For information on benefits and eligibility, please contact the First Priority Health Provider Services Unit at 1-800-822-8752 or utilize NaviNet^sm. See Section I, "Billing Information" - for further information regarding NaviNet^sm.

The Case Management program is a voluntary program offered to BlueCare HMO members as part of their benefit package at no additional cost. Case Management’s role is to coordinate necessary interventions and services with an individual’s health care needs in a quality and cost effective manner. The program is proactive and may begin prior to the occurrence of any actual utilization, in anticipation of preventing the utilization from occurring.

Intervention may occur at any point in the continuum of care, i.e., prior to hospitalization, during hospitalization, and post hospitalization.

Potential cases can be referred to case management, internally or externally, by medical directors, utilization management staff or other internal departments, providers, social workers, discharge planners, physicians, vendors, subscribers, family, or other health care plans. Admission notification reports are generated and analyzed for possible case management involvement/intervention. Referrals are then triaged to determine the appropriateness of case management based on criteria.

The Case Management Program is designed to augment, not replace the discharge planner.

A case management assessment is available for members who:

• have chronic long term illness;
• are terminally ill;
• require frequent hospital admissions;
• may require high-tech or intensive home care; and/or
• have sustained traumatic injury.

The Case Manager works collaboratively with the providers and members to coordinate available benefits and facilitate available alternatives.

The First Priority Health (FPH) Utilization Management Department performs utilization review functions for all BlueCare HMO members.

Concurrent review nurses or clinicians utilize InterQual criteria and other criteria as appropriate when reviewing hospitalizations.

1. The FPH nurse analyst verifies that all scheduled admissions and ambulatory surgery procedures requiring pre-certification have in fact taken place.
   
   
2. After a member is admitted, the nurse analyst will contact the admitting facility’s Utilization Review/Quality Assurance Department to schedule a medical update.
   
   
3. Once an initial update has been received, the FPH nurse analyst will follow the clinical status of the member on an ongoing basis with the facility’s Utilization Review/Quality Assurance Department, discharge planners, physicians, and social workers as needed in non-DRG facilities. If the case is denied, a denial letter is mailed to the member, provider & facility stating the denial reason and that specific criteria for denial is available upon request.
   
   
4. The number of approved days will be assigned in non-DRG facilities. The FPH nurse analyst will schedule another medical update as the member’s condition warrants. Utilization Management must receive comprehensive medical updates within one (1) business day of the scheduled date.
   
   
5. Through medical updates, early coordination for home health services as well as referrals for case management intervention can be implemented.
   
   
6. Days will be administratively denied if delivery of required inpatient services are delayed. Examples of administrative denials are:

1. Delays in scheduling of services
2. Equipment failure
3. Inadequate staffing
4. Failure of the treating physician to order services in a timely manner (i.e. writing a discharge order on the last medically necessary day).

7. FPH Utilization Management Department requires all FPH participating home health agencies with NaviNet^SM access to utilize NaviNet^SM to precertify their home health admissions. If they do not have NaviNet^SM access, they must fax in their initial reviews on the Home Health Worksheet. All concurrent reviews need to be faxed into the FPH Utilization Management Department using the worksheet. Please refer to Section I, "Billing Information", for more information on NaviNet^SM.

8. Inpatient psychiatric and substance abuse require continued stay reviews. Concurrent review is determined at the time of pre-certification. Contact the Regional Referral Center at 1-800-559-2428. Behavioral Healthcare services are only available to BlueCare HMO Group Product members.

1. Emergency medical transportation is provided for all BlueCare HMO members by the nearest available ambulance service.
   
   
2. Emergency medical transportation does not require pre-certification from FPH.

1. A FPH participating ambulance provider must be utilized for ALL non-emergency transfers.
   
   
2. If a patient requires a medically necessary transport after business hours, please contact one of the participating ambulance providers or utilize your hospital ambulance service, if applicable. You may leave a telephone message on the FPH Utilization Management Department’s answering machine or telephone FPH the next business day.
   
   
3. Non-emergency transfers to a non-participating facility requires a pre-certification from the FPH Utilization Management Department.
   
   
4. Only non-participating ambulance require pre-certification.

1. The participating facility emergency room personnel should evaluate and stabilize the BlueCare HMO member.
   
   
2. If a BlueCare HMO member requires admission after stabilization in the emergency room, pre-certification is required and can be obtained by contacting the FPH Utilization Management Review Department Monday through Friday.

Business Hours: 8:00 a.m. to 4:15 p.m. 1-800-962-5353

3. If during business hours you do not receive a phone call from the FPH Utilization Management Department personnel, the BlueCare HMO member should be admitted, if the admission is medically necessary. The FPH Utilization Management Department will return your call within 24 hours and the admission would need to be reviewed for medical necessity.
   
   
4. During business hours, the FPH Utilization Management Department personnel will provide the caller with a pre-certification number. If the FPH Utilization Management Department is notified via answering machine during non-business hours, a representative from the FPH Utilization Management Department will return the call on the next business day. The pre-certification number can be viewed via NaviNet^sm once obtained through the FPH Utilization Management Department
   
   
5. If the admission occurs after normal business hours, the admitting facility is responsible for notifying the FPH Utilization Management Department of the admission within 48 hours or the next business day if the admission occurs on the weekend. All inpatient admissions need to be reviewed for medical necessity and/or appropriateness of site.
   
   
6. If the BlueCare HMO member is admitted through the emergency room, the emergency room copayment does not apply.

If the BlueCare HMO member is treated in the emergency room and is consequently placed in an observation bed or treatment in a SPU, the member will not be responsible for the emergency room copayment, as long as the observation bed or SPU, if required, was authorized by the FPH Utilization Management Department.

1. First Priority Health encourages members to notify their Primary Care Physician (PCP) of an emergency room visit within 24 hours of the emergency.
   
   
2. The FPH member is responsible for an emergency room copayment. Do not collect the member’s copayment at the time of service. After you receive your remittance advice, you will be able to determine the member’s liability along with the FPH payment.
   
   
3. Emergency medical or accident follow-up services are payable, less applicable copayments, only with pre-certification from the member’s PCP.
   
   
4. An emergency room prior authorization may be issued by the BlueCare HMO member’s PCP if the member was directed to the emergency room by their PCP in advance of the service, and the service could have been provided by the BlueCare HMO member’s PCP. The BlueCare HMO member would then be responsible for an office visit copay not the emergency room copay.

FPH Utilization Management Department will not be reviewing maternity admissions for medical necessity or appropriateness of care. However, the information documented on the Maternity Admission Fax Sheet is required for your claim to be processed. Please fax the completed fax sheet (refer to Section K, "Forms") to FPH Claims Department at 570-200-6790 within 24 hours after discharge.

If you wish to confirm the pre-certification number, call our Provider Services Unit at 1-800-822-8752 or the pre-certification number may be obtained by utilizing NaviNet^sm.

Services covered by the maternity admission pre-certification include labor and delivery, newborn care and, if noted, post-delivery tubal ligation.

If baby is detained after the mother is discharged, an additional pre-certification is required by contacting FPH Utilization Management Department. Please refer to "Admission/Discharge," Section E, Pre-admission Certification". For services rendered within 31 days of the baby’s birth, submit all claims for the baby utilizing the mother’s BlueCare HMO ID number or the father’s BlueCare HMO ID number (if the mother is not covered). If after 31 days the newborn does not have a BlueCare HMO Member ID Card, please confirm benefits via NaviNet^sm or the Provider Services Unit at 1-800-822-8752.

For information on early discharge, postpartum skilled nursing visit, please refer to Act 85 of 1996 available through http://www.legis.state.pa.us/WU01/LI/LI/CL/ACT.HTM

1. The Primary Care Physician or admitting Specialist is responsible for obtaining pre-certification for scheduled admissions.
   
   
2. The admitting physician and/or PCP obtains the pre-certification number either by utilizing NaviNet^SM or by calling the FPH Utilization Management Department. It is the facility’s responsibility to verify that the pre-certification has been completed.
   
   
3. If after stabilization in the emergency room the member is admitted for an inpatient stay, it is the facility’s responsibility to obtain pre-certification. If the member is admitted through the emergency room for an SPU or observation, pre-certification may be required for select services. Refer to the most current FPH Focus Outpatient Procedure Pre-certification list in your provider bulletin or contact the Provider Services Unit at 1-800-822-8752.
   
   
4. Under certain circumstances such as, urgent/emergent or after hours/weekend services, pre-certification must be obtained the following business day by calling the FPH Utilization Management Department at 1-800-962-5353 or by utilizing NaviNet^SM.
   
   
5. Comprehensive clinical information must be received by the First Priority Health Utilization Department within one (1) business day of admission.

Comprehensive clinical information is defined as:

• All symptomatology related to the admission.
• Previous pertinent medical history.
• Treatment plan.
• Discharge plan.

6. All Inpatient admissions to an acute care, rehab, and skilled nursing facility, except maternity, require a pre-certification number before the services are rendered:
   
   
7. Other services requiring pre-certification are:

• Home Health Services
• Outpatient Therapies (certain groups may require pre-certification. Verify benefit information prior to service).
• PET Scans
• MRI/MRA – refer to the most current list of select MRI/MRA’s
  (contact Provider Services Unit at 1-800-822-8752 or the Provider Bulletin)
• Observation Service
• Mental Health/Chemical Recovery (Regional Referral Center at 1-800-599-2428).
• Selected Surgical Procedures (Refer to the most current FPH FOCUS Outpatient Procedure Pre-Certification list in the Provider Bulletin or contact Provider Services Unit at 1-800-822-8752).

8. BlueCare HMO members shall have access to outpatient services when medically necessary and appropriate.
   
   
9. Outpatient services may be provided in a physician office, outpatient facility or short procedure unit. Outpatient services when performed in a hospital are provided at a designated area of a hospital (treatment room, G.I. lab, radiology unit, etc.) or other health care facility where procedures are performed that do not require an operating room setting/sterile environment.

To verify site appropriateness of procedures, please reference "The Outpatient Billing Expert" at the hospital.

10. If a member receives inpatient, SPU, mental health, chemical recovery, or other services that require pre-certification without the appropriate pre-certification, FPH will reject the claim. Members cannot be billed for these services. FPH requires that pre-certification is obtained prior to services being rendered, with the exception of urgent/emergent or after hours/weekend services where pre-certification should be obtained by the following business day.
    
    
11. Pre-certification must be obtained even if FPH is the member’s secondary insurance.
    
    
12. Pre-certification is not a guarantee of payment.

1. The participating hospital shall be responsible for furnishing to FPH Utilization Management department any required medical information relative to the pre-certification process.
   
   
2. In the event that one of the following situations occurs, an inpatient admission may be denied and the participating hospital may not charge either FPH or the member for services rendered with respect to such admission.

1. a pre-certification was required, but not performed, and the participating hospital, nonetheless, admitted the member;
   
   
2. a pre-certification was required and performed, but the admission was medically denied by FPH. The participating hospital admitted the member without adequate prior written notice to the member that the admission would not be paid by FPH, and without the member acknowledging this fact in writing, together with a request to be admitted and to assume financial responsibility; or
   
   
3. a pre-certification was required and performed, but the admission was an inappropriate admission, and the diagnosis/procedure treated or performed differed from that certified and approved.

Pre-admission testing will be covered even if the procedure is cancelled.

Pre-admission testing can be performed at a different facility/entity than where the surgery is being performed.

The First Priority Health Utilization Management Department bases its decision on specific criteria to determine medical necessity. This criteria is available to all FPH providers upon request.

Criteria may be requested by either contacting or faxing the FPH Utilization ManagementDepartment with the following information: member’sname, FPH identification number, date(s) of service, date(s) of denial and facility where services were rendered or by calling the Provider Services Unit at 1-800-822-8752.

First Priority Health
Medical Management Department
19 North Main Street
Wilkes-Barre, PA 18711-0302


Phone: 1-800-962-5353
Fax #:(570) 200-6788

First Priority Health’s (FPH’s) ancillary provider network is a comprehensive system of alternative health care services. The ancillary network provides a substitute to inpatient hospitalization and/or an alternative to more costly services when developing an individualized plan of care.

FPH’s ancillary network consists of the following provider types.

• home health;
• hospice;
• skilled nursing facility;
• ambulatory surgery;
• chemical recovery;
• ambulance;
• DME;
• home infusion;
• MRI;
• prosthetic/orthotic;
• independent lab;
• dialysis services.

Contact Provider Customer Service at 1-800-822-8752 for verification of benefits.

Pre-admission certification maybe required prior to ancillary services being rendered (check your Provider Bulletins for current information on pre-admission certification). Nurse analysts are available to answer questions, precertify and make all arrangements for the requested services. The FPH Utilization Management Department is available to receive calls at 1-800-962-5353 Monday through Friday, 8:00 a.m. to 4:15 p.m. Pre-admission certification maybe submitted electronically via NaviNet^sm.

During business hours, the First Priority Health (FPH) Utilization Management Department personnel will provide the caller with a pre-admission certification number. If the FPH Utilization Management Department is notified via answering machine during non-business hours, a representative from the FPH Utilization Management Department will return the call on the next business day. The pre-admission certification number can be viewed via NaviNet^sm once obtained through the FPH Utilization Management Department.

If during business hours you do not receive a phone call from the FPH Utilization Management Department, the BlueCare HMO member should be admitted, if the admission is medically necessary. FPH will return your call within 24 hours and the admission would need to be reviewed for medical necessity.

If the admission occurs after normal business hours, the admitting facility is responsible for notifying the FPH Utilization Management Department of the admission within 48 hours or the next business day if the admission occurs on the weekend.

Benefits will be available if the member is homebound and the attending physician has: (1) ordered home health care, (2) received pre-admission certification approval from First Priority Health, and (3) furnished, in consultation with the participating home health agency’s professional personnel prior to the first visit, a written plan of treatment stating that the services ordered are medically necessary. Continuing eligibility requires that the attending physician provide such a plan of treatment at thirty (30) day intervals.

NOTE: As of January 1, 2006, providers who are NaviNet^SM enabled MUST submit the initial precertification request for home health or inpatient rehabilitation services via NaviNet^SM.

BlueCare HMO Home Health providers offer the following services:

• registered nurse (excludes private duty nursing);
• medical social worker;
• physical therapy;
• occupational therapy;
• speech therapy;
• home phototherapy; and
• home health aide

Home infusion is designed to provide intravenous medication or solutions to members at home.

BlueCare HMO home infusion therapy providers offer the following services:

• total parenteral nutrition (TPN)*;
• enteral nutrition*;
• intravenous therapy (e.g., medication, hydration, treatment, etc.);
• chemotherapy;
• anti-infective therapy (including Lyme Disease)*;
• pain management (continuous and epidural analgesics); and
• immune globulin therapy*.

Home infusion therapy benefits will be provided only if the member’s physician prescribes the services. Certain home infusion benefits require prior authorization by the Pharmacy Management Department by calling 1-800-722-4062. The Pharmacy Management Department’s fax number is 570-200-6870. Claim submission for home infusion charges must be on a HCFA 1500 form. Refer to Section I, for billing information.

Hospice care is a health care program, which provides an integrated set of services, primarily in the member’s home, designed to provide palliative and supportive care to terminally ill members and their families. Services are coordinated through a hospice interdisciplinary team and the member’s attending physician. The focus is on care, not cure.

BlueCare HMO shall provide coverage for hospice benefits when the member’s attending physician certifies in writing to First Priority Health that the member has a terminal illness with a medical prognosis of six (6) months or less and when the member or responsible party elects in writing to receive care primarily in the home to relieve pain. Hospice services do not require pre-admission certification.

BlueCare HMO will provide coverage for hospice services based on one (1) of three (3) levels of care. The hospice agency shall be responsible for administering the following benefits:

• routine;
• continuous - coverage for continuous care, during periods of crisis, consisting of nursing care for up to twenty-four (24) hours per day necessary to maintain the member at home; or
• respite - coverage for respite care on a short-term inpatient basis in a participating skilled nursing facility when necessary to relieve primary caregivers in the member’s home. This is limited to ten (10) days per lifetime, and is subject to applicable deductible and/or coinsurance.

The following services shall be eligible for coverage to an approved essentially homebound patient by an approved hospice agency responsible for the member’s overall care:

• professional nursing services (excludes private duty nursing);
• home health aide services;
• laboratory services;
• therapy services (except for dialysis treatments);
• durable medical equipment and medical and surgical supplies;
• prescribed drugs;
• oxygen and its administration;
• medical social services provided by a social worker;
• palliation for pain control and symptom management;
• respite care in a participating skilled nursing facility (limited to ten (10) days per lifetime, and is subject to applicable deductible and/or coinsurance);
• family counseling related to the member’s terminal condition;
• dietician services;
• hospice inpatient room, board and general nursing services for acute pain management (payable under the basic hospital benefit); and
• bereavement counseling (limited to two (2) visits).

BlueCare HMO shall provide coverage at a skilled nursing facility (SNF) when certified as medically necessary by a physician. Pre-admission certification is required at least forty-eight (48) hours prior to an admission to a skilled nursing facility.

BlueCare HMO patient care in a SNF is covered if all of the following factors are met:

• Skilled nursing services or skilled rehabilitation services are performed by or under the supervision of a licensed/certified professional.
• The member requires the skilled services on a daily basis [at least five (5) days per week].
• Skilled services are provided only on an inpatient basis in the SNF.

BlueCare HMO rehabilitation services in an SNF include the following:

• skilled physical therapy;
• speech pathology; and
• occupational therapy.

Ambulatory surgical services can be safely performed in a less intensive, non-acute care environment and are generally surgical in nature but can include endoscopic/diagnostic procedures. For pre-admission certification requirements, refer to Section E, "Admission & Discharge", pages 4 and 5.

Magnetic resonance imaging (MRI) is a noninvasive diagnostic imaging modality. This technique uses an interaction of a magnetic field and radiofrequency waves in order to generate, with computer assistance, an image of an area of the body. MRI scans must meet the criteria of medical necessity and reasonableness. It should be performed when the results are expected to impact the diagnosis and treatment of the member. Pre-admission certification may be required. Please refer to your provider bulletin for a current list of MRI services that need pre-admission certification. Claim submission for MRI charges must be on a HCFA 1500 form. See Section I for billing information.

Inpatient detoxification is provided either in a participating hospital or on an inpatient basis in a participating non-hospital facility, which is licensed as an approved alcohol and/or drug addiction treatment program and is approved by the Pennsylvania Department of Health. Not all BlueCare HMO members will have this coverage. Contact Provider Customer Services at 1-800-822-8752 to verify member benefits/eligibility.

Outpatient alcohol or other drug abuse services are provided in a participating facility appropriately licensed by the Pennsylvania Department of Health as an alcohol or drug addiction treatment program.

Contact Regional Referral Center (RRC) (1-800-599-2428) to precertify all inpatient and outpatient treatment for BlueCare HMO members. In order to obtain pre-admission certification, the attending physician must provide evidence prior to ordering such treatment, in a format satisfactory to RRC, that alcohol or drug abuse treatment is medically necessary and appropriate.

Durable medical equipment (DME) is a device such as a wheelchair or walker, which can withstand repeated use, is primarily used to serve a medical purpose and would also be appropriate for use in the home. DME does not require pre-admission certification, however, services must be deemed medically necessary to be eligible for reimbursement, and are subject to benefit limitations. Claim submission for DME must be on a HCFA 1500 form. See Section I for billing information.

Prosthesis is the replacement of a missing body part/organ by an artificial substitute, such as an artificial extremity. Orthotics is any device added to the body to stabilize or immobilize a body part, prevent deformity, protect against injury, or assist with function. P&O does not require pre-admission certification, however, services must be deemed medically necessary to be eligible for reimbursement, and are subject to benefit limitations. Claim submission for P&O charges must be on a HCFA 1500 form. See Section I for billing information.

Emergency and non-emergency medical transport services are provided for BlueCare HMO members

based on benefits and eligibility. Ambulance services do not require pre-admission certification, however, services must be deemed medically necessary to be eligible for reimbursement. Claim submission for ambulance charges must be on a HCFA 1500 form. See Section I for billing information.