BlueCare® HMO
FACILITY POLICY & PROCEDURE MANUAL

TABLE OF CONTENTS

1. WELCOME
   
   
2. TELEPHONE DIRECTORY & FAX NUMBERS
   
   
3. INDEX
   
   
4. GLOSSARY OF TERMS
   
   
5. ADMISSION & DISCHARGE
   
   
6. ANCILLARY SERVICES
   
   
7. APPEALS
   
   
8. BEHAVIORAL HEALTH CARE
   
   
9. BILLING INFORMATION
   
   
10. BLUECARD^®
    
    
11. FORMS
    
    
12. LEGISLATIVE
    
    
13. MEDICAL MANAGEMENT REVIEW
    
    
14. MEMBER OVERVIEW
    
    
15. OTHER TYPES OF PRODUCTS
    
    
16. POLICIES
    
    
17. QUALITY MANAGEMENT
    
    
18. REGIONAL INFORMATION

First Priority Health^®, (FPH), an affiliate company of Blue Cross of Northeastern Pennsylvania (BCNEPA) and Highmark Inc., welcomes you as a participating provider. As the majority partner of FPH, BCNEPA welcomes and values the opportunity to partner with you in providing quality care to our Blue Care HMO members.

FPH is committed to forging a strong, supportive partnership with network health care providers. Together, FPH, and its network of providers set the standards for progressive, high quality medical care that is also cost effective. First Priority Health’s primary service area includes:

• Bradford, Carbon, Clinton, Lackawanna, Luzerne, Lycoming, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne, Wyoming Counties

FPH also has providers located in surrounding contiguous counties.

This manual does not contain subscriber benefits information. Please call the phone numbers listed in Section B, "Telephone Directory" or refer to the phone number listed on the back of the member’s identification card.

Blue Cross of Northeastern Pennsylvania (BCNEPA) and Highmark Blue Shield (Highmark) have restructured the relationship they have shared for many years. Highmark now shares a percentage of ownership with BCNEPA of the First Priority Health, (FPH) affiliate.

FPH offers several managed care products, including a group, an accompanying conversion product and individual (non group) enrollment products. The new product names are as follows and all have the prefix of YZH:

• BlueCare HMO - group
• BlueCare Plus - group
• BlueChip - non group
• adultBasic - non group
• BlueCare HMO Individual Conversion - non group

Please note that benefits co-payments and coinsurances may apply and may vary by group. For benefit information, contact Provider Customer Services at 1-800-822-8752.

To provide innovative solutions that support more affordable health care, promote personal accountability for health and wellness, and to offer superior service and partnership to the constituents we serve.

To be at the forefront of innovation and delivery of improved health management and financing services that promote healthier communities.

The Provider Relations Department, which is part of the overall Health Delivery Division of BCNEPA, plays an integral role in network development and maintenance.

Some of the responsibilities of personnel include, but are not limited to:

• serve as liaison between you and BlueCare HMO;
• educate participating network providers; and
• conduct provider training to ensure timely communication of key issues.

For all your needs, Provider Relations is just an e-mail or phone call away at (570) 200-4700 or
1-800-451-4447, Monday through Friday, 8:00 a.m.- 5:00 p.m.

For claims, benefits and eligibility information, contact Provider Customer Service at
1-800-822-8752, Monday through Friday, 8:00 a.m.- 5:30 p.m.

BlueCare HMO members should be directed to call Customer Service at 1-800-822-8753, Monday through Friday, 8:00 a.m.- 5:00 p.m. with any questions regarding their coverage. Hearing and/or speech-impaired subscribers/dependents may call (TTY/TDD) 1-866-280-0486.

Acute Care: Applies to services that deal with needs of short-term duration (30 days or less), that are primarily oriented toward medical problems requiring intensive attention and treatment to restore a previous state of health or to prevent the worsening of a present state, that may at times, be emergent and may have related long-term effects. From a structural point of view, such care is most commonly found in organizations like hospitals, surgical centers and some clinics.

Admission Notification: The process by which the admissions department notifies the First Priority Health Utilization Review Department of a scheduled or emergency admission.

Agreement: A written document given to the member which outlines benefits, exclusions, etc. Applicable to the coverage(s) applied for by the member.

Allowable Charge: Generic term referring to the maximum fee that a third party will use to reimburse a provider for a given service.

Ambulatory Care: All types of health services that are provided on an outpatient basis, in contrast to services provided in the home or to persons who are inpatients.

Ancillary Care: Care provided by a nurse, X-ray, lab or emergency medical technicians, etc.

Ancillary Facility: An institution or entity other than a hospital which is licensed, where required, to provide covered services. Ancillary facilities include:

• Ambulatory Surgical Facility
• Behavioral Health Facility
• Durable Medical Equipment Supplier
• Freestanding Dialysis Facility
• Home Health Care Agency
• Home Infusion Therapy Agency
• Hospice
• Orthotics and Prosthetics Supplier
• Skilled Nursing Facility

Appeal: Procedure that reviews an adverse plan determination.

Assistant Surgeon: A registered medical physician who aids a surgeon in performing an operation.

BlueCard: A program, which allows a member to receive covered services from participating providers located outside the geographic area serviced by First Priority Health and which are participating with their local Blue Cross and/or Blue Shield licensee. The local Blue Cross and/or Blue Shield licensee, which serves the geographic area where the covered service is provided, is referred to as the on-site Blue Cross and/or Blue Shield licensee.

Blue Cross Plan: A corporation which administers a prepayment program for the purchase of hospital services in accordance with the membership standards of the Blue Cross and Blue Shield Association. Blue Cross of Northeastern Pennsylvania is the Blue Cross Plan that serves 13 counties of northeastern and north central Pennsylvania.

Blue Cross and Blue Shield Association: The national trade association of Blue Cross and Blue Shield.

Case Management: A collaborative process that assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual’s health care needs through communication and available resources to promote quality, cost-effective outcomes.

CBHNP: Community Behavioral Healthcare Network is an organization exclusively devoted to mental health/chemical recovery services.

Chronic: Chronic: Of long duration.

Claim: A request for payment for services provided by a health care provider.

Coinsurance: A provision in a member’s coverage that limits the amount of coverage by the Plan to a certain percentage, commonly 80%.

Complaint: A dispute or objection by an enrollee regarding a participating health care provider, or the coverage (including contract exclusions and non-covered benefits), operations or management policies of a managed care plan, that has not been resolved by the managed care plan and has been filed with the plan or the Department or the Insurance Department. The term does not include a grievance.

Concurrent Review: On-going review (of the treatment plan) during the patient’s hospitalization, to ensure that it meets established medical criteria in a timely manner, certifies the necessity, and the appropriateness, and quality of services during a hospital episode.

Control Plan: A Plan administering a National Account and acting as an agent for the participating plans.

Coordination of Benefits (COB): Provisions and procedures used by insurers or third-party payers to avoid duplicate payment for losses covered under more than one policy or subscription agreement.

Copayment: The amount members must pay directly to providers in connection with the covered services set forth in the Member Copayment Schedule attached to their contract.

Cosmetic Procedures: Medical or surgical procedures which are intended to improve the appearance of any portion of the body and from which no improvement in physiologic function can be expected.

Coverage: The extent of benefits provided under a member’s contract issued by the Plan.

Covered Services: Those medically necessary health services that a member is entitled to receive and which are eligible for payment or reimbursement under the terms of the applicable Plan document.

Credentialing: Internal certification process prior to acceptance into First Priority Health’s network and re-certification process at a set period of time thereafter.

Criteria: Predetermined elements of health, the presence, absence and completeness of which indicate the quality of medical services.

Custodial Care: Services to assist an individual in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet, preparation of special diets, and supervision of medication that usually can be self-administered. Custodial care essentially is personal care that does not require the continuing attention of skilled, trained medical or paramedical personnel. In determining whether a person is receiving custodial care, the factors considered are the level of care and medical supervision required and furnished. The decision should not be based on diagnosis, type of condition, degree of functional limitation or rehabilitation potential or place of service.

Deductible: That portion of covered hospital and medical charges that a member or insured person must pay before the Plan’s liability begins.

Detoxification: The process whereby an alcohol intoxicated or drug-intoxicated or alcohol-dependent or drug-dependent person is assisted, in a facility licensed by the Pennsylvania Department of Health, to perform detoxification through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or other drugs, alcohol, drug or other drug dependency factors or alcohol in combination with drugs as determined by a licensed physician, while keeping the physiological risk to the patient at a minimum.

Diagnosis: The identity of a condition or cause of disease; e.g., admitting diagnosis, discharge diagnosis, final diagnosis, etc.

Diagnostic Related Group (DRG): Diagnostic related group refers to a hospital payment arrangement that provides a prospective rate based on the patient’s diagnosis. With DRG, the provider assumes the financial risk of managing the care of an individual, regardless of the length of stay, for a fixed amount based on the patient’s diagnosis.

Disenrollment: The process of termination of coverage.

Drug Formulary: A continually updated list of prescription medications that represents the current clinical judgment of the members of First Priority Health's Pharmacy and Therapeutics Committee. This committee is comprised of physicians and pharmacists, many of whom are providers and experts in the diagnosis and treatment of disease. The drug formulary contains both brand name drugs and generic drugs, all of which have FDA approval.

Durable Medical Equipment (DME): Equipment that can withstand repeated use; is primarily and customarily used to serve a medical purpose; generally is not useful to a person in the absence of an illness or injury; and is appropriate for use in the home.

Elective Surgery: Surgery not considered an emergency because reasonable delays will not affect the outcome unfavorably, even though such surgery is necessary and may be major.

Emergency Medical Condition: Any health care service provided to a member after the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

• Placing the health of the member, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;
• Serious impairment to bodily functions; or
• Serious dysfunction of any bodily organ or part.

Employee Retirement Income: This act of 1974 provides protection for employees and Security Act (ERISA): their dependents covered by private pension and welfare plans.

Explanation of Benefits (EOB): A statement to the member which explains action taken on each claim.

Fee For Service (FFS): A method of payment for health services in which a healthcare provider is reimbursed according to a current fee schedule.

First Priority Health (FPH): Managed care commercial product administered by Blue Cross of Northeastern Pennsylvania for the non-Medicare population.

Gatekeeper: The Primary Care Physician who serves as the initial point of contact for patients of managed care.

Generic Name: The established, official or nonproprietary name by which a drug is known as an isolated substance, irrespective of its manufacturer.

Grievance: A request by a member or a provider with his/her written consent, to have FPH or a utilization review entity review the denial of a health care service based on medical necessity and appropriateness.

Health Care Practitioner: An individual who is authorized to practice some component of the healing arts by a license, permit, certificate or registration issued by a Commonwealth licensing agency or board.

Health Maintenance Organization (HMO): A managed care system that combines the delivery and financing of health care and provides basic health services to voluntarily enrolled subscribers for a fixed prepared fee. Emphasis is placed on preventive and primary care.

HEDIS^®: The Health Plan Employer Data and Information Set is a standardized set of performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans.

HIPAA: The federal Health Insurance Portability and Accountability Act of 1996.

1. Staff - a prepaid health care system in which most physicians are employed by the HMO entity.
2. Group - a prepaid health care system that contracts with one physician group to provide health care services.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

3. Independent Practice Association (IPA) - a prepaid health care system that contracts with individual physicians to deliver services in return for a single capitation rate.
4. Network - a prepaid health care system that contracts with two or more physician groups.
5. Mixed - a prepaid health care system characterized by at least two of the model types and no one model being predominant.

Homebound: A member will be considered homebound, if he/she has a condition due to and illness or injury which restricts his/her ability to leave his/her place of residence except with the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, the use of special transportation, or the assistance of another person, or if he/she has a condition which is such that leaving his/her home is medically contraindicated. The condition of these members should be such that there exists a normal inability to leave home and, consequently, leaving their homes would require a considerable and taxing effort.

Home Health Care Agency: A facility/other provider that has been approved by the Joint Commission on the Accreditation of Health Care Organizations or First Priority Health that:

1. provides skilled outpatient services on a visiting basis in the member’s home; and
2. is responsible for supervising the delivery of such services under a plan authorized by the Primary Care Physician.

Home Infusion Therapy Agency: A facility/other provider that provides hi-tech services designed to coordinate the effective provision of physician-directed nursing, pharmacy and related services necessary to conduct a parenteral/enteral regime safely and effectively in the patient’s home.

Hospice: A facility/other provider approved by First Priority Health that is primarily engaged in providing palliative care to terminally ill individuals.

Hospital: A provider that is a short-term, acute care or rehabilitation hospital approved by the Joint Commission on the Accreditation of Healthcare Organizations, the American Osteopathic Hospital Association or by First Priority Health and:

1. is a duly licensed institution;
2. is primarily engaged in providing inpatient diagnostic and therapeutic services for the diagnosis, treatment and care of injured and sick persons by or under the supervision of physicians;
3. has organized departments of medicine and/or major surgery;
4. provides 24-hour nursing service by or under the supervision of registered nurses; and
5. is not, other than incidentally, a:

• skilled nursing facility
• nursing home
• custodial care home
• health resort
• spa or sanitarium
• place for rest
• place for the aged
• place for the treatment of mental illness
• place for the provision of hospice care, or
• personal care home.

Hospital Based Physician: A physician who provides services in a hospital setting and has a contractual relationship with the hospital (e.g., is paid a salary by the hospital or receives compensation from or through the hospital).

Inpatient: A member who is treated as a registered overnight bed patient in a hospital or facility/other provider.

Inpatient Mental Health Hospital: A short-term acute care hospital, which has been approved by the Joint Commission on the Accreditation of Healthcare Organizations, or the American Osteopathic Hospital Association, or a similar accrediting agency acceptable by the Plan and which provides services that are necessary for short-term evaluation, diagnosis, and treatment (or crisis intervention) of serious mental illness.

Inpatient Non-Hospital Residential Care: The provision of acute medical, nursing, counseling, or therapeutic services to patients suffering from alcohol and/or drug abuse or dependency in a residential environment, according to individualized treatment plans.

Inpatient Non-Hospital Residential Facility: A facility other provider licensed by the Pennsylvania Department of Health to render an alcohol and/or drug abuse treatment program designed to provide inpatient non-hospital residential care. (This is not a halfway house or group home).

Long-Term Residential Care: The provision of long-term diagnostic or therapeutic services (i.e.: assistance or supervision in managing basic day to day activities and responsibilities) to patients suffering from alcohol and/or drug abuse or dependency. This care is provided in a long-term residential environment known as a Transitional Living Facility, on an individual, group, and/or family basis, with a program duration greater than sixty (60) days. Long-Term Residential Care is not inpatient non-hospital residential care.

Managed Care A prepaid health plan or insurance program in which beneficiaries receive medical care in a coordinated manner to eliminate the duplication of services. This is accomplished through the use of quality assurance and utilization review to ensure the appropriate delivery of care. Managed care focuses on health care benefit management, and cost-containment strategies that facilitate the individual’s return to an active,
productive lifestyle.

Medicaid: Grants to states for Medicaid assistance programs as set forth in Title XIX of the Social Security Act, amended from time to time.

Medical Criteria: Predetermined elements of health, the presence, absence and completeness of which indicate the quality of medical services.

Medical Necessity: (Medically Necessary or Medical Necessity): Services or supplies rendered by a provider that FPH determines are:

(a) appropriate for the symptoms and diagnosis or treatment of the member's condition, illness, disease or injury; and

(b) provided for the diagnosis, or the direct care and treatment of the member's condition, illness, disease or injury; and

(c) in accordance with the current standards of medical practice; and

(d) not primarily for the convenience of the member or the member's provider; and

(e) the most appropriate source or level of service that can safely be provided to the member. When applied to hospitalization, this further means that the member requires acute care as an Inpatient due to the nature of the services rendered or the member's condition, and the member cannot receive safe or adequate care as an outpatient.

Medical Record Reviews: Process performed by FPH to monitor the appropriateness of care, consistency of charting and completeness of records. The content of the member’s record is documentation of the quality of the care provided. Quality providers must consistently maintain both excellent medical care standards and follow up
with comprehensive documentation. Medical record reviews can be conducted in a hospital and/or ambulatory care system.

Medicare: A third-party reimbursement program administered by the Social Security Administration that underwrites the medical costs of qualified persons age 65 and over and some qualified persons under age 65. "Part A" covers hospital services and related care; "Part B" covers physician services and other health services, sometimes referred to as Title XVIII of the Social Security Act.

Member: Person who is properly enrolled with FPH and who otherwise is entitled to receive covered services under a Plan document. A member can be either the policy holder or a dependent.

Member Handbook: Written material provided to all members by First Priority Health, containing a summary of covered services, an explanation of how to access all benefits, Member Rights and Responsibilities and a copy of the group’s specific contract.

MH/CR: Mental Health/Chemical Recovery.

National Committee for Quality Assurance (NCQA): A private, not-for-profit organization dedicated to improving the quality of health care by assessing and reporting on the quality of the nation's managed care plans to provide information that enables purchasers and consumers of managed health care to distinguish among plans based on quality, thereby allowing them to make more informed health care purchasing decisions.

NaviNet^sm: A web-based system that is designed to simplify administrative processes.

Network: The group of providers who are contracted with First Priority Health.

Observation: A stay to determine or monitor a patient for possible admission.

Open Enrollment: The time frame during which individuals may elect to enroll in a health insurance plan or prepaid group practice.

Out-of-Area: Not in the approved Department of Health service area served by this Plan.

Outpatient: A member who receives services or supplies while not an inpatient.

Partial Hospitalization: The provision of medical, nursing, counseling or therapeutic services on a planned and regularly scheduled outpatient basis through a hospital or non-hospital facility licensed as a mental health or alcohol and/or drug abuse treatment program by the Pennsylvania Department of Health, designed for a patient or client who would benefit from more intensive services than are offered in outpatient treatment but who does not require inpatient care.

Point of Service (POS): A plan in which the member decides whether to consult a participating or a non-participating provider at the time medical care is needed. If the member consults a participating provider, health care delivery resembles that of a traditional HMO, with prepaid comprehensive coverage. If the member consults a non-participating provider, health care delivery resembles that of an indemnity insurance product, with less comprehensive coverage and deductibles and/or coinsurance.

Practitioner of the Healing Arts: Any person who engages in the diagnosis or treatment of disease or any ailment of the human body.

Pre-admission Testing: Routine tests and examinations performed in an outpatient facility or the outpatient department of a hospital prior to a scheduled admission.

Pre-admission certification (PAC or Precertification): The process whereby Participating Providers are required to obtain certification from First Priority Health for Covered Services prior to the date of service. Pre-certification is usually conducted via telephone or telefax and the process results in the issuance of a pre-certification number by First Priority Health, without which the claim will not be paid. It is the responsibility of a Participating Provider to obtain pre-certification, when required, in accordance with First Priority Health’s policies and procedures. First Priority Health, at its discretion, may add or delete services which require pre-certification, as it deems necessary.

Primary Care Physician: A physician who supervises, coordinates and provides initial care and medical services as a general or family care practitioner, an internist or a pediatrician, to members within the scope of practices approved by FPH; and maintains continuity of patient care.

Prior Authorization: The process whereby members are given approval to receive covered services from a provider other than their Primary Care Physician. Prior authorization is pre-certification from First Priority Health, in accordance with First Priority Health’s policies and procedures.

Prosthetic Devices: Items (such as artificial limbs) used as substitutes for body parts.

Provider: A hospital, physician, ancillary facility or professional, licensed where required, administering health care services within the scope of that license.

1. Participating Provider - a provider that has an agreement with, has met all credentialing criteria and has been accepted as such by First Priority Health pertaining to payment for covered services rendered to a member.
   
   
2. Non-participating Provider - a provider that does not meet the definition of a participating provider.

Quality Management: The process of objectively and systematically monitoring and evaluating the quality, timeliness, and appropriateness of care, and administrative functions and of pursuing opportunities to improve processes and resolve identified problems.

Regional Referral Center: First Priority Health’s dedicated unit that provides eligibility verification, triage, referral and utilization management for behavioral health care services, including referrals to psychiatrists.

Rider: An additional benefit to a subscriber/group contract.

Secondary Carrier: The contract which pays the balance (or up to contract limits) when a member has two contracts and primary benefits are provided by the other contract.

Self-Funded: A health care program in which employers assume the risk for medical costs, funding benefit plans from their own resources without purchasing insurance. Self-funded plans may be self-administered or the employer may contract with an outside administrator for an administrative service only.

Self-Insured: An individual or group of individuals, employer, or organization that assumes complete financial responsibility for medical expenses.

Short Procedure Unit (SPU): Surgical event which requires a stay of less than 24 hours.

Skilled Nursing Facility (SNF): An institution or a distinct part of an institution, that provides skilled nursing care and rehabilitation services to patients who do not require full hospital care.

Specialist Physician: A physician who provides medical care in any generally accepted medical specialty or subspecialty.

Subrogation: The act of attempting to recover money the Blue Cross Plan has paid for services for which a third party, who has caused injury to a subscriber, or the third party’s insurance carrier, is liable.

URAC (Utilization Review Accreditation Company or Corporation): A nationally recognized external review organization.

Utilization Management: A quality component of managed health care with the comprehensive purpose of monitoring effective, efficient and timely use of covered services. Some of the activities utilized are pre-admission certification, admission review and concurrent review.

Utilization: The extent of usage of Plan benefits by subscribers or members.

Utilization Review: Evaluation of the necessity, appropriateness and efficiency of admission, services ordered and provided, length of stay and discharge practices, both on a concurrent and retrospective basis.

Worker’s (or Workmen’s) Compensation: A state law that assigns liability to the employer for injury or illness resulting from on-the-job accidents or conditions. Neither Blue Cross nor Blue Shield benefits are provided for this care.