Important NewsBCBSNC prior Plan approval process improvement for Blue OptionsSMApril 20th, 2005At Blue Cross and Blue Shield of North Carolina (BCBSNC), it is extremely important to make sure our members get the right care in the right setting. Thus, our Medical Resource Management department ensures our members have access to appropriate, high quality health care through programs like prospective, retrospective and concurrent review, case management and continuity of care assistance. These programs are nothing new for group administrators, as we've had them in place for years. However, on July 1, 2005, BCBSNC will implement a process improvement to one of these programs that should be transparent to our members who visit participating providers. BackgroundFor years, BCBSNC, also referred to as "Plan," has required physicians treating a Blue Care® (HMO) or Blue Choice® (POS) patient to obtain prior Plan approval for service-specific services like durable medical equipment, certain surgeries, home health care and services that are potentially cosmetic. We refer to these as "service-specific services" on the BCBSNC prior approval list. For Blue OptionsSM, PPO members, BCBSNC has reviewed claims for these services after the services have taken place to ensure the services were considered medically necessary under BCBSNC policy. What's changing?Understandably, physicians found this arrangement confusing, so to be consistent across all of our products, BCBSNC will begin to perform prospective review of these service-specific services for Blue Options members instead of retrospective review. This change will be effective for services received on or after July 1, 2005, and will apply to both participating and nonparticipating providers. All BCBSNC participating providers have been notified of this change and are responsible for requesting approval from BCBSNC prior to services being rendered. If a member visits a nonparticipating provider, the member is responsible for requesting prior approval from BCBSNC before services are rendered. To find out if a service has been approved, a member can call the Customer Service number on their BCBSNC ID card. BCBSNC began including text for this change in benefit booklets distributed to groups starting with June 2004 renewals. Some groups that print their own booklets may not have received this updated language. BCBSNC will work with these groups on an individual basis to ensure that the appropriate information is communicated to members in a timely manner. Frequently Asked Questions
What are retrospective reviews, prospective reviews, and prior Plan approvals (PPA)?
What services are being moved from retrospective review to prospective review?
Why is this change beneficial to my covered employees?
Can members appeal a denial decision related to not obtaining PPA?
How do members request prior approval from BCBSNC for services?
Who should members contact regarding the BCBSNC prior Plan approval list?
What are retrospective reviews, prospective reviews, and prior Plan approvals (PPA)? Retrospective review is the process of reviewing health care services after they occur to determine if the service is considered medically necessary per BCBSNC medical policy. Prospective review and prior Plan approval (PPA) mean the same thing. It is the process by which Blue Cross and Blue Shield of North Carolina (referred to as "Plan") reviews health care services before they occur to determine if the service is considered medically necessary under BCBSNC medical policy.
What services are being moved from retrospective review to prospective review? The services that are being moved from retrospective review to prospective review will be included on the prior Plan approval (PPA) list under the heading "Service-specific services." This list can be found on our Web site at http://www.bcbsnc.com/content/providers/ppa/. They are also listed at the end of this document for your convenience. Members can also contact the BCBSNC Medical Resource Management department at 1-800-672-7897 for a list of services requiring PPA. This change will be effective for services received on or after July 1, 2005.
Why is this change beneficial to my covered employees? Moving these specific service codes from retrospective review to prospective review increases the consistency of requirements for participating providers and members. Currently, BCBSNC HMO and POS lines of business have both inpatient and outpatient prior approval requirements. Applying the same requirements to all lines of business avoids the confusion of varied requirements. In addition, providers and members can feel more confident that the services will be reimbursed if they obtain prior approval from BCBSNC first. (Please note: Prior approval from BCBSNC is not a guarantee of payment because some groups exclude certain benefits. Please refer to your benefit booklet for specific information about your coverage.) If a member goes to a participating provider for services outlined as "service-specific services" on the BCBSNC prior approval list, the participating provider will obtain prior approval from BCBSNC on behalf of the member. If prior approval was not obtained on behalf of the member, the participating provider will have to write off the amount that he or she failed to preauthorize. The participating provider cannot charge the member for the service. If a member goes to a nonparticipating provider for services outlines as "service-specific services" on the prior Plan approval list, the member is responsible for requesting approval from BCBSNC before the services are rendered. Failure of the member to obtain PPA for these services may result in denial of claims. Members will be responsible for paying the nonparticipating provider for the services that he or she (the member) failed to preauthorize.
Can members appeal a denial decision related to not obtaining PPA? Members have the right to request a formal appeal of a denial of benefit coverage. BCBSNC will work with you to resolve the issue. For each step in the appeals process, there are specified time frames for filing a grievance and for BCBSNC to notify you or your provider of the decision. A detailed description of the appeals process may be found in your benefit booklet. Customer Service can also assist you in starting the appeal process.
How do members request prior approval from BCBSNC for services? Members can follow the same procedure that they do today for requesting prior approval from BCBSNC for inpatient services. They can call, mail or fax their request to us at: Medical Resource Management Department Toll-free number: 1-800-672-7897
Who should members contact regarding the BCBSNC prior Plan approval list? Members can follow the same procedure that they do today for requesting prior approval from BCBSNC for inpatient services. They can call, mail or fax their request to us at: Medical Resource Management Department Toll-free number: 1-800-672-7897 Members should call the BCBSNC Customer Service number on the back of their ID card for questions related to the prior approval list. Blue OptionsSM prior plan approval (PPA) listGeneral services already on prior plan approval for Blue OptionsInpatient admissions:
Private duty nursing Skilled nursing facility (SNF) and acute rehabilitation Transplants – solid organ or bone marrow/stem cell Mental health/substance abuse treatment
Certain prescription drugs** Outpatient services on prior plan approval for Blue Options
|
