BCBSAZ Provider E-learning: Eligibility, Benefits, and .../media/azblue/files/misc_pdfs/e...When it...
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Provider Partnerships 02-2020 BCBSAZ Provider E-learning: Eligibility, Benefits, and Precertification
BCBSAZ Provider E-learning: Eligibility, Benefits, and .../media/azblue/files/misc_pdfs/e...When it comes to our member population, one size does not fit all. As you can see, we support
• See samples of member ID cards for different lines of business
• Understand how checking eligibility and benefits helps your practice and get a preview of changes to the online search tool
• Learn about the 2020 precertification changes and the online request tool
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This e-learning module covers what’s new for 2020 and takes you through a brief overview of our different lines of business. We discuss eligibility and benefits and give you a preview our re-designed eligibility and benefits inquiry tool. We also go over 2020 precertification and the new online precert request tool.
Let’s take a look at where we are with products and networks for 2020.
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Types of healthcare plans
INDIVIDUAL (NON-GROUP) PLANS
BCBSAZIndividual/Family Plans
Medicare Advantage (MA) Plans
Medicare Supplement Plans
EMPLOYER GROUP PLANS
BCBSAZ Employer Group
Plans
BlueCard (out-of-area) Employer
Group Plans
Federal Employee Program® (FEP®)
Plans
Corporate Health Services (CHS)
and BCBSAZ-TPA Co-administered
Plans
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When it comes to our member population, one size does not fit all. As you can see, we support several types of plans. That’s one of the reasons it’s so important to check eligibility and benefits for every member. Some of our members have an individual or family plan that was purchased either on or off the Health Insurance Marketplace (Exchange). Some members have Medicare Supplement or Medicare Advantage plans. Others are covered through an employer group benefit plan or the Federal Employee Program (FEP). Some employer group members have plans that are administered or co-administered by a TPA. These include: CHS Groups (Corporate Health Services) – this is our division that handles the employer groups that are self-administered and they actually “rent” our provider network for coverage within Arizona. Most of them use a Third Party Administrator (TPA) as the main point of contact. BCBSAZ-TPA Co-administered plans – these groups collaborate with us in administering their plans and they include access to the national BlueCard network.
BCBSAZ has assumed full responsibility for “BCBSAZ Advantage” (MediSun) plans
BCBSAZ contracts with P3 Health Partners to administer the HMO networks and plans for members in Pima and Santa Cruz counties
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We’ve made some organizational changes to expand our 2020 BCBSAZ Medicare Advantage products: BCBSAZ is now the sole owner of MediSun (also known as BCBSAZ Advantage) and we’ve assumed full responsibility for administering the 2020 plans issued by the MediSun entity. BCBSAZ is also contracted with CMS for MA plans and for 2020, we’ve issued new HMO and PPO plans. We still contract with P3 Health Partners to administer the HMO networks and plans for members in Pima and Santa Cruz counties.
Medicare Advantage overview for 2020NETWORK SERVICE AREA BENEFIT PLAN PREFIX PLAN ADMINISTRATOR
Blue Advantage (MediSun)
Maricopa County and parts of Pinal County
Blue MA Classic (HMO)M2K
BCBSAZEDI: 53589
Blue MA Plus (HMO)
BluePathway HMO NEW! Maricopa CountyBluePathway Plan 2 (HMO)
M2VBluePathway Plan 3 (HMO)
BlueJourney PPO NEW! Maricopa and Pima counties BlueJourney (PPO) M3P
P3 (Blue Advantage)Pima County Blue MA Classic (HMO)
M2KP3 Health Partners
EDI: 58375Santa Cruz County Blue MA Standard (HMO)
P3 (BluePathway) NEW! Pima County BluePathway Plan 2 (HMO) M3V
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This table shows the 2020 Medicare Advantage networks, service areas, and benefit plan names with the new member ID prefixes. It also shows which networks and plans are administered by BCBSAZ and which ones are administered by P3 Health Partners.
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NETWORK PARTICIPATION AGREEMENTSStatewide PPO Network, used for BCBSAZ members with PPO plans using this network; BlueCard members with PPO plans; FEP members; CHS group members; members with BCBSAZ-TPA co-administered plans BCBSAZ provider participation agreement – includes
these lines of business for all contracted providersStatewide Indemnity Network, used for BCBSAZ members w indemnity plans using this network; BlueCard members w plans using the Traditional Network
Statewide HMO Network BCBSAZ agreement – optional line of businessWorkers’ Compensation Network BCBSAZ agreement – optional line of businessMedicare Supplement Network BCBSAZ agreement – optional line of business
BCBSAZ Medicare Advantage agreement or amendment, or separate P3 amendment
VA-PC3 Program Network – TriWest Healthcare Alliance Separate TriWest Agreement issued by BCBSAZ (BCBSAZ is responsible for contracting this network)
BlueDental PPO Network | BlueDental Prime Network | BlueDental DHMO Network BCBSAZ provider participation agreement with dental reimbursement exhibit
FEP Dental Network Optional line of business in the BCBSAZ dental agreement
FEP BlueDental Network Separate DeCare agreementDenteMax National Dental Network Separate DenteMax agreementDavis Vision Network Separate Davis Vision network agreementChiropractic Services Network - American Specialty Health (ASH) Separate ASH provider network agreement
Network overview
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Here is a list of all of our provider networks, as well as the provider participation arrangements for each of them. The new networks for 2020 are shown in red font. Part of checking eligibility and benefits includes checking to see which network the member’s plan uses.
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Which plans can I accept?
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If you’re not sure which networks you’re in or which plans you can accept, you can check your listing in the provider directory. On azblue.com, you’ll see a Find a Doctor.
Two websites; two secure provider portals; two provider directories!
azbluemedicare.com
azblue.com/providers
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Please note: At the moment, we have two websites – our main website at azblue.com serves most lines of business and we also have one just for Medicare Advantage (azbluemedicare.com). The azblue.com website does not include the resources you need for Medicare Advantage members. Even the provider directories are different, so you’ll need to check both directories to get the complete picture of the plans you can accept. The directory navigation on both sites is similar.
We recommend that you check each of your provider directory listings on a regular basis to make sure they’re accurate. Please let us know right away if anything needs to be updated. We have a “Provider Change” form you can use to request the changes.
2020 member ID prefixes (for standard benefit plans)Network Name / Product Type Member ID PrefixStatewide PPO Network – PPO plans for employer groups XBB, XBM, XBP
• FEP (Federal Employee Program) – FEP plans use Statewide PPO Network RIndemnity Network XBC, XBDStatewide HMO Network – Open-access HMO plans for employer groups XBK, XBOStatewide HMO Network – PCP Coordinated Care HMO plans for employer groups XHKSenior Preferred/Medicare Supplement Network XBSBlueDental Network – Stand-alone dental benefit plans 99D, MUMAlliance Network* – PPO plans for employer groups XBNAlliance Network* – PCP Coordinated Care HMO plans for employer groups XAHMaricopaFocus Network* NEW – PCP Coordinated Care HMO plans for individuals/families residing in Maricopa County FLHNeighborhood Network* – PCP Coordinated Care HMO plans for individuals/families residing outside of Maricopa and Pima Counties NNG, NNJ
PimaFocus Network* – PCP Coordinated Care HMO plans for individuals/families residing in Pima County FQLPimaConnect Network* – PPO plans for employer groups PMAPimaConnect Network* – PCP Coordinated Care HMO plans for employer groups PMKMedicare Advantage: Blue Advantage Network – HMO plans for Medicare-eligible individuals M2KMedicare Advantage: BluePathway Network NEW – HMO plans for Medicare-eligible individuals M2V, M3VMedicare Advantage: BlueJourney Network NEW – PPO plans for Medicare-eligible individuals M3P
* BCBSAZ exclusive network, limited in geographic scope. Only providers with a separate agreement or amendment for a particular exclusive network are considered in network for plans associated with that network.
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This reference list shows you the prefixes for our standard benefit plans. Most BCBSAZ members have plans with these prefixes. And these prefixes are associated with a specific network.
Unique prefixes for employer groups – partial listEmployer Group Name Unique PrefixCity of Chandler CTZ
City of Phoenix PXO
Fender Musical Instruments Corporation FZR
Kingman Regional Hospital KGM
Knight Transportation KTO
Northern Arizona University NOR
Northwest Arizona Employees Benefit Trust NBT
OB Sports Golf Management, LLC OBT
Pima County Community College District PCL
Snell & Wilmer, LLP SWB, SNK
State of Arizona (ADOA) SYD
Swift Transportation SWT
Teamsters Western Region & New Jersey Fund TYW
Tohono O’odham Nation ODM
Truly Nolen of America, Inc. TTK
U-Haul International, Inc. UHL
Yuma County UYU
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This partial list shows some of our employer groups that have unique prefixes. You always need to check the member ID card to see which network is being used because for these members, because a unique prefix doesn’t necessarily indicate a specific network. The groups highlighted in the light yellow have customized precertification requirements.
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This document is updated and re-posted as needed. Member ID Prefix List PDF
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We post our list of prefixes on the secure provider portal. Many providers find it to be a very helpful resource to understand what type of plan the member has.
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Download current prefix lists
azblue.com/providers
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In the secure provider portal at azblue.com, you can find the member ID prefix lists link in the Practice Management menu under Eligibility & Benefits.
ID card displays the designated PCP for each member
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The member ID card for a PCP Coordinated Care HMO plan displays the designated PCP for each family member. This type of plan requires BCBSAZ-approved referrals for most specialty care.
This shows an example of a plan for an employer group that is headquartered outside of Arizona. The group might have employees living or traveling here in Arizona.
This card shows the new M2K prefix for the Blue Medicare Advantage Classic plan. You’ll want to check the network name and service area to see if you’re considered in-network for the member’s plan.
XBU is associated with dates of service up to the end of 2019. All MA plans issued for the 2020 calendar year have new prefixes.
2019 ID card sample
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The Medicare Advantage “XBU” prefix is only relevant to service dates before January 1, 2020. For 2020, we have assigned new prefixes for all members. Some members have not yet received their 2020 cards. If a member presents an ID card with the XBU prefix, please call us for eligibility and benefits information. We’ll give you the new member ID.
A plan that is co-administered by BCBSAZ and a TPA will have a notice in the bottom left corner of the card. The TPA handles the member side of things and precertification. We handle everything else on the provider side.
Use the BCBSAZ-assigned group number on the claim (3 letters followed by 3 numbers)
Contact the TPA for eligibility and benefits information
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CHS member ID cards are issued by the group’s TPA and they do not have the BCBSAZ logo on the front of the card. Notice the PPO Medical Group number that has been assigned by BCBSAZ. It’s extremely important to use this number on the claim – it typically has 3 letters followed by 3 numbers (e.g. ABC123). This card sample also displays an internal group number. You will see that on some CHS cards. That number is for TPA use only and should not be put on your claim. Again, because BCBSAZ prices the claims and then sends them on to the TPA, you need to use the PPO Medical Group ID number on the claim – this will help avoid your claim being returned because we can’t route it to the TPA.
You’ll find our logo on the back of the card. You might also see logos from other carriers indicating access to networks for out-of-Arizona care. CHS groups only get the use of the BCBSAZ provider network – they do not have access to the national BlueCard network outside of Arizona. So sometimes, a group will arrange to give their members access to another carrier’s network for covered services that are provided outside of Arizona.
Self-funded CHS employer groups design their own benefit plans
BCBSAZ
1. Access to PPO Network(in Arizona only)
2. Claim Pricing (sends priced claims to TPA for processing)
TPA (third party administrator)
Eligibility & Benefits Precertification
Claim Processing Remits / EOBs
Medical Policy Records Requests
Appeals & Grievances
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This slide illustrates the roles and responsibilities of BCBSAZ and the TPA. As you can see, the TPA handles almost everything. The only function the TPA doesn’t handle is claim pricing, which we do here at BCBSAZ. So you do need to submit claims to us, but then after we price them, we immediately forward them to the TPA for processing. The TPA is your contact for everything, including eligibility and benefits information.
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Eligibility & benefits resources on the secure portal
azblue.com/providers
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You can access the eligibility and benefits resources in the secure provider portal in the Practice Management menu under eligibility and benefits. Notice the link for CHS Group Information. That takes you to a page where you can find contact information for the group’s TPA and any precertification vendors they might be using.
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Download a PDF copy of the list (updated monthly)
Use the online search tool (updated real-time)
Or:
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The CHS/TPA Information page gives you the option to: Download an all-inclusive list of our currently contracted CHS Groups and their TPA contact information (updated monthly) OR Find a specific group using the search tool (the information is updated real-time)
CHS group search – sample results pageUse the BCBSAZ-assigned group # for eligibility inquiries and on all claims. The ID has 3 letters followed by 3 numbers.
Contact info for eligibility & benefits, and claims
Contact info for precertification
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Here you can see a sample of the kind of information you get when you do a CHS group search. It includes the BCBSAZ-assigned group number (ABC123) right at the top. You’ll see contact information and sometimes a link to the TPA’s website.
Eligibility and benefits features:• Filter benefit inquiries by relevant
types of service• Hear benefit limits and status on
accumulated benefits• Request a fax of the member’s
benefits• Stop the benefits playback and
move on to other functions• Receive a call reference number
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Our IVR system gives you up-to-date eligibility and benefits information. As you can see on this slide, there are several features you might find helpful. We understand that sometimes you have questions that can’t be answered through the IVR and we are still here to help you get that deeper layer of information. After you have successfully followed the IVR prompts to identify yourself and the member, you can say “representative” at any time during your call to talk with someone on the provider service team.
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Eligibility & benefits resources on the secure portal
azblue.com/providers
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You can access the eligibility and benefits inquiry tool from the secure provider portal in the Practice Management menu under eligibility and benefits.
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Eligibility & benefits quicksearch from homepage
azblue.com/providers
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You can also use the quicksearch tool right from the homepage.
Works for BCBSAZ, FEP and BlueCard (out-of-area) members
2. Enter Member Birthdate
1. Enter Member IDNote: For BCBSAZ members, you may use the Member Name or SSN instead of the member ID.
4. Select Service Type(s)
3. Enter Date of Service
5. Click Search Eligibility for detailed results.
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This tool works not just for BCBSAZ members, but also for FEP and BlueCard (out-of-area) members as well. Remember, for CHS group members, you’ll need to go through the TPA. 1. Enter the member information. If the patient is a BCBSAZ member, you have some additional options you can use instead of the member ID. For FEP and BlueCard members, you’ll need to use the member ID from the ID card, including the prefix. 2. When you click on Service Type, you’ll get a drop down menu that’s set up according to HIPAA X12 standards.
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Select your specific specialties
Select up to 5 Service TypesNotes: 1. You can use the search function or you can scroll
through the menu to select service types. 2. The “Health Benefit Plan Coverage” option displays an
indicator for members delegated for eviCore precertification (for certain specialty services and drugs).
Click OK
See Quick Reference Guide for complete list of available service types and responses, according to HIPAA X12.
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You can select up to five service types to get the detailed information you need. If you’re not sure which ones to use, you can download the Quick Reference Guide to see the kinds of information that each type displays. The “Health Benefit Plan Coverage” option will show you if that specific member is delegated for eviCore precertification for certain specialty services and drugs.
Select one or click the Member ID link to view details.
Results page
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Here is a sample of the Eligibility and Benefits Results page, displaying results for any member searches you’ve done in the past five days. Select a row or click on a Member ID link for details.
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Detailed results page
Get detailed information by opening these menus In Network (coverage and cost share)
Out of Network (coverage and cost share)
Network Not Applicable (benefit accumulation, etc.)
View member ID card(for BCBSAZ members only) Access benefit books
(for BCBSAZ members only)
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This slide shows you a detailed results page. You can access the member’s ID card and benefit books here (for BCBSAZ members only). Notice the blue headers – that’s where you’ll find the details. When you click on the first two, you get specific coverage and cost share information. The Network Not Applicable menu displays things like how many PT sessions the benefit allows and how many have been used. Be sure to open the Network Unknown menu - it includes other important information that further details the member’s benefits, such as whether or not the member is delegated for eviCore precertification for certain specialty services and drugs. You might see related precertification requirements, the meaning of benefit abbreviations, and relevant procedure codes. If the member is currently in a grace period, that information will also show up here.
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“In Network” menu: Deductible information
Deductible remaining
Out-of-pocket information
Deductible information
We refresh these menus at the start of each business day to give you the most current and comprehensive information available.
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This screenshot shows you an excerpt of the “In Network” menu. It displays the member’s benefit information, including calendar year deductible, deductible remaining, copay, and out-of-pocket amounts.
“Network Unknown” menu: eviCore delegation information
The “Health Benefit Plan Coverage” service type displays a message if the member is delegated for eviCore precertification.This is also where you would find grace period information.
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Many of our members are delegated for eviCore precertification. So how do you know which members are included in the eviCore program? The “Network Unknown” menu displays a message if the member is delegated for eviCore precertification. This is also where you’ll see grace period information.
Month 1• Member is eligible. All claims are processed and paid as usual.
Month 2• Member is eligible. All claims are pended. Notification letter is sent to provider.• Pharmacy claims are denied at point of service.
Month 3• Member is eligible. All claims are pended. Notification letter is sent to provider.• Pharmacy claims are denied at point of service.
TERM• Member is terminated (retroactive to last day of Month 1 of the grace period) for non-payment.• Pended claims are adjusted and denied as “member not eligible.”
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This slide gives you a snapshot of what happens with eligibility and claims during a grace period (for members with subsidized plans purchased on the Exchange who have fallen behind on premium payments). As you can see, the member remains eligible throughout the three months of the grace period. However, the claims start to pend in Month 2. If the member is terminated after the grace period, the pended claims will be denied. When you’re consistent in always checking eligibility and benefits, you can be proactive in helping patients and also in helping your practice manage a grace period situation.
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My Patients List
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The My Patients List brings up all the eligibility inquiries your organization has done in the past 7 months. You can update the service types and dates of service and resubmit inquiries right from this page.
Changes to the homepage and eligibility/benefits search tool
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We’re launching some revisions to the secure portal homepage and eligibility/benefits search tool.
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Homepage with re-designed eligibility/benefits tool
azblue.com/providers
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Here is a preview of the new homepage with the re-designed Eligibility and Benefits Search tool. I’m guessing you’ll fin it simpler and more user-friendly.
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Two search options
azblue.com/providers
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You can search by member ID or by name. Please note that searching by name only works for BCBSAZ members, not FEP or out-of-area BlueCard members. You need the date of birth for both options.
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Search results (top of page)
azblue.com/providers
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Some of the features you’ll see on the results page include: The status bar at the top, showing if the member is currently active. This bar is green – the member is currently active. Important messaging, such as this alert in the blue box saying that the member has a PCP Coordinated Care HMO plan. The eligibility summary includes grace period information if the member is currently in a grace period.
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Search results (bottom of page): Deductibles
azblue.com/providers
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As you scroll down, you’ll see the deductible and out-of-pocket information.
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Search results (bottom of page): Benefits
azblue.com/providers
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When you scroll down even further, you’ll see several dark blue benefits menu, based on the service types you selected. When you open those, you’ll see information specific to the member’s benefit plan. We recommend that you always check the Health Benefit Plan Coverage menu at the top, because that’s where you’ll find the information about eviCore delegation.
This member is delegated for our eviCore precertification program for certain specialty services and medications.
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When you click the “Network Unknown” tab, and open the messages under “Additional Information” you’ll see a message if the member is enrolled in our eviCore precertification program for certain specialty services and medications. If there is no message there about eviCore, the member is not delegated for the program. Instead, BCBSAZ will be handling the precertification requests for those types of services.
Put protocols in place to avoid delays:• Use a COB form to collect other insurance
information from the member.
• Verify the other sources of insurance coverage.
• Have the member sign the form and submit it to their Blue plan at the address on the back of the ID card.
Tip: Update COB information regularly with the member.
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COB is the #2 reason for claim denial. We recommend that you make it a protocol in your practice to collect COB information up front, at least once a year. You can use a form to gather information, have the member sign it, and send it to their Blue plan. BCBSAZ will not accept the form unless it is signed. If you receive a COB-related denial and you have a current, signed copy of the COB form from the member, you can upload it to the provider portal as correspondence and that will help move things along for that claim.
Next, let’s talk about informed consent. Generally speaking, BCBSAZ network providers are prohibited from balance billing for any services that are denied as not medically necessary or experimental/investigational. If you anticipate this to be the case, you need to proactively advise the patient that BCBSAZ may not cover the service that you’re recommending. You are contractually required to fully discuss with the patient, and document, all issues related to the proposed service, including the expected cost. The patient can then make an informed decision to have the service and agree to pay for it, knowing that their insurance plan may deny coverage. If this discussion and documentation process doesn’t happen well in advance of the service, you won’t be able to charge the member for the services and you will be liable for all costs.
For your support, we offer an optional waiver form that can be used in a situation where you need the patient’s informed consent. This slide shows where you’ll find the form.
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Limited waiver of restriction agreementWhen you recommend services that might not be covered:
1. Document in writing all disclosures and discussions held with member. Include details about the $ amounts.
2. Use a waiver form to capture consent to pay.
3. To ensure payment, have the member sign the agreement..
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Let’s say you have a situation where the patient has made an informed decision to go ahead with a service anyway, after being cautioned orally and in writing that it may not be covered. You then need to get the patient’s written waiver of billing protections for the service. We will respect that agreement. If you decide to create your own form, the Provider Operating Guide (section 14) offers guidance on what to include. Whether you’re using our form or your own, make sure to have the member sign the consent agreeing to pay.
• Precertification (pre-service)• Certain outpatient services/items • Scheduled inpatient admissions• Extended stays• Admissions for post-acute care – SNF, EAR, LTAC
(we process these very quickly!)
• Notification of unscheduled inpatient admissions
• Concurrent reviews
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Optimizing the value of healthcare for our members is a team effort. It includes precertification for certain outpatient services or items, as well as all scheduled inpatient admissions, including for post-acute care. We also need you to notify us of unscheduled inpatient admissions and send us documentation for concurrent reviews.
Unscheduled inpatient admission notificationWe require notification of unscheduled inpatient admissions (includes behavioral health) within 48 hours or the next business day (24 hours for Medicare Advantage). Coverage determination criteria for these admissions follows InterQual® guidelines. General principles include:• Severity of signs/symptoms• Medical predictability of an adverse event• Need for care that can only be delivered safely
and effectively in the inpatient setting
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For unscheduled inpatient admissions, we require notification within 48 hours or the next business day. Coverage criteria is based on medical necessity, according to InterQual guidelines.
After an initial admission (or extended stay), we do concurrent reviews. Medical necessity criteria apply. • Severity of signs/symptoms• Medical predictability of an adverse event• Need for care that can only be delivered
safely and effectively in the inpatient setting
Concurrent review focuses on care continuity and discharge planning.
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Our concurrent reviews focus on care continuity and discharge planning.
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Navigating our precertification requirements2020 Precertification Requirements eviCore programOur standard requirements (includes services/medications in our eviCore precertification program) apply to most BCBSAZ benefit plans:
• Most PPO plans, including PPO plans using Alliance and PimaConnect networks (XBB,XBM, XBP, XBN, PMA, and other unique prefixes)
• Indemnity plans (prefixes XBC, XBD)• HMO plans (XBK, XBO, and other unique prefixes)
Request precert from eviCore for delegated members for certain services/medications; Request precert from BCBSAZ for all othermembers for these services
Requirements for our PCP Coordinated Care HMO plans (these members not delegated for eviCore)• PCP Coordinated Care HMO plans (prefixes FLH, FQL, NNG, NNJ, PMK, XAH, XHK)• These plans have a dedicated precertification request tool, fax form, and phone line N/A
Requirements that are customized for certain large group plans (these members not delegated for eviCore)• ADOA – State of Arizona (prefix SYD; group 030855)• City of Phoenix (prefix PXO; groups 040000 and 040004)• Northwest Arizona Employee Benefit Trust (prefix NBT; group 03746)• OB Sports Golf Management, LLC (prefix OBT; group 038043)• Snell & Wilmer (prefixes SWB, SNK; group 030313)• Teamsters (prefix TYW; groups 031843 and 031844)
N/A
Requirements for FEP® plans (these members not delegated for eviCore)Standard, Basic, and Blue Focus plans (prefix R) N/A
Requirements for Medicare Advantage prior authorization (BCBSAZ list and P3 Health Partners list)
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Most of our benefit plans use the standard precertification requirements. And most of the members in this category are delegated for our eviCore program for certain services and medications. Our PCP Coordinated Care HMO plans use a slightly different list. Some of our large employer groups have customized precertification requirements. The Federal Employee Program has its own precertification and prior approval requirements. And our Medicare Advantage plans use either the BCBSAZ MA prior authorization requirements or the P3 Health Partners requirements.
Let’s look at some of our online resources related to precertification requirements: our standard code list, our compiled precertification requirements lists, and the specialty medication list.
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This slide shows an excerpt from our current version of the standard precertification code list. We are continuing our line-by-line review of the list to meet two important goals: To do what’s right for our members To avoid unnecessary administrative burden for our network providers We will release the final version of the list later this year. Please note that the fourth column gives you the precert administrator information – it could be BCBSAZ or it could be eviCore.
eviCore programWe are currently partnering with eviCore for precertification for the following specialty services and medications:
• Lab management
• Medical oncology
• Radiation oncology
• Radiology
• Specialty drugs
The specific codes for these services and drugs are included in the standard precertification code list.
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Our standard precertification code list displays all the codes in our eviCore program (includes lab management, oncology, radiology, and specialty drugs). Not all members are delegated for the eviCore program (see slide 48 for information about finding the eviCore indicator in the eligibility and benefits results).
72 Proprietary & ConfidentialStandard precertification code list includes eviCore codes
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Here is another excerpt of the standard precert code list showing some of the eviCore program codes. For these codes, if the member is delegated for the eviCore program, request precert directly from eviCore. If the member is not delegated for eviCore, request precert from BCBSAZ.
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Our compiled precertification requirements PDF includes:• Standard list• PCP Coordinated Care HMO list• Six different customized lists for large employer groups• FEP list
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Our precertification requirements lists PDF gives you a snapshot of nine different precert requirements lists. It doesn’t get down to the code level of detail but it’s a good overview of the types of services that require precert for various lines of business. It doesn’t currently include the requirements for Medicare Advantage. You’ll find those lists on the secure provider portal at azbluemedicare.com.
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Our comprehensive specialty medication list gives you detailed precertification information for specialty medications covered under medical and pharmacy benefits. This list is currently being updated and will be re-posted online soon.
We also have some great resources for checking clinical criteria.
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Clinical criteria
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Here is where you’ll find access to our clinical criteria resources. The InterQual search tool displays all of the clinical criteria we use except for those associated with eviCore (for certain specialty services and drugs) and those associated with ASH (for chiropractic services). Keep in mind that other Blue plans use their own criteria. The same is true for FEP and for our CHS groups. So you’ll see links for all of those other resources.
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InterQual® search tool
Tool displays all criteria used by BCBSAZ except those associated with: 1. eviCore (for certain specialty services and drugs) 2. ASH (for chiropractic services).
azblue.com/providers
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The InterQual search tool is easy to use – just enter a key word or medical code and click the blue “Find Subsets” link. Once you find the criteria, you can download the “SmartSheets” that shows all the logic depending on the patient’s condition.
• Check if precertification is required for a particular service
• Request precertification
• Check precertification status for FEP and most BCBSAZ members
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You can use the IVR system to check precertification requirements for a particular service. You can also request precertification or check the status of a precert for FEP and most BCBSAZ members.
There are a several different resources for precertification requests on the secure provider portal. We have three different online tools – one for BCBSAZ (for most members), one for eviCore, and one specifically for PCP Coordinated Care HMO plans. You also have a router tool for BlueCard members.
The online precert tool makes it easy to request precertification for medical services and items, as well as medications covered under medical benefits.
New online precertification request tool on azblue.com is not meant for all lines of business!DON’T use the new BCBSAZ online request tool for: DO request precertification this way:
BCBSAZ members with plans that require eviCoreprecertification for certain specialty services/drugs (when those services/drugs are needed)
Use the eviCore online request tool for eviCore-managed services/drugs
BCBSAZ members with PCP Coordinated Care HMO plans (member ID prefixes FLH, FQL, NNG, NNJ, PMK, XAH, XHK)
Use the PCP-HMO online request tool in the secure provider portal at azblue.com/providers > Practice Management > Precertification > BCBSAZ Members-Requests: PCP HMO
Members with plans that are administered by a third-party administrator (TPA)
Contact the TPA or precertification administrator listed on the member ID card
Members with out-of-area BlueCard® plansUse the BlueCard router tool at azblue.com/providers > Practice Management > Precertification > BlueCard (out-of-area) Members
Members with Federal Employee Program® (FEP®) plans Call 602-864-4102 or 1-800-345-7562
Members with BCBSAZ Medicare Advantage plans Use the prior auth fax form available in the BCBSAZ Medicare Advantage secure provider portal at azbluemedicare.
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This reference slide shows you how to request precertification or prior authorization for various lines of business.
BlueCard (out-of-area) precertification toolThis precertification tool only works for members from other Blue plans.
The member’s ID prefix automatically routes you to the website of the member’s Blue plan where you can access information about precertification requirements and requests.
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You can use this router tool to do pre-service reviews for BlueCard out-of-area members. When you enter the member’s ID prefix, you land right on the member’s Blue plan website for information about precert requirements and requests.
BCBSAZ Care Management programRefer patients to our Care Management program at no charge• Clinically trained and licensed staff
• Professional one-on-one assistance for members facing catastrophic medical events, chronic disease diagnoses, or other support needs
• Comprehensive and multi-disciplinary approach to support diverse patient health goals, concerns, and challenges
• Coaching to engage members in life-style changes and treatment adherence
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The way our care management model works is that the member has one point of contact (the care manager) but the team can include several other people that act as consultants for the member’s case. We have weekly case conferences to discuss the cases.
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Care management referral form
azblue.com/providers > Provider Resources > Forms
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The Care Management referral form is available at azbluemedicare.com in the resources section. You can use it to let us know about a member who might benefit from this program.
What is something you’ve learned today that will help you in your work?
What are the next steps you need to take?
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What was something you found particularly valuable in this eLearning module or something you want to implement in your office… Make a note of how you want to follow up or any changes you want to make.
You can always call or email your assigned NCS (Network Contract Specialist) for more clarity on something or with questions specific to your particular practice. Not sure who that is? The next few slides will show you how to find out.
For help with your secure provider portal account, contact our eSolutions Technical Support team
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If you are logged in to the secure portal, go to the “Contact Us” page and you’ll find a link to the NCS search tool there as well as the contact information for our tech support team.
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Get contact info for your NCS
azblue.com/NCS
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If you’re not logged into the portal, you can go to the “Contract with Blue” menu and click on “Contract Specialist.” The tool itself is really simple and easy to use.
