Provider Network Participation Policy
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1 Participation Policy Blue Cross and Blue Shield of Montana HCS Administrative Policy Version: 8 Original Effective Date: 05/03/2004 Version Effective Date: 09/23/2013 Replaces: N/A Scope This policy applies to the following networks: BCBSMT Traditional Participating BCBSMT Managed Care Montana HealthLink (PPO) - includes HealthLink PPO network with the traditional provider network wrapped around it for Blue Card purposes Healthy Montana Kids (HMK) TriCare MedicareBlue PPO (Medicare Advantage) Purpose The purpose of this policy is to document the types of professional and facility Health Care s (providers) and specialties allowed to participate in the provider networks offered or administered by BCBSMT. Policy BCBSMT contracts with providers located in and licensed by the State of Montana, or in the contiguous counties bordering the state of Montana, as necessary, to provide the benefits and services described in the health plans offered or administered by BCBSMT. BCBSMT does not contract with out-of-state ancillary DME, and Specialty Pharmacy s unless there is a compelling reason to do so. BCBSMT does not contract with DME providers for home sleep studies. s are not allowed to be a participating provider at one location and a nonparticipating provider at another location. The only exception to this requirement is allowed when the provider is an owner at one location and a non-owner employee at the other location, and the employer at the location where the provider is employed requires participation for employment. When this exception does occur, BCBSMT will not list the provider in any of its provider directories. In addition to the above, BCBSMT may individually consider circumstances in the interest of BCBSMT members and to preclude any confusion in the marketplace. The specific provider types or specialties included in each of the networks are described below in descending order of participation. BCBSMT is a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. Page 1 of 8
2 BCBSMT Traditional Participating The BCBSMT Traditional Participating can include the following types of providers or specialties: Air Chiropractor Dentist Durable Medical Equipment (DME) Home Health Hospice Care Inpatient Mental Health I.V. Infusion Therapy Outpatient and X-Ray (PRTF) Skilled Nursing / Extended Care Credentialing is required for all provider types for prior to participation in the Traditional Participating, with the exception of the following: Air Federal Employee Program All FEP eligible provider types are contracted through the HealthLink PPO. Eligible providers many not opt out of FEP. BCBSMT Managed Care The BCBSMT Managed Care includes the following types of providers or specialties: Participation Policy Page 2 of 8
3 Chiropractor Durable Medical Equipment (DME) I.V. Infusion Therapy Licensed Addiction (LAC and CCDC) Outpatient and X-Ray (PRTF) Skilled Nursing/ Extended Care All providers, with the exception of the following, must be participating in the BCBSMT Traditional Participating to be eligible for the BCBSMT Managed Care : Licensed Addiction Credentialing is required for all providers in the Managed Care except: Participation Policy Page 3 of 8
4 Montana HealthLink (PPO) The BCBSMT HealthLink includes the following types of providers: All providers must be participating in the BCBSMT Traditional Participating to be eligible for participation in the BCBSMT HealthLink. The traditional provider network is wrapped around the HealthLink PPO to create a full network for BlueCard purposes and is defined as the BCBSMT PPO product for the purpose of BlueCard. Healthy Montana Kids (HMK) The HMK includes the following types of providers or specialties: Certified Diabetic Educator Family Planning Indian Health Service I.V. Infusion Therapy Licensed Addiction (LAC and CCDC) Naturopathic Physician Optician Outpatient and X-Ray Public and General Preventive Medicine Rehabilitation Therapy Center (PRTF) HMK providers are not required to participate in the BCBSMT Traditional Participating. Credentialing is required for all physicians who participate in the HMK. Participation Policy Page 4 of 8
5 TriWest The TriWest includes the following types of providers or specialties: Dentist (providing medical care) Home Health Hospice Care IV Infusion Therapy Medical Equipment Oral Surgeon (DMD/DDS) Psychiatric Respiratory Therapist Skilled Nursing / Extended Care TriWest providers are not required to participate in the BCBSMT Traditional Participating. Credentialing is required for all providers. Participation Policy Page 5 of 8
6 MedicareBlue PPO (Medicare Advantage) The BCBSMT MedicareBlue PPO includes the following types of providers or specialties: Chiropractor Durable Medical Equipment (DME) Federally Qualified Health Center (FQHC) Home Health Hospice Care IV Infusion Therapy Oral Surgeon (DMD) (DPM) Rural Health Clinic (RHC) Skilled Nursing / Extended Care Credentialing is required for all providers in the BCBSMT MedicareBlue PPO except: Rationale/ Source This policy documents BCBSMT business operations. Participation Policy Page 6 of 8
7 Cross- References For additional information, refer to the following: Document Name Credentialing Application Requirements Credentialing Approval Policy Credentialing Individual Review Practitioner Credentialing Procedure and Decision Making Process Scope of Credentialing and Recredentialing for Allied Health s Scope of Credentialing and Recredentialing for Facilities Scope of Credentialing and Recredentialing for Mental Health s Scope of Credentialing and Recredentialing for Mid-Level Health Care s Scope of Credentialing and Recredentialing for Physicians DocuWare Index Number: Formal Review or Revision Date History This policy was reviewed or revised, and approved as documented below: Version and Approval Date Version and Approval Date Version and Approval Date V-01 05/03/2004 V-02 10/12/2004 V-03 03/28/2005 V-04 03/13/2006 V-05 9/17/2008 V-06 11/1/2008 V-07 04/22/2009 V /27/2009 V-08 09/23/2013 Governance Responsibility for adoption and/or implementation of this policy is as follows: Executive Approval Date Signature on File 09/23/2013 Paul Pedersen Sr. Director, Administration and Contracting Signature on File 09/23/2013 Mark A. Burzynski DSVP Services MT 2004 Blue Cross and Blue Shield of Montana Participation Policy Page 7 of 8
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