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Blue Cross Medicare Advantage(HMO/DSNP)SMSupplement to the Blue EssentialsSMBlue PremierSM,Blue Advantage HMOSM andMyBlue HealthSMProvider ManualRevised 12-10-2021HMO plans are provided by Blue Cross and Blue Shield of Texas, which refers to GHS InsuranceCompany (GHA), an Independent Licensee of the Blue Cross and Blue Shield Association, GHSis a Medicare Advantage organization with a Medicare contract. Enrollment in GHA plansdepends on contract renewal.A Division of Health Care Service Corporation, a Mutual Legal Reserve Compan y, an Independent Licensee of the Blue Cross and Blue Shield Association
Blue Cross Medicare Advantage(HMO/DSNP) Provider Manual SupplementTable of ContentsOverview Introduction The Blue Cross Medicare Advantage HMO Network The Blue Cross Medicare Advantage HMO SNP NetworkGeneral Information ID Cards, Eligibility and Benefits Sample HMO ID Card Sample HMO SNP ID Card ID Card Copayment Information Verification of How a Particular Service Will Be Paid Lab Provider – Quest Diagnostics Addresses for Claims Filing & Customer Service Phone Numbers Benefit or Traveler Benefit Medical Records 24-Hour Coverage Emergency Services Definition Emergency Medical Conditions Emergency Care eviCore Out-of-Area Renal Dialysis Services Preventive Services Inpatient Hospital Admissions Behavioral Health Services PredeterminationRoles and Responsibilities Role of the Primary Health Care Provider (PCP) Panel Closure Backup PCPs Capitated IPA/Medical Group Referrals to Specialty Care Health Care Providers are not required Role of the Specialty Care Health Care Provider Specialist as a Primary Health Care ProviderClaim Information Claims Process Claim Submission Information Duplicate Claims Coordination of Benefits Claim Disputes Process Used to Recover Overpayments on Claims Balance Billing Nondiscrimination 2828293132333434343535363636ConfidentialityBasic RuleP2
Blue Cross Medicare Advantage(HMO/DSNP) Provider Manual SupplementTable of Contents Uniform BenefitsBenefits During Disasters and Catastrophic EventsAccess and Availability RulesCost-Sharing for In-Network Preventive ServicesDrug Coverage Medical Supplies Associated with the Delivery of InsulinClinical TrialsAdvance DirectivesPerformance and Compliance Standards – UtilizationManagementPage3838384041424242 Medical Necessity43 Medical PolicyPrior Authorization Requirements List44 Inpatient Prior Authorization4445 Availity Authorizations and Referrals46 Concurrent Hospital ReviewDischarge Planning4747Performance and Compliance Standards – CaseManagement Care Coordination Initial Health Risk Assessment Annual Health Assessment Annual Wellness Visit Resources48484949Performance and Compliance Standards – QualityImprovement Quality Improvement Program Quality of Care Issues CMS Star Ratings Cooperation Utilization Management Program Specialty Care Health Care Provider Health Care Provider Responsibilities 30 Day Readmissions5051525353545455Care Management Care Management Second Medical or Surgical Opinion Clinical Review Criteria Health Risk Assessment56585859P3
Blue Cross Medicare Advantage(HMO/DSNP) Provider Manual SupplementTable of ContentsDisease Management ProgramsHealth Care Providers Performance Standards and ComplianceObligations Evaluating Performance of Participating Health Care Providers Health Care Provider Compliance to Standards of Care Laws Regarding Federal Funds Marketing Sanctions under Federal Health Programs and State LawSelection and Retention of Participating Health Care Providers Participation Requirements Credentialing & Recredentialing of Participating HealthCare ProvidersCredentialing & Recredentialing of Institutional ProvidersAppeal Process for Health Care Provider ParticipationDecisionsNotification to Members of Health Care Provider TerminationMedical Records Medical Record Review Standards for Medical Records Advance Directives Confidentiality of Member InformationReporting Obligations Cooperation in Meeting Centers for Medicare & MedicaidServices (CMS) RequirementsCertification of Diagnostic DataInitial Decisions, Appeals and Grievances Initial Decisions Appeals and Grievances Appeals Address and Claim Inquiries Phone Number Resolving Grievances/Complaints Resolving Appeals Further Appeal Rights Participating Health Care Provider Obligations –Organization Determinations Participating Health Care Provider Obligations – AppealsMember Rights and Responsibilities Rights Responsibilities Member 686970707072747475767879
Blue Cross Medicare Advantage(HMO/DSNP) Provider Manual SupplementTable of ContentsServices Provided in a Culturally Competent MannerAdvance DirectiveMember Complaints/GrievancesPage797979Obligation to Provide Access to Care Member Access to Health Care Guidelines Health Care Provider Availability Health Care Provider Confidentiality Statement Prohibition Against DiscriminationGlossary of TermsBlue Cross Medicare Advantage HMO Provider QuickReference Guide Key Contacts ListDisclaimersP58080818182848687
Blue Cross Medicare Advantage (HMO)Provider Manual - SupplementOverviewIntroduction Blue Cross Medicare Advantage HMO is pleased to welcome youas a Participating health care provider. The Blue EssentialsSM ,Blue Advantage HMOSM , Blue PremierSM and MyBlue HealthSMProvider Manual plus this Provider Manual Supplement explain thepolicies and procedures of the Blue Cross Medicare AdvantageHMO network. We hope it provides you and your office staff withhelpful information as you service our members. The information isintended to provide guidance your office will encounter whileparticipating in Blue Cross Medicare Advantage HMO. ThisProvider Manual Supplement is applicable only to the operation ofBlue Cross Medicare Advantage HMO.The BlueCrossMedicareAdvantageHMONetworkBlue Cross Medicare Advantage HMO health care providerswho are contracted/affiliated with a capitated IPA/Medical Group mustcontact the IPA/Medical Group for instructions regarding referral andprior authorization processes, contracting, and claims-related questions.Additionally, Blue Cross Medicare Advantage HMO health careproviders who are not part of a capitated IPA/Medical Group but whoprovide services to a Blue Cross Medicare Advantage HMOmember whose PCP is contracted/ affiliated with a capitated IPA/Medical Group must also contact the applicable IPA/Medical Group forinstructions. Blue Cross Medicare Advantage HMO health careproviders who are contracted/ affiliated with a capitated IPA/MedicalGroup are subject to that entity’s procedures and requirements forBlue Cross Medicare Advantage HMO health care providerscomplaint resolution.Blue Cross Medicare Advantage HMO is a Medicare AdvantagePlan. Blue Cross Medicare Advantage HMO maintains and monitorsa network of participating health care providers including physicians/professional providers, hospitals, skilled nursing facilities, ancillaryproviders and other providers through which members obtain CoveredServices. Although selection of a primary care physician\provider isrequired, members are encouraged to have their participating healthcare providers coordinate their care with other participating healthcare providers.P6
Blue Cross Medicare Advantage (HMO)Provider Manual - SupplementOverviewBlue Cross Medicare Advantage HMO SNPSM is a coordinated carespecial needs plan (SNP) specifically designed to provide targetedcare and limited enrollment to special needs individuals who areeligible for both Medicare and Medicaid. The plan is an integrated caremodel used to improve the health of our most vulnerable members.Additionally, the Model of Care (MOC) is considered a vital qualityimprovement tool and integral component for ensuring that theunique needs of each beneficiary enrolled in a Special Needs Plan(SNP) are identified and addressed. CMS requires all contracted andout-of-network providers seen by members on a routine basis toreceive training on the SNP MOC.DSNP Training for Providers and Staff1. All DSNP State Plans will need to provide ongoing staff trainingand provider training on the DSNP Model of Care. This canoccur through live in-person training sessions as well as WebExor Computer-based Training (CBT) Modules.2. Training must occur at least annually for providers and internalstaff and will be ongoing for staff as needed.SNP MOC Goals1. Improve access to affordable care2. Integrate and coordinate care3. Ensure use of preventive health services4. Improve management of chronic disease through goal setting5. Improve beneficiary health outcomesCost Sharing Protections for Dual Eligible MembersCMS Notification Network Providers (effective 2022):(1) must not hold a Dual Eligible Member liable for the Cost SharingObligations; and(2) must accept as payment in full the MA Dual SNP’s payment of theCost Sharing Obligations and must not seek additional payment fromHHSC or a Dual Eligible Member for healthcare services coveredunder the MA Product offered by the MA Dual SNP and provided tothe Dual Eligible Member.Medicare Advantage DSNP TrainingsBlue Cross Medicare Advantage Dual Care (HMO SNP) Model of CaretrainingP7
Blue Cross Medicare Advantage (HMO)Provider Manual - SupplementOverviewThe BlueCrossMedicareAdvantageHMONetwork,cont'dBlue Cross Medicare Advantage HMO and HMO SNP willmarket its Medicare Advantage Plans to people eligible forMedicare Parts A and B that live in the following approvedService Area in the state of Texas:Blue Cross Medicare Advantage (HMO SNP) Service AreasAtascosa, Bandera, Bastrop, Bexar, Blanco, Bosque, Brazos,Burleson, Burnet, Caldwell, Collin, Colorado, Comal, Coryell, Dallas,Denton, Falls, Fayette, Gonzales, Grimes, Guadalupe, Hays, Hill,Kendall, Lampasas, Lavaca, Lee, Leon, Limestone, Llano, Madison,Medina, Milam, Mills, Navarro, Robertson, Rockwall, San Saba,Somervell, Tarrant, Travis, Williamson, and Wilson counties.The following additional counties are effective as of 1/1/2022Brazoria, Ellis, Johnson, Parker, Rockwall, and Waller counties.Blue Cross Medicare Advantage HMO and HMO SNP will furnishmembers with a Member Handbook and Evidence of Coverage that willinclude a summary of the terms and conditions of its plan.P8
Blue Cross Medicare Advantage (HMO)Provider Manual - SupplementGeneral InformationID Cards,EligibilityandBenefitsEach Blue Cross Medicare Advantage HMO and SNP memberwill receive a Blue Cross Medicare Advantage HMO or HMOSNP identification (ID) card containing the member's name,member ID number, and information about their benefits.At each office visit, your office staff should: Ask for the member’s ID card Copy both sides of the member’s ID card and keep thecopy with the patient’s file Determine if the member is covered by another healthplan to record information for coordination of benefitspurposes Refer to the member’s ID card for the appropriate telephonenumber to verify eligibility of Blue Cross MedicareAdvantage HMO or HMO SNP deductibles, coinsuranceamounts, copayments, and other benefit information Check eligibility and for other relevant informationSample ID Cards are located on pages 10 and 11P9
Blue Cross Medicare Advantage (HMO)Provider Manual - SupplementGeneral Information, cont'dSample IDCard (front &back)P10
Blue Cross Medicare Advantage (HMO)Provider Manual- SupplementGeneral Information, cont'dSample IDCard (front &back)P11
Blue Cross Medicare Advantage (HMO)Provider Manual- SupplementGeneral Information, cont'dID CardCopaymentInformation The office visit copayment (in-network) or coinsurance (out-ofnetwork) is determined by how a health care provider is contractedfor Blue Cross Medicare Advantage (HMO). If the physician is contracted for Blue Cross Medicare Advantage(HMO) as a PCP, the health care provider should collect the innetwork copayment indicated on the member ID card for the PCP. If the health care provider is contracted for Blue Cross MedicareAdvantage (HMO) as an in-network Specialty Care Physician/Professional Provider, the health care provider should collect the innetwork copayment indicated on the member ID card for Specialists. If the health care provider is contracted as a Primary Care Physicianand a Specialty Care Physician, then the health care provider shouldcollect the PCP in-network copayment indicated on the member IDcard. If the health care provider is out of network, contact the CustomerService number listed on the member's ID card to determine themember's patient share.NOTE: BCBSTX strongly encourages providers to check patienteligibility and benefit information prior to every scheduledappointment. Refer to the back of the member's ID card for theCustomer Service phone number or check benefits throughAvaility or your preferred Web vendor.P12
Blue Cross Medicare Advantage (HMO)Provider Manual- SupplementGeneral Information, cont'dVerificationof How aParticularService WillBe PaidUnder the Prompt Pay Legislation, providers of service have theright to request verification that a particular service will be paid bythe insurance carrier. Verification as defined by the TexasDepartment of Insurance (TDI) is a guarantee of payment forhealth care or medical care service if the services are renderedwithin the required timeframe to the patient for whom the servicesare proposed.Requests for "verification" of services will be issued by Blue CrossMedicare Advantage HMO if the claim processing will beperformed by Blue Cross Medicare Advantage HMO.Note: If your request is for a service covered under a capitatedindependent physician association (IPA), medical group, or otherdelegated entity responsible for claim payment, please make yourrequest for verification directly to the appropriate IPA or entity.Refer to section B of the "Blue Essentials, Blue Advantage HMO,Blue Premier and MyBlue Health Provider Manual" onbcbstx.com/provider for more information on verifications.P13
Blue Cross Medicare Advantage (HMO)Provider Manual- SupplementGeneral Information, cont'dBlue CrossMedicareAdvantageHMO OnlyLab Provider– QuestDiagnostics,Inc.Quest Diagnostics, Inc. is the preferred outpatient clinicalreference laboratory provider for Blue Cross MedicareAdvantage HMO members.Note: This arrangement excludes lab services provided duringemergency room visits, inpatient admissions and outpatient daysurgeries (hospital and free standing ambulatory surgery centers).Quest Diagnostics Offers: On-line scheduling for Quest Diagnostics' PatientService Center (PSC) locations. To schedule a PSCappointment, log onto www.QuestDiagnostics.com/patientor call 1-888-277-8772. Convenient patient access to over 150 PSCs. 24/7 access to electronic lab orders, results, and otheroffice solutions through Care360 Labs and Meds.For more information about Quest Diagnostics lab testing solutionsor to setup an account, contact your Quest Diagnostics’ PhysicianRepresentative or call 1-866-MY-QUEST.Reminder of CLIA RequirementsThis is a reminder that Blue Cross Medicare Advantage HMOfollows the same billing and coverage guidelines as originalMedicare. This includes the requirement to report the ClinicalLaboratory Improvements Amendments of 1988 (CLIA) number onclaims submitted by all laboratories, including physician officelaboratories. The CLIA number must be included on each FormCMS-1500 claim for laboratory services by any laboratoryperforming tests covered by CLIA. The CLIA number is required infield 23 of the paper Form CMS-1500. Modifier QW must bereported on claims for CLIA waived laboratory tests. The CLIAnumber is not required on the Form CMS-1450 (UB04).P14
Blue Cross Medicare Advantage (HMO)Provider Manual- SupplementGeneral Information, cont'dAddressesfor ClaimsFiling &CustomerServicePhoneNumbersThe member’s ID card provides claims filing and customer serviceinformation. If in doubt, please call Blue Cross MedicareAdvantage HMO Provider Customer Service at the numbers listedbelow. Although the submission of claims electronically is thepreferred method, when a paper claim is submitted for a memberwith a PCP not affiliated with a capitated Independent PracticeAssociation (IPA) or Medical Group, use the appropriate addressindicated below.Plan/GroupBlue Cross MedicareAdvantage HMOProvider CustomerService:Claims and Refunds Filing AddressBlue Cross Medicare Advantage HMOc/o Provider ServicesP.O. Box 3686Scranton, PA 18505 - 99981-877-774-8592Note: If a Blue Cross Medicare Advantage HMO member’s PCP isaffiliated with a capitated Independent Practice Association(IPA) or Medical Group, claims for certain types of services mustbe submitted to the IPA or Medical Group, rather than to the normaladdress used for BCBSTX claims. If a claim should have been sent toan IPA or Medical Group but was submitted to the Blue CrossMedicare Advantage HMO address, the claim will be rejected andyou will receive notice to re-file it with the appropriate IPA or MedicalGroup.Types of services that should be submitted to the IPA or MedicalGroup include the following: Physician ServicesOutpatient diagnostic testing servicesTo determine the appropriate IPA or Medical Group for claimssubmission, refer to the Blue Cross Medicare Advantage HMOmember’s ID card to obtain the Physician Organization (PORG) codeor contact Blue Medicare Advantage Customer Service and then referto the table below:IPA PORGRNPOVAMAEPICIPA Claims and Refunds Filing AddressRPO ClaimsP.O Box 2888Houston, Tx 77252P15
Blue Cross Medicare Advantage (HMO)Provider Manual- SupplementBenefit orTravelerBenefitsGeneral Information, cont’dWhen you are continuously absent from our plan’s service area formore than six months, we usually must disenroll you from ourplan. However, we offer as a supplemental benefit avisitor/traveler program in the U.S., which will allow you to remainenrolled in our plan when you are outside of our service area forup to 6 months. This program is available to all Blue CrossMedicare Advantage members who are temporarily in thevisitor/traveler area. Under our visitor/traveler program you mayreceive all plan Medicare-covered services at in-network costsharing when you notify the plan in advance of your travel.Please contact the plan for assistance in locating a provider whenusing the visitor/traveler benefit.If you are in the visitor/traveler area, you can stay enrolled in ourplan for up to 6 months. If you have not returned to the plan’sservice area within 6 months, you will be disenrolled from the plan.Please Note Throughout this provider manual there will beinstances when there are references unique to Medicare AdvantageHMO and/or Blue Advantage HMO. These network specificrequirements will be noted with the network name.P16
Blue Cross Medicare Advantage (HMO)Provider Manual- SupplementGeneral Information, cont’dMedicalRecords24-HourCoverageNetwork providers are required to provide medical recordsrequested by Blue Cross Medicare Advantage HMO. Themedical records are used for CMS audits of risk adjustment datawhich are used to determine health status adjustments to CMScapitation payments to the Blue Cross Medicare AdvantageHMO organization. Medical records are also used for the following: Advance determination of coverage Plan coverage Medical necessity Proper billing Quality reporting Fraud and abuse investigations Plan initiated internal risk adjustment validationParticipating physicians and professional providers are required toprovide coverage for Blue Cross Medicare Advantage HMOmembers 24 hours a day, 7 days a week. When a participatinghealth care provider is unavailable to provide services, theparticipating health care provider must ensure that he or she hasarranged for coverage from another participating health careproviders. Hospital emergency rooms or urgent care centers arenot substitution for covering participating health care providers.Participating health care providers can consult their Blue CrossMedicare Advantage HMO Provider Directory to identify healthcare providers participating in the Blue Cross MedicareAdvantage HMO network. You may also contact the Blue CrossMedicare Advantage HMO Provider Customer Service Departmentat the number listed on the back of the member’s ID card withquestions regarding which health care providers participate in theBlue Cross Medicare Advantage HMO network.P17
Blue Cross Medicare Advantage (HMO)Provider Manual- SupplementGeneral Information, cont’dEmergencyServicesDefinitionCovered inpatient or outpatient services that are: EmergencyMedicalConditionsfurnished by a provider qualified to furnish EmergencyServices; andneeded to evaluate or stabilize an Emergency MedicalCondition.When you, or any other prudent layperson with anaverage knowledge of health and medicine, believethat you have medical symptoms that requireimmediate medical attention to prevent loss of life,loss of a limb, or loss of function of a limb. Themedical symptoms may be an illness, injury, severepain, or a medical condition that is quickly gettingworse. Cost sharing for necessary emergency servicesfurnished out-of-network is the same as for suchservices furnished in-network.Medical conditions of a recent onset and severity, including but notlimited to severe pain, that would lead a prudent laypersonpossessing an average knowledge of medicine and health to believethat his or her condition, sickness, or injury is of such a nature thatfailure to receive immediate medical care could result in: Serious jeopardy of the patient’s health; Serious impairment to bodily functions; Serious dysfunction of any bodily organ or part; Serious disfigurement.P18
Blue Cross Medicare Advantage (HMO)Provider Manual- SupplementEmergencyCareEmergency Care services are health care services provided in ahospital or comparable facility to evaluate and stabilize medicalconditions of a recent onset and severity, including but not limitedto severe pain, that would lead a prudent layperson possessing anaverage knowledge of medicine and health to believe that his orher condition, sickness, or injury is of such a nature that failure toreceive immediate medical care could result in: Serious jeopardy of the patient’s health;Serious impairment to bodily functions;Serious dysfunction of any bodily organ or part;Serious disfigurementEmergency Care services necessary to evaluate and stabilize anEmergency Medical Condition are covered by Blue Cross MedicareAdvantage HMO. Members with an Emergency Medical Condition shouldbe instructed to go to the nearest Emergency Provider. Evaluation andstabilization of an Emergency Medical Condition in a hospital orcomparable facility does not require precertification. Providers need tonotify the UM department of inpatient admissions for post stabilizationcare services within one (1) business day of the admission followingtreatment of an emergency medical condition for Medicare AdvantageHMO members. Failure to timely notify BCBSTX and obtain pre-approvalfor further post-stabilization care services may result in denial of theclaim(s) for such post-stabilization care services, which cannot be billed tothe member pursuant to your provider agreement with BCBSTX.Emergency Care services will be covered at the in- network benefit level.eviCore Blue Cross and Blue Shield of Texas (BCBSTX) has contracted witheviCore healthcare (eviCore) to provide certain utilizationmanagement prior authorization services. Services requiring priorauthorization as well as information on how to prior authorizeservices with eviCore are outlined on the Utilization Managementpage and on the eviCore page on our provider website.Services performed without prior authorization or that do not meetmedical necessity criteria may be denied for payment, and therendering provider may not seek reimbursement from the member.P19
Blue Cross Medicare Advantage (HMO)Provider Manual- SupplementGeneral Information, cont’dOut-of-AreaRenalDialysisServicesA member may obtain medically necessary dialysis services fromany qualified health care provider the member selects when he/she is temporarily absent from the Blue Cross MedicareAdvantage HMO Service Area and cannot reasonably accessBlue Cross Medicare Advantage HMO dialysis health careproviders. Prior authorization is not required. Note: Prenotification from the member is recommended in order for themember’s case manager to follow-up with the member to makesure that all is going well. Without pre-notification from themember, the case manager will not always know what is takingplace for the member. Also, a member may voluntarily adviseBlue Cross Medicare Advantage HMO if he/she will temporarilybe out of the Service Area. Blue Cross Medicare AdvantageHMO may assist the member in locating a qualified dialysishealth care provider.PreventiveServicesMembers may access the following services directly from anyapplicable participating health care provider. Some examples are: Screening mammogramsAnnual routine vision examsGlaucoma screeningHearing screeningInfluenza or pneumococcal vaccinations (Members are notcharged a copayment for influenza or pneumococcalvaccinations)Routine and preventive women’s health services (such aspap smears & pelvic exams)Bone mass measurementsColorectal screening examsProstate cancer screening examsCardiovascular disease screeningDiabetes screeningDiabetes self-management trainingMedical nutritional therapySmoking cessationAnnual physical examAbdominal Aortic Aneurysm Screening for high-riskindividuals.Access Centers for Medicare & Medicaid Services (CMS)Medicare Learning Network Medicare Preventive Servicesfor detailed information on Medicare Preventive Services.P20
Blue Cross Medicare Advantage (HMO)Provider Manual- SupplementGeneral Information, cont'dInpatientHospitalAdmissionsAll inpatient hospital admissions require prior authorization from the BlueCross Medicare Advantage HMO Utilization Management (UM) Department.The prior authorization process for admissions is carried out by the admittinghealth care provider or hospital personnel.In addition, providers need to notify the UM department of inpatientadmissions for post stabilization care services within one (1) business day ofthe admission following treatment of an emergency medical condition forMedicare Advantage HMO members. Failure to timely notify BCBSTX andobtain pre-approval for further post-stabilization care services mayresult in denial of the claim(s) for such post-stabilization careservices, which cannot be billed to the member pursuant to yourprovider agreement with BCBSTX.Additionally, when a Blue Cross Medicare Advantage (HMO) member arrives atthe facility for an elective admission, providers should notify the BCBSTX UMdepartment to assist in patient care coordination.Admitting health care providers are responsible for contacting the UtilizationManagement Department to request precertification for additional days if anextension of the approved length of stay is required. The admitting health careprovider will provide appropriate referrals for extended care. Blue CrossMedicare Advantage UM personnel will assist with coordinating all servicesidentified as necessary in the discharge planning process.BehavioralHealthServicesBlue Cross Medicare Advantage HMO members requiring Behavioral HealthServices (Mental Health and Chemical Dependency) are required to callMagellan Healthcare Customer Service at 1-800-327-9251. Telephonicaccess is available 24 hours a day, 7 days a week.The Care Managers will provide: Prior Authorization for hospital admissions and outpatient careReferral services, if requiredCase ManagementAssistance in the selection of a participating health care providerCrisis InterventionP21
Blue Cross Medicare Advantage (HMO)Provider Manual- SupplementGeneral Information, cont’dBehavioralHealthServices,cont'dThe following procedures apply to behavioral health services only:-BH Services that require authorizations include:Inpatient Levels of Care Inpatient Mental HealthInpatient Substance AbusePartial Hospital Program MentalHealth Partial Hospital ProgramSubstance AbuseOutpatient Levels of Care/Services Intensive Outpatient Program Mental HealthIntensive Outpatient Program SubstanceAbuse Electro- Convulsive TherapyPsych TestingNote: Whether the services are Medically Necessary must bedetermined before a prior authorization number will be issued. Claimsreceived that do not have a prior authorization number for ahospital admission or outpatient care will be denied.Blue Cross Medicare Advantage HMO behavioral healthprofessionals or physicians may not seek payment from the memberwhen a claim is denied for lack of a prior authorization number.The call to prior authorize can be made by the member, the behavioralhealth professional, physician or a member’s family member.Behavioral health professionals and physicians are encouraged toadmit patients to a participating facility unless an emergencysituation exists that precludes safe access to a participating facilityor if the admission is approved for a non-participating facility.The member will only receive in-network benefits when services areperformed at a participating Blue Cross Medicare Advantage HMOfacility unless the admission is approved for a non-participating facility.Magellan ClaimsFiling AddressBlue Cross MedicareAdvantage HMOP.O. Box1289Maryland Heights, MO 63043Payor ID837P - Prof essional: 01260837I - Institutional: 01260P22
Blue Cross Medicare Advantage (HMO)Provider Manual- SupplementGeneral Information, cont'dPredeterminationRequestsA predetermination of benefits is a voluntary, written request forreview of treatment or services, including those that may beconsidered experimental, investigational or cosmetic.Prior to submitting a predetermination of benefits request, youshould always check eligibility and benefits f
Blue Cross Medicare Advantage (HMO/DSNP)SM Supplement to the Blue EssentialsSM Blue PremierSM, Blue Advantage HMOSM and MyBlue HealthSM Provider Manual Revised 12-10-2021. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
