Chapter 2 Provider Responsibilities Unit 4: PCP Policies and Procedures For All Products

Chapter 2 Provider Responsibilities Unit 4: PCP Policies and Procedures For All Products In This Unit Topic See Page Unit 3: PCP Policies And Procedures For All Products Arranging for PCP Absence 2 Locum Tenens Policy 4 Requesting a Contract Copy 5 Member Removal Policy (Western Region Only) 6 Member Removal Procedure (Western Region Only) 9 How to Close and Re-open Your Practice To Members 11 Eligibility Rosters 12 How to Read the Eligibility Roster 13

2.4 Arranging For PCP Absence Introduction The purpose of this section is to explain what the PCP needs to do before leaving for vacation or other time off. Making The Necessary Arrangements 1. Find a PCP who participates in the same network(s) as you to provide medical treatment to members during your absence. 2. Resolve payment arrangements, including co-payments 3. Inform office staff of the above arrangements and ask that the covering physician inform his or her office staff of the arrangements. 4. Be sure that your answering service informs patients of the arrangement. Appointments Most members will be able to wait for their regular PCP s return. However, there will be some cases when a member will require an office visit during his or her PCP s absence. For such cases, the covering PCP s office staff should make an appointment or arrangements and give the member clear directions. Important: Authorization Requests During The PCP s Absence If the PCP is planning to be away for a short duration (less than 5 days), the covering PCP can request authorizations, and advise members to go to specialists or the emergency room during the PCP s absence. The covering physician may keep a list of these incidents, which he or she then shares when the member s PCP returns. For the treatment that took place during the absence, the member s PCP should submit any authorization requests expediently to avoid payment delays. Continued on next page 2

2.4 Arranging For PCP Absence Continued Reimbursement And Copayments We advise physicians to work out their own payment arrangements prior to covering for one another. We do not provide additional reimbursement to practitioners who are covering for other PCPs. The collection of co-payments works the same way. The two physicians involved should come to an agreement as to how this will be handled. Informing The Office Staff It is imperative that both the regular and the covering physicians office staffs be aware of any temporary coverage arrangements. Failing to notify the office staffs may decrease continuity of care to network members. 3

2.4 Locum Tenens Policy Overview Highmark allows providers with established assignment accounts to utilize the services of a locum tenens to cover for a credentialed provider of the group or provide additional coverage for increased demands or cover while recruiting additional providers. Rules To Utilize Locum Tenens In order for a provider to obtain this type of coverage the locum tenens: must be licensed to provide services in Pennsylvania can only provide services for a total of six months or less within any 12-month period beginning with the first date of active service. Procedure Step Action 1 Practice must notify their Provider Relations Representative (PRR) of their request for locum tenens. 2 The PRR must obtain the following information from the provider: A Participating Provider Agreement with Highmark Blue Shield form signed by the locum tenens (if they do not currently have a valid individual Highmark provider number or are currently nonparticipating). A Request for Addition/Deletion to Existing Assignment Account form signed by the locum tenens assigning payment for their services. The Locum Tenens form, available on the Provider Resource Center under Provider Forms, completed by the practice indicating, if applicable, who the locum tenens is covering for and the specific dates they will be providing services The Locum Tenens UPIN, Medicare welcome letter and NPI number if the group provides services to Medicare Advantage members. 3 The PRR will verify that the Locum Tenens was added to the assignment account and has not provided or will provide services in a time frame not to exceed 6 months. The PRR will notify applicable Highmark internal departments. 4 The PRR will notify the Assignment Account of the start and end dates of the locum tenens or of the reason the Locum Tenens cannot be added and notify the requesting provider. 4

2.4 Requesting A Contract Copy Overview Highmark allows participating providers to request copies of their participating physician contract, as required. Highmark will provide a copy of the contract with participating physicians including certain contracts with physician organizations or physician groups where participating physicians participate. Highmark is restricted, however, to provide contracts to requesters if the terms of the contract restrict the request. If you have further questions about this process, please contact your Provider Relations Representative. How To Request A Copy/Track The Status Of Your Participating Physician Contract Providers must direct a written request for a copy of their contract to: Highmark Blue Shield Provider Information Management P.O. Box 898842 Camp Hill, PA 17089-8842 Upon receipt of the request, Highmark s Provider Maintenance department will provide the requestor one copy of their participating physician contract, unless otherwise requested. To check the status of your request, please call 1-866-763-3224, option 4. Requests generally take 15 business days to process. Please allow ample time for processing before checking the request status. 5

2.4 Member Removal Policy Western Region Only Policy All members of Highmark Blue Shield and the Western Region s managed care programs have a responsibility to maintain a cooperative physician/patient relationship. Documented occurrences of members not fulfilling their responsibilities may result in a practitioner requesting discharge of the member from his or her practice. Background The relationship between a PCP and his or her members is crucial in the managed care environment. However, sometimes problems can occur which cause a serious rift in the doctor/patient relationship. In such cases, we ask the PCP to attempt to resolve the matter directly with the member. If this does not correct the problem, the PCP is supported in his or her effort to remove the member from the practice. Valid Reasons For Member Removal Valid reasons for discharge of a member include: Patient fraud: All cases of potential fraud and abuse should be reported to Highmark Special Investigations Department at 1-800-438-2478 by either the practitioner or the Highmark employee. Abusive behavior: Examples include profanity or threats of physical violence. For mentally competent members over the age of 21, the noted behavior must be exhibited by the member and not by family members. For mentally incompetent adults or minors, the noted behavior must be exhibited by the immediate family members and/or guardians. Medical non-compliance: This includes a member failing to follow a recommended course of treatment. The practitioner must be able to demonstrate that non-compliance has jeopardized, or could likely jeopardize the health/safety of the member. Network procedures non-compliance: This includes a member who has missed more than two appointments within the past 12-month period without appropriate notification. The practitioner must have a written policy that informs the member of the consequences of missed appointments. Continued on next page 6

2.4 Member Removal Policy Western Region Only, Continued Valid Reasons For Member Removal (continued) Member fails to meet the financial obligation of the plan: This includes nonpayment of copayments after reasonable effort has been made to collect monies. This does not include outstanding charges the member owes the practitioner prior to the effective date with Highmark or the western region network managed care programs. Legal action: This includes past legal action by the member or legal action that has been threatened against the practitioner or the practitioner s staff. It does not include legal action involving providers other than the practitioner requesting the discharge. Out-of-area members: Members must reside permanently in the network area. For Highmark s western region Medicare Advantage HMO, members may be out of the service area for up to six months while retaining their in-area PCP. Highmark s western region medicare advantage HMO considers any greater period to be a permanent move and the member will be involuntarily disenrolled from the program. Exceptional circumstances: This includes circumstances where the doctor/patient relationship could be jeopardized due to irreconcilable differences between the practitioner and the member. The practitioner should be able to demonstrate/document incidents as shown in the medical record. Providers may also discharge (or not accept) members who were previously removed from the practice but attempt to select the practice again. Members who unknowingly select a practice during open enrollment that has been closed may not be added to the practice. Member Services shall promptly notify the member that the practice is closed and that they will need to select another practice. Continued on next page 7

2.4 Member Removal Policy Western Region Only, Continued Invalid Reasons For Removing A Member Invalid reasons for removing a member include: Race Sexual orientation Age (Unless the member s age is outside of the scope of the practice. For example, an adult patient in a pediatric practice.) National origin Diagnosis Physical disability Religion Gender Health status factors (e.g., medical condition, claims experience, receipt of healthcare medical history, genetic information or evidence of insurability) Health care insurance coverage Before You Request Removal... Removing a member from your practice should be used as a last resort. You must make a sincere attempt to resolve the situation with the member prior to requesting his or her removal. Your efforts must be documented in the member s chart. 8

2.4 Member Removal Procedure Western Region Only Member Removal The following steps describe the member removal procedure. Stage Who Does It What Happens 1 PCP Identifies the problem, communicates the problem to member or member s legal representative, and documents the problem in the member s medical record. 2 PCP In those situations, where documented evidence of physician/member relationship breakdown exists, the practitioner must send a written request on practice letterhead via mail or fax to the Provider Relations Department. NOTE: It is not necessary to send a written request for PPOBlue, EPOBlue, ClassicBlue or DirectBlue products as they do not require PCP selection. In The Western Region: Provider Relations Member Disenrollment Fifth Avenue Place, Suite 721 120 Fifth Avenue Place Pittsburgh, PA 15222-3099 Western Region Fax: 412-544-8871 What Region Am I? The request must contain the following information: Member name Member ID # and insurance product Member address Member telephone number Specific documentation of the situation as evidenced in the medical record Evidence that practitioner tried to resolve the situation A practitioner or designee from the practice must sign the request. Continued on next page 9

2.4 Member Removal Procedure Western Region Only, Continued Member Removal (continued) Stage Who does it What happens 3 Provider Relations Review the PCP s request: Does the request contain all required information? If yes, proceed to stage 5. If no, and the PCP is unwilling or unable to provide more 4 Medical Director 5 Provider Relations 6 Member Services information, forward the request to the medical director. Review PCP s request: Is the request valid? If yes, proceed to stage 5. If no, call PCP to discuss alternative resolution. Document resolution and forward to Provider Relations. Forward the request to the appropriate member service department. Contact the member and assist with selecting a new PCP. Contact Provider Relations with the effective date of the change. The effective date of the change is the first day of the month after the member has been provided at least 30 days advance notice, unless both provider and member agree to an earlier discharge date. (New provider effective date must always be the first day of a month.) 7 Provider Relations Contact PCP by telephone to confirm the member s removal and effective date. 8 PCP Provide access to services until the termination date Provide urgent care if necessary. If requested to do so by the member or Highmark, the practitioner must, at no cost to the patient, forward medical records to the new PCP within thirty days. 10

2.4 How To Close And Re-Open Your Practice To Members Introduction This section is intended to explain how to close and re-open your practice to new members. Definition: Closed Practices When a practice is closed to new members, it means that the PCP practice is temporarily not available for selection by new members. Definition: New Member A new member is one who has: Never been seen by a physician of the practice Not been seen by a physician of the practices within the past 36 months. Rationale By closing to new members, your practice can limit the number of new members. This can be especially helpful to practices that are new to managed care, or to practices that have a shortage of physicians or office staff. Guidelines Your practice must provide written notice to the western region network 60 days prior to the anticipated closing date and/or re-opening date. Closure takes place on the first day of the month following the 60-day period. You must continue to accept new members up to the end of the 60-day period when closure is in place. You must accept existing members who choose you as their PCP. You must close to all new Highmark plan members. How To Close Or Re-Open Your Practice To close or to re-open your practice to new members, simply mail or fax written notification on practice letterhead, including practice name, address, vendor number, effective date, and authorized signature for the requested change, to: What Region Am I? Western, Central and Eastern PA Regions: Highmark Blue Shield Provider Information Management P.O. Box 898842 Camp Hill, PA 17001-9937 Fax: 1-800-236-8641 Northeastern PA Region: Blue Cross of Northeastern Pennsylvania Provider System Support 19 North Main Street Wilkes-Barre, PA 18711 Fax: 1-570-200-6880 11

2.4 Eligibility Rosters Definition The Eligibility Roster is a list of members currently enrolled with a specific primary care practice. Purpose The Eligibility Roster is intended to give PCP practices a way to identify which members are assigned to their practice for any given month. The Eligibility Roster contains no financial information other than the co-payment that you may collect from the member for office visits. Report Frequency Eligibility rosters are available online monthly through NaviNet. For those practices that do not have NaviNet, the rosters are mailed at the end of each month. The roster contains enrollment information for the following month. How To Download Eligibility Rosters 1. In the NaviNet toolbar, select Report Inquiry. 2. Select Eligibility Roster in the Report Type Field. Click Search. 3. Choose month desired. Click Select. 4. Select Download. The generated file will be in.txt format. Select Save or Open based on your preference. Single Roster Each PCP practice receives a single roster that is separated by product. Rosters are available for the following products: DirectBlue, Western Region Individual HMO and Western Region Medicare Advantage HMO. Rosters for DirectBlue (group) members will only be printed if the member selected a PCP. Members do not formally choose a PCP for certain products including, but not limited to DirectBlue (individual), PPOBlue EPOBlue and ClassicBlue so a roster is not produced for those products. Information Contained On The Roster Eligibility rosters list the names and identification numbers of all members enrolled in a PCP s practice. 12

2.4 How To Read The Eligibility Roster Information Fields On The Roster This table lists each field on the roster with an explanation of its function. Please refer to the example illustration following the table. Field RUN DATE RUN TIME PRODUCT PRACTICE NAME PCP NUMBER STAT CHG MEMBER NAME MEMBER ID MEM NUM GROUP NUMBER SEX AGE Function Run date and time indicates when the roster was printed for the monthly period identified on the roster. The roster is separated by product. The product s name and code appear at the top of the roster to identify the product. The practice name and PCP number. The field will also show the reimbursement method of the practice for each product: FFS (fee-for-service). Status change indicates new or terminated members to the provider since the last eligibility roster. A = New member added T = Member terminated Member name listed alphabetically (last name, first name) Identification number is the subscriber s unique member identifier assigned to all members of the family who are enrolled under the subscriber s coverage. Member number is a two-digit number that notes the member covered. For example: 00 = subscriber 01 = spouse or dependent 02 and up = additional dependents Group number identifies the employer group or the benefit plan for which the member is eligible. Shows the member s sex. Shows the member s age. Continued on next page 13

2.4 How To Read The Eligibility Roster, Continued Information Fields On The Roster (continued) Field BEGIN DATE END DATE FINANCIAL INDICATOR COPAY Function Begin date is the date the member enrolled with the provider under the given group number. End date is the date the member cancelled with the provider under the given group number. Financial indicator shows the member s employer group s financial arrangements relative to managed care. F = Fee-for-service Shows the co-payment that you may collect from the member for office visits. Continued on next page 14

2.4 How To Read The Eligibility Roster, Continued Illustration An illustration of an Eligibility Roster appears below. This statement is for example purposes only. Line and/or page totals may be mathematically inaccurate. 15