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BlueCare TennesseeProvider Administration tion Health ManagementCare ManagementMember Education and OutreachClinical Practice GuidelinesMedical Necessity DeterminationsSecond OpinionsUse of Cost Effective AlternativesTreatment PlanningTreatment Record RequirementsDiagnosisCare CoordinationTransitions of CarePrior AuthorizationsProvider Initiated NoticeLevels of ServicePsychiatric Rehabilitation Services1. Service ComponentsD.E.F.G.H.I.J.K.L.M.N.Crisis ServicesPsychiatric Residential Treatment ServicesTranscranial Magnetic StimulationBuprenorphine Enhanced and Supportive Medication Assisted Recovery and TreatmentMethadone Medication Assisted TreatmentApplied Behavior Analysis (ABA)Access and Availability of Behavioral Health ServicesBlueCare Behavioral Health Quality ManagementProvider Network ParticipationBilling GuidelinesContact UsXVI.Provider Network Participation CriteriaChanges in PracticeProviders Denied ParticipationRemoval of Providers from BCBST/BCT Provider NetworksProvider Termination Appeal ProcessFederal Exclusion Screening RequirementsSubcontractingProvider Identification Number ProcessInteroperability Standards and HITECH ActIntroductionCredentialing ApplicationCredentialing Policies1.2.3.4.5.6.D.XVIII.Credentialing Process for Practitioner:Credentialing Process for Behavioral Health Practitioners/ProvidersRecredentialing ProcessBlueCross BlueShield of Tennessee/BlueCare Tennessee Approved SpecialtiesCredentialing Process for Medical Organizational ProvidersBCBST/BCT Tennessee Recognized Accrediting BodiesPractice Site/Medical Record StandardsCoverKidsA.Introduction7

BlueCare TennesseeProvider Administration ManualB.C.D.E.F.G.H.EligibilityApplicationMember ID CardBenefitsReimbursement MethodologyUtilization ManagementContact UsXIX.Provider Audit GuidelinesXX.TennCare KidsXXI.BEST PRACTICE NETWORK (BPN) PROVIDER MANUALA.B.C.D.E.A.B.C.D.E.F.A.B.OverviewAudit ProcessOperational Guidelines for Facility Emergency Department Claims Audit ProcessData Mining and Claims AuditingReconsideration ProcessTennCare Kids Services – (Does not apply to CoverKids)TennCare Kids Screening GuidelinesInterperiodic ScreeningCoordination of CareTennCare Kids Resources and Helpful TipsTennCare Kids Provider TrainingIntroductionHow to Identify SelectKids Members1.2.3.4.C.BPN Provider Roles and Responsibilities1.2.3.4.5.D.Immediate Eligibility for Children in State CustodyInitial Enrollment of SelectKids MemberPCP Membership ListingSelectKids Member Transition (out of state custody)BPN Primary Care Provider (BPN PCP)Dental ProviderBehavioral Health ProviderHealth Department ServicesClinical Health RecordsDepartment of Children’s Services (DCS)1. Roles and Responsibilities2. DCS Well Being StaffE.Confidentiality, Informed Consent and Medical Records1. Confidentiality and Informed Consent2. Medical Records3. Health Services Confirmation and Follow-up Notification Form and Release ofInformation FormF.XXII.General InformationCHOICES (Long-Term Services and Supports efits1. Covered Services2. Exclusions3. Consumer Direction8

BlueCare TennesseeProvider Administration Manual4. Self-Directed Health Care TaskD.Care Coordination1. Person-Centered Support Plan (PCSP)2. Authorizations3. Coordination with State and Local Departments and AgenciesE.Provider Roles and Responsibilities1. Primary Care Provider2. Care Coordinator3. Long-Term Services and Supports ProvidersF.G.H.I.J.K.Provider Agreement RequirementsProvider Contracting/CredentialingBilling and ReimbursementMember Grievances and AppealsProvider Appeal ProcessGeneral Information1.2.3.4.5.6.7.XXIII.SELECTCOMMUNITY PROGRAMA.B.IntroductionHow to Identify SelectCommunity Members1.2.3.4.C.D.E.F.XXVII.Determining EligibilityEnrollment of SelectCommunity MemberID CardPCP Membership ListingSelectCommunity Provider Roles and Responsibilities1.2.3.4.5.XXIV.XXV.XXVI.Background Checks and Registry ChecksReportable Event ManagementNeglect and Abuse InformationCoordination with other Managed Care Organizations (MCOs)BlueCare Tennessee Provider Compliance PlanNursing Facility Patient LiabilityKatie Beckett Part A ProgramPCP ResponsibilitiesReferrals for Specialty CareCoordination of CarePCP Care Management FeePreventive CareNurse Care ManagerMedical RecordsGeneral InformationGlossaryAttachment I: Non-Emergency Medical Transportation (NEMT) ServicesAttachment II: Tennessee Health Care Innovation Initiative (THCII) ProviderGuideAttachment III: BlueCare Tennessee Change of Ownership (CHOW) Policy9

BlueCare TennesseeProvider Administration ManualI.IntroductionVolunteer State Health Plan, Inc., dba BlueCare Tennessee provides a fully integrated health offeringincluding behavioral health services for BlueCare and TennCareSelect Members. BlueCare Tennessee is aHealth Maintenance Organization and wholly owned subsidiary of BlueCross BlueShield of Tennessee, Inc.and an independent licensee of the BlueCross BlueShield Association. BlueCare and TennCareSelect areproducts underwritten by BlueCare Tennessee.BlueCare Tennessee complies with the applicable federal and state laws, rules and regulations and does notdiscriminate against Members or participants in the provision of services on the basis of race, color,ethnic/national identity, gender, age, sexual orientation, religion, patient type (e.g. Medicaid) or disability inany health program or activity. If a Member or participant needs language, communication or disabilityassistance, or to report a discrimination complaint, please, call 1-800-468-9698 for BlueCare, 1-888-325-8386for CoverKids or 1-800-263-5479 for TennCareSelect. For TTY help call 771 and ask for 888-418-0008.Information about the civil rights laws can be found at http://www.bcbst.com/ or from the Department of Healthand Human Services at http://www.hhs.gov/ocr/index.html .This BlueCare Tennessee Provider Administration Manual (“Manual”) contains comprehensive informationregarding BlueCare , CoverKids, and TennCareSelect operating policies and procedures. The informationcontained in this Manual applies to Providers who care for BlueCare Tennessee Members (“Members”). Therequirements, policies and processes defined in this Manual are a contractual obligation as stipulated inBlueCare Tennessee’s BlueCare and/or TennCareSelect Provider Agreements.BlueCare Tennessee will have in place, written policies and procedures for the selection and retention ofProviders. These policies and procedures shall not discriminate against particular providers that service highrisk populations or specialize in conditions that require costly treatment.BlueCare Tennessee will not discriminate for the participation, reimbursement, or indemnification of anyProvider who is acting within the scope of his or her license or certification under applicable state law, solelyon the basis of that license or certification. BlueCare Tennessee’s ability to credential Providers as well asmaintain a separate network and not include any willing Provider is not considered discrimination.BlueCare Tennessee will not discriminate against Providers and entities in accordance with the federalprohibition against discrimination as provided for under the collective “federal health care Provider conscienceprotection statutes,” referenced individually as the Church Amendments, 42 U.S.C. § 300a–7, section 245 ofthe Public Health Service Act, 42 U.S.C. § 238n, and the Weldon Amendment, Consolidated AppropriationsAct, 2010, Public Law 111–117, Div. D, Sec. 508(d), 123 Stat. 3034, 3279–80.”Furthermore, no person shall be subjected to any form of retaliation to include, threats, coercion, intimidationor discrimination as a result of filing a complaint, testifying, assisting or participating in an investigation,proceeding or hearing.Changes to this Manual will be communicated to Providers at least thirty (30) days prior to implementation(excludes medical policy changes driven by new technology). Such changes are communicated using one ormore of the following resources:BlueAlert Monthly Provider NewsletterIndividual Provider MailingsQuarterly Provider Manual UpdatesBi-Monthly CHOICES Provider NewsletterUpdates to Medical Policy Manual on company websites, www.bcbst.com orhttp://bluecare.bcbst.com.10

BlueCare TennesseeProvider Administration ManualA. BlueCross BlueShield of Tennessee Statement of Purpose BUSINESSOur Business is financing affordable health care coverage. PURPOSEOur Purpose is Peace of Mind. LONG-TERM CORPORATE GOALSOur Long-Term Corporate Goals are: AffordabilitySustainabilityOutreachCode of ConductBlueCross BlueShield of Tennessee and BlueCare Tennessee have been a part of the TennCareprogram since 1993. We have built a bond of trust with the people we serve, as well as the vendors andsuppliers with whom we do business.To strengthen that bond of trust, the BlueCross BlueShield of Tennessee Board of Directors adopted aset of policies and Code of Conduct that applies to all BlueCare Tennessee employees, officers,contracted vendors, and members of the Board of Directors. We are willing to share our own Code ofConduct, along with related policies and procedures, with our business partners in order to relay ourcommitment to a corporate culture of ethics and compliance. The Code of Conduct sets an ethical tonefor the organization and provides guidelines for how we and our business partners are expected toconduct business.We encourage suppliers and third parties with which we do business to adopt and follow a Code ofConduct particular to their own organization that reflects a commitment to prevent, detect and correct anyoccurrences of unethical behavior. In addition, we embrace fraud prevention and awareness as essentialtools in preserving affordable quality health care and actively work with our business partners and lawenforcement agencies to combat health care fraud. More information regarding fraud, waste and abuseeducation and training can be found on the Centers for Medicare & Medicaid Services (CMS) website ach-and-EducationIncluded in our Code of Conduct are two sections entitled “Conflicts of Interest” and “Dealing withCustomers, Suppliers, and Third Parties”. The primary focus of these sections is to help ensure businessdecisions are based on the merit of the business factors involved and not on the offering or acceptance offavors. Additionally, any activity that conflicts or is otherwise incompatible with our professionalresponsibilities should be avoided. You may review the BlueCare Tennessee Code of Conduct in itsentirety online at .pdf.Please share this information with all your employees who interact with our company. If you should haveany questions, or wish to report a suspected violation or fraud, waste or abuse, please call theConfidential Compliance Hotline, 1-888-343-4221 or e-mail compliancehotline@bcbst.com.B. Description of Health Plans and Health Plan Sub-ProgramsBCBST has a long-standing commitment to provide excellent service to the people who depend on us.The increased emphasis at both federal and state levels for establishing National Health CareReform resulted in the State of Tennessee’s introduction of the TennCare Program. BlueCrossBlueShield of Tennessee, through BlueCare Tennessee, is only one of the Managed Care Organizations(MCOs) administering the TennCare Program in the State of Tennessee.Rev 06/2111

BlueCare TennesseeProvider Administration Manual1. BlueCare Tennessee operates two TennCare Program Health Plans:A. BlueCareBlueCare is a product underwritten by BlueCare Tennessee and provides medical care for itsTennCare Members. BlueCare strives to ensure Members receive the highest quality of care in themost cost-effective manner.BlueCare is a Primary Care Practitioner (PCP)-driven HMO network focusing on PCPs providingappropriate care to Members in accordance with established clinical guidelines offering its Membersand Providers programs in medical management, quality improvement, education and development,as well as quality customer service. The customer service areas are designed to provide efficientaccess and assistance to our Providers and Members.B. TennCareSelectTennCareSelect is the State’s self-insured TennCare Health Maintenance Organization that isavailable to select TennCare Enrollees effective July 1, 2001. It is administered by BlueCareTennessee, a subsidiary of BlueCross BlueShield of Tennessee, and has the same benefits as allother MCOs. Enrollees cannot choose TennCareSelect; only the Division of TennCare can enrollMembers. Some of the groups identified by the State, as “select populations” are children whoseeligibility category is SSI (children receiving Social Security Insurance benefits); children who are inthe custody of the state; and children who are in an institutional eligibility category. TennCareSelectserves as the backup program to handle overflow in a geographic area in which other TennCareMCOs do not provide adequate capacity to serve all Enrollees in the region.In addition to serving select populations, TennCareSelect is the State’s safety net network.TennCareSelect was created by the state in response to the Provider community’s request that asafety net be created for the TennCare Program. TennCareSelect reduces disruptions in claimspayment and cash flow in the event MCOs experience future problems.As administrator, BlueCross BlueShield of Tennessee manages the Provider network, processesclaims and prior authorizations, and performs related functions. TennCareSelect Enrollees areentitled to all TennCare Covered Services to include behavioral health services and dental services.The availability of TennCareSelect gives the state an additional option for use in providing effectiveand efficient health care services to needy people in Tennessee. The availability of this optioncontributes to the stability of the program as a whole, while offering TennCare an opportunity toexamine and evaluate new service delivery strategies. Innovations such as TennCareSelect arecritical in preserving TennCare’s strength and vitality for the future.Certain TennCareSelect and BlueCare Members are also eligible to receive enhanced servicesprovided through three sub-programs. The programs are known as CHOICES, ECF CHOICES, andSelectCommunity, which the following more fully describes:Enhanced Services Programs:C. CHOICES Long-Term Services and Support (LTSS) – Effective 8/1/2010TennCare implemented the CHOICES Long Term Services and Supports (LTSS), which includescare in a nursing facility, as well as care at home or in the community, known as Home andCommunity Based Services (HCBS). The Program promotes quality and cost-effective coordination ofcare for CHOICES Members with chronic, complex, and complicated health care, social service andcustodial needs. Care Coordination involves the systemic process of assessment, planning,coordinating, implementing and the evaluation of care received through a fully integrated physical,behavioral health and LTSS program to ensure the care needs of the Member are met. (See SectionXXII. CHOICES in this Manual for more detailed information.)D. Employment and Community First (ECF) CHOICESThe State of Tennessee’s Employment and Community First (ECF) CHOICES program is a managedlong-term services and supports program that offers home and community-based services to eligibleindividuals with intellectual and developmental disabilities enrolled in the program. ECF CHOICES12

BlueCare TennesseeProvider Administration Manualassists individuals with disabilities in leading the life they want to live by providing supports in aperson’s home or in the community. Supports that are individualized help Members obtain andmaintain a job, be actively engaged in their community, and live as independently as possible. (SeeSection XXIII. Employment and Community First (ECF) CHOICES in this Manual for more detailedinformation.)E. SelectCommunity (TennCareSelect only)The Division of TennCare established a TennCareSelect program for certain persons with IntellectualDisabilities called SelectCommunity. The program is open primarily to persons enrolled in one of theState’s Section 1915(c) Home and Community Based Services Waiver programs for persons withintellectual disabilities, as well as Members of the former Arlington class residing in a privateIntermediate Care Facility for individuals with Intellectual Disabilities (ICF/IID). All SelectCommunityMembers are assigned a Nurse Care Manager who serves as the Member’s and Provider’s primarypoint of contact for physical and behavioral health needs. (See Section XXIV. SelectCommunity inthis Manual for more detailed information).F. CoverKidsThe State of Tennessee’s CoverKids plan provides free, comprehensive health coverage forqualifying children under age 19 years, and pregnant women. The coverage includes an emphasis onpreventive health services and coverage for Physician services, hospital visits, vaccinations, wellchild visits, developmental screenings, behavioral health care services, prenatal and postpartum care,pharmacy, dental care, and vision care. CoverKids does not cover any chiropractic, routine vision, orroutine dental care for pregnant women 19 years and older. There are low co-pays for medicalservices, though well-child visits and immunizations are covered at 100 percent. BlueCare Tennesseeadministers the CoverKids program on behalf of the State of Tennessee. Effective July 1, 2016,CoverKids was supported by the CoverKids Network. Effective January 1, 2021, CoverKids issupported by the BlueCare Network. (See Section XVIII. CoverKids in this Manual for more detailedinformation.)A map defining the Gra

We strive to deliver important updates to you quickly through the Provider FAQ, though some of the details may conflict with information currently in our Provider Administration Manual (PAM). If a current Provider FAQ conflicts with a provision in the PAM, the FAQ temporarily takes prece