Kidney health evaluation for patients with diabetes
- Statin therapy for patients with cardiovascular disease – received therapy
- Statin therapy for patients with cardiovascular disease – adherence 80%
- Statin therapy for patients with diabetes – adherence 80%
- Use of imaging studies for low back pain
- Well-child visits in the first 30 months of life
- Weight assessment and counseling for children/adolescents – BMI percentile
* Name changed from “Chlamydia Screening in Women”
** Name changed from “Diabetes Care—Eye Exam”
Utilization measures - 30%
- Acute hospital utilization
- For members 18 years of age and older, the risk-adjusted ratio of observed to expected acute inpatient and observation stay discharges during the measurement year.
- Emergency department utilization
- For members 18 years of age and older, the risk-adjusted ratio of observed to expected emergency department (ED) visits during the measurement year.
- Plan all-cause readmissions
- For members 18 years of age and older, the number of acute inpatient and observation stays during the measurement period that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission.
Patient Experience of Care survey - 10%
Attest that you perform a patient experience of care survey by December 31. The attestation form is located on the Applications tab in our Resource Center in our provider web portal via Availity Essentials.
If you have any questions, please contact your Provider Engagement Consultant. If you do not know who your Provider Engagement Consultant is, please email Us at CBCPEC@capbluecross.com or use the Provider Engagement Lookup Tool.
Throughout your course of participation in the Program, your Provider Agreements with Capital Advantage Insurance Company® (CAIC)/Capital Advantage Assurance Company® (CAAC) and Keystone Health Plan® Central (KHPC), including provisions such as the scope of Covered Services, the application of cost sharing provisions due from a Member, and the payment of services in full when the charges are less than the applicable fee schedule, will remain in full force and effect. The Program does not in any way modify or amend those agreements (except for applicable reimbursement provisions).
QualityFirst Primary Care Recognition ProgramSM – Quality Improvement (QI) Contact Email Addresses
QualityFirst Primary Care Recognition Program Providers can now enter their QI contact email addresses via the Provider Attestation Forms link on the ‘Applications’ tab of Capital Blue Cross’ Payer Spaces page on Our Provider Portal.
This email address is very valuable to help ensure QI-related information is delivered to the appropriate individual within your group/organization.
QualityFirst Commercial and Medicare Gaps in Care ProgramSM
Our Gaps in Care programs help PCPs identify specified HEDIS and STARs* quality measure care gaps. To verify eligibility, please refer to your Provider Engagement Consultant. A gap in care is a discrepancy between recommended best practices and care actually provided. It represents possible missed opportunities including, but not limited to, preventive services, missing age-based or seasonal vaccines which help ensure Members receive important health care services.
Commercial and Medicare Gaps in Care HEDIS measures are accessible via Theon™. Providers who need access to Theon™, please email CBCPEC@capbluecross.com and include your contact information and practice name or contact your Provider Engagement Consultant.
*The Centers for Medicare & Medicaid Services (CMS) five-star quality rating system which measures Medicare beneficiaries’ experience with their health plans.
The LeapFrog Value-Based Purchasing Program
Our Leapfrog Value-Based Purchasing Program uses nationally recognized, evidence-based data from the Leapfrog Hospital Survey to benchmark achievement and reward high performance in hospital quality and patient safety. Data from this program also provides support to hospitals for continuous performance improvement initiatives specific to patient safety. Scores are benchmarked nationally, statewide, and against a regional cohort.
Blue Distinction specialty care overview
In collaboration with the Blue Cross Blue Shield Association and other Blue Plans, We developed a national Blue Distinction Specialty Care program for specific specialty care services. Each Provider has been selected through a rigorous evaluation of clinical data that provides insight into the Provider’s structures, processes, and outcomes of care. These nationally established criteria were developed with input from medical experts and organizations and support the consistent, objective assessment of specialty care capabilities. The criteria may evolve over time and designations are refreshed periodically to provide this quality and cost differentiation to consumers, employers, and Providers.
The Blue Distinction Specialty Care Program includes two levels, Blue Distinction Center and Blue Distinction Center+. Providers with a Blue Distinction Center designation will be recognized for delivering expert specialty care while Providers with a Blue Distinction Center+ designation will be recognized for delivering expert specialty care efficiently. Only Providers that first meet national established, objective quality measures for Blue Distinction Centers will be considered for designation as a Blue Distinction Center+.
Blue Distinction Specialty Care has eleven areas of specialty care: bariatric surgery, cancer care, cardiac care, knee and hip replacement, maternity care, spine surgery, substance use treatment and recovery, transplants, fertility care, cellular immunotherapy, and gene therapy.
The designations are differentiated in the National Doctor & Hospital Finder, bcbs.com, and on CapitalBlueCross.com, with an audience including over 115 million Blue Members. Such differentiation helps Blue Members select Blue Distinction Centers for their care. We, as well as other Blue Plans, offer benefit options that lower cost share for Members who utilize Blue Distinction Centers. When verifying Member eligibility and benefits for one of the eleven specialty areas, remember to ask about this benefit. When medically appropriate, please consider referring Members to a Blue Distinction Specialty Care Center.
We participate in the national Blue Distinction Centers listed below.
Blue Distinction® Centers for Bariatric Surgery
Blue Distinction Centers for Bariatric Surgery provide a full range of bariatric surgical care services including inpatient care, postoperative care, outpatient follow-up care, and patient education. These facilities must meet stringent clinical criteria, as established by expert physicians and medical organizations.
- Please Note: Not all products and employer groups cover bariatric surgery. For Capital Blue Cross Medicare Advantage Members, bariatric surgical care services must be performed in an approved CMS bariatric surgery facility.
Blue Distinction® Centers for Transplants
The Blue Distinction Centers for Transplants program provides a range of services of transplants, including:
- Heart (adult and pediatric).
- Lung (adult only).
- Liver (deceased or living donor) (adult).
- Liver (pediatric).
- Bone marrow/stem cell (adult and pediatric).
- Kidney (deceased or living donor) (adult).
- Kidney (pediatric).
Each Blue Distinction Center for Transplants facility is designated for one or more of the listed types of transplants. These facilities offer comprehensive transplant services through a coordinated, streamlined transplant management program and have demonstrated their commitment to quality care, resulting in better outcomes for transplant patients.
Blue Distinction® Centers for Cardiac Care
To be recognized as a Blue Distinction Center for Cardiac Care, each facility must meet stringent clinical criteria, developed in collaboration with expert physician and medical organization recommendations, including the American College of Cardiology (ACC) and the Society of Thoracic Surgeons (STS). Facilities must perform the following elective procedures, for adult patients who area at least 18 years old:
- Percutaneous Coronary Interventions (PCI).
- Coronary Artery Bypass Graft (CABG).
- Aortic Valve Replacement (AVR).
- Mitral Valve Replacement and Repair (MVRR).
A facility must provide both PCI and cardiac surgery services to be considered for a Blue Distinction Center for Cardiac Care designation. Additionally, each applicant facility must participate and provide registry data from the ACC, STS, and publicly reported data from Hospital Compare.
Blue Distinction® Centers for Fertility Care
The Blue Distinction Centers for Fertility Care program focuses on in vitro fertilization (IVF) which is widely becoming the preferred option for fertility treatment. This program is open to IVF ART Providers in various care settings, including individual physicians, physician groups, and clinics.
Blue Distinction® Centers for Maternity Care
The Blue Distinction Centers for Maternity Care demonstrate expertise and a commitment to quality care for vaginal and cesarean section deliveries. These facilities demonstrate better overall patient satisfaction and a lower percentage of early elective deliveries. The Maternity Care program aims to improve outcomes related to birth for both mothers and babies. The program focuses on vaginal delivery and cesarean delivery episodes of care, routine obstetrical services, and follow up care.
In addition to the selection criteria established by the BCBSA, Capital will also require that hospitals participate with and annually submit the Leapfrog Hospital Survey to The Leapfrog Group according to The Leapfrog Group guidelines, beginning with the 2022 survey. Our Leapfrog Value-Based Purchasing Program uses nationally recognized, evidence-based data from the Leapfrog Hospital Survey to benchmark achievement and reward high performance in hospital quality and patient safety. The Leapfrog Data from this program includes measures of maternal care and provides support to hospitals for continuous performance improvement initiatives specific to patient safety. Please visit The Leapfrog Group for details.
Blue Distinction® Centers for Spine Care
The Blue Distinction Centers for spine surgery provide comprehensive surgery services for adult patients 18 years or older, including the following procedures:
- Discectomy, laminectomy, and decompressions (without fusion).
- Fusion.
Blue Distinction® Centers for Knee and Hip Replacement
Blue Distinction Centers for Knee and Hip Replacement focus on quality care and better overall outcomes for patients requiring knee and hip replacement procedures. These facilities offer comprehensive inpatient knee and hip replacement services, including the following:
- Total hip replacement.
- Total knee replacement.
- Revision of total knee replacement.
- Revision of total hip replacement.
Blue Distinction® Centers for Substance Use and Treatment Recovery
The Blue Distinction Centers for Substance Use Treatment and Recovery program aims to improve patient outcomes and value by focusing on the treatment of substance use disorder, including opioid use disorder. The program addresses the full continuum of care delivery, which includes residential, inpatient, intensive outpatient, or partial hospitalization services.
Skilled Nursing Facility (SNF) initiative
Capital Blue Cross continues our commitment to providing members with access to a high-quality network of health care providers. Capital's Skilled Nursing Facility (SNF) Quality Initiative was developed to support safe transitions of care, high-quality outcomes, and value for our members.
To ensure quality and safety standards are being met, Capital routinely performs systematic reviews of our entire SNF network. SNFs will be evaluated based on CMS Overall Star ratings, Quality Measures STAR ratings, and short-stay metrics. There is an additional focus on hospital readmissions and Emergency Department visits within 30 days of an SNF admission and/or discharge.
Facilities with CMS STAR ranking below average can expect to be contacted by a Capital representative to discuss your facility's quality performance and opportunities for improvement.
Commonly used value-based program acronyms and definitions
- AAHC – Accreditation Association for Ambulatory Healthcare
- Private, nonprofit organization that develops standards to advance and promote patient safety, quality care, and value for ambulatory health care through peer-based accreditation processes, education, and research.
- ACA – Accountable Care Arrangement
- CPT – Current Procedural Terminology
- Codes that are numbers assigned to every task and service a medical Practitioner may provide to a patient including medical, surgical, and diagnostic services. They are used by insurers to determine the amount of payment a Practitioner will receiver. Since everyone uses the same codes to mean the same thing, they ensure uniformity.
- ED – Emergency Department
- A section of a hospital that is staffed and equipped to provide rapid and varied emergency care, especially for those who are victims of severe trauma or stricken with sudden and acute illness.
- FOBT – Fecal Occult Blood Test
- A fecal occult blood test is a screening test for colorectal cancer that helps to detect the presence of hidden blood in the stool using a small amount of stool placed onto a special chemically treated card, pad, or wipe.
- gFOBT – guaiac Fecal Occult Blood Test
- A fecal occult blood test is a screening test for colorectal cancer that helps to detect the presence of hidden blood in the stool using a small amount of stool placed onto a special chemically treated card, pad, or wipe treated with guaiac. Guaiac denotes the name of the paper surface used in the test which has a phenolic compound, alpha-guaiaconic acid.
- HCPCS – Healthcare Common Procedure Coding System
- Codes used by Medicare and monitored by the Centers for Medicare & Medicaid Services (CMS). They are based on the Current Procedural Technology (CPT) codes developed by the American Medical Association. HCPCS codes are numbers assigned to every task and service a medical Practitioner may provide to a Medicare patient including medical, surgical, and diagnostic services. Since everyone uses the same codes mean the same thing, they ensure uniformity.
- HEDIS – Healthcare Effectiveness Data Information Set®
- Used by more than 90 percent of America’s health plans to measure performance of care and service
- Hospital Based Provider Practices
- Provider practices that are owned and operated by a hospital organization, however, they continue to see and manage their own panel of patients. This designation can also apply to a clinically integrated network.
- ICD-10-CM Procedure – International Classification of Disease
- ICD-10-CM procedure codes are based on the official version of the World Health Organization’s Tenth Revision, International Classification of Diseases (ICD-10).
- IESD – Index Episode Start Date
- The earliest episode date during the intake period that meets specific criteria of the measure.
- iFOBT – Immunochemical Fecal Occult Blood Test
- A fecal occult blood test is a screening test for colorectal cancer that helps to detect the presence of hidden blood in the stool using a small amount of stool placed onto a special chemically treated card, pad, or wipe. Immunochemical FOBTs (iFOBTs) are a newer and more sensitive option for detecting unseen blood in the stool.
- Independent Provider Practices (geographically-based)
- A geographically-based group of Provider practices that are independently owned and operated by the Providers that make up the individual practices but are geographically organized to operate as a collective unit, similar to a formal ACO, but have no contractual obligation to one another.
- IPSD – Index Prescription Start Date
- The earliest prescription dispensing date for a medication during the period of 30 days prior to the IESD (inclusive) through 14 days after the IESD.
- LOB – Line of Business
- LOINC – Logical Observation Identifiers Names and Codes
- Dataset of universal identifiers for laboratory and other clinical observations to facilitate exchange and storage of clinical results or vital signs for patient care.
- MMR – Measles, Mumps, and Rubella Vaccine
- An immunization against measles, mumps, and rubella (also called German measles).
- NCQA – National Committee for Quality Assurance
- NCQA is a private, nonprofit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations.
- NDC – National Drug Code
- The National Drug Code (NDC) is a unique 11-digit, three-segment code (including leading zeroes) used in the United States as a universal product identifier for human drugs. For billing purposes, the NDC must be in the standard 11-digit format.
- The 11-digit NDC format is arranged as 5 digits for the labeler, 4 digits for the product, and 2 digits for the package (5-4-2). If an FDA-listed NDC is displayed in a 10-digit format, add a leading zero to the appropriate segment to create the standard 11-digit, 5-4-2 structure required for billing.
- OP – Outpatient Therapy
- Outpatient therapy is a form of therapeutic treatment that is offered to people who do not need to be hospitalized. A number of types of therapy can be offered on an outpatient basis, including psychological, physical, and postsurgical care.
- Pap Test – Papanicolaou Test
- Screening test used to detect potentially precancerous and cancerous processes in the endocervical canal (transformation zone) of the female reproductive system.
- PCMH – Patient Centered Medical Home
- The Patient Centered Medical Home is a care delivery model in which the patients’ care is coordinated through their Primary Care Physician (PCP) to ensure they receive the necessary care when and where they need it and in a manner they can understand. Care provided is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.
- Peer Group
- Providers within Capital Blue Cross’ 21-county network that are not included in the Panel identified as a PCP in Family Medicine, Internal Medicine, or multi-specialty PCP, and includes physician extenders. Pediatric practices may be included.
- PMPM – Per Member Per Month
- The health care financing term that refers to the average amount per month that each Member costs their insurance Provider.
Product Lines
- Blue High Performance Network (BlueHPN®) is a national, narrow network focused on enhancing quality and increasing savings.
- HMO, POS, PPO
- HMO is a Health Maintenance Organization Product. POS is a Point of Service Product. PPO is a Preferred Provider Organization Product.
- POS – Place of Service
- Place of service codes are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. CMS maintain POS codes used throughout the health care industry.
- QFMN – QualityFirst Medical Neighborhood ProgramSM
- Quality Compass® – NCQA
- Quality Compass is an indispensable tool used for selecting a health plan, conducting competitor analysis, examining quality improvement, and benchmarking plan performance.
- Rev Codes – Revenue Codes
- Inpatient hospitals must use national revenue codes to summarize the charges for each cost center.
- Td – Tetanus and Diphtheria Vaccine
- An acronym for the collective vaccines preventing tetanus and diphtheria.
- Tdap – Tetanus, Diphtheria, and Pertussis Vaccine
- An acronym for the collective vaccines preventing tetanus, diphtheria, and pertussis.
- TJC – The Joint Commission
- An independent not-for-profit organization, The Joint Commission accredits and certifies health care organizations and programs in the United States. The accreditation and certification are recognized nationwide as a symbol of quality that reflects commitment to meeting certain performance standards.
- UB-Revenue – Uniform Billing Revenue Codes. Codes entered on the UB form to identify specific accommodation and/or ancillary charges.
- USPTF – United States Preventive Task Force
- Created in 1984, the U.S. Preventive Services Task Force (USPSTF or Task Force) is an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, or preventive medications.
- VZV – Varicella Zoster Virus
- A vaccination for the prevention of chickenpox, one of eight herpes viruses known to infect humans.
