In an effort to improve insured/member(s) outcomes related to management of chronic illnesses and prenatal care, Blue Cross of Northeastern Pennsylvania continues its effort and emphasis on Health and Disease Management programming. Currently, Blue Cross offers six (6) health improvement programs to its insured/member(s). They include: Asthma, Coronary Artery Disease, Depression, Diabetes, Prenatal and Tobacco Cessation. Three (3) new programs were added in early 2007: Heart Failure, COPD and Weight Management.

Health and Disease Management is defined by Blue Cross as the integration of prevention, wellness and diseased-focused education and condition management processes designed to promote healthy lifestyles, encourage consideration of lifestyle changes and improve compliance with physician recommended treatment plans for insured/member(s) with specific medical conditions.

The goals of the Health Improvement/ Disease Management Programs are to:

Blue Cross of Northeastern Pennsylvania has developed a generic Disease Management model (see attached process flow) to provide the framework for implementation our programs. Components include:

  1. Insured/Member(s) Identification

This is accomplished through a retrospective analysis of medical and pharmacy claims; or a referral generated by the insured/member(s), physician, or Blue Cross Care Management/ Utilization management staff.

  1. Risk Stratification

Blue Cross applies a sophisticated predictive modeling strategy to stratify insured/member(s) into low, moderate or high risk categories which directs the intensity of outreach and program interventions.

  1. Enrollment

Insured/member(s) are enrolled in programs using both an Opt-Out and Opt-In methodology. Insured/member(s) identified for Asthma, CAD, COPD, Diabetes and Heart Failure are sent an enrollment packet and welcomed into the program. Insured/member(s) are considered enrolled unless they actively "opt-out." Insured/member(s) identified for the Depression, Prenatal, Tobacco Cessation and Weight Management programs are invited to join and must complete an enrollment form to "opt-in" to each specific program.

  1. Insured Interventions

Insuredmember(s) interventions are provided based on the risk status of the insured.

  1. Low risk insured/member(s) receive a program-specific educational booklet which provides a comprehensive overview of the condition, its pathophysiology and evidenced-based disease treatment options. In addition, insured/member(s) receive quarterly newsletters and other relevant educational materials based on individual need or request.
  2. Moderate risk insured/member(s) receive the same intervention as low risk insured/member(s) with the addition of at least two (2) outbound calls from program staff (RN's) to provide telephonic coaching and disease monitoring.
  3. The high risk insured/member(s) receives the full range of services consisting of all educational materials, at least (4) outbound calls from program staff in addition to intensified care management or home health services when appropriate.
  1. Practitioner Interventions
  1. Distribution of the appropriate clinical practice guidelines;
  2. Support and reinforcement of physician treatment plan;
  3. Ongoing communication relative to insured'smember(s)' health status;
  4. Insured/member(s) profiling;
  5. Enhancement of insured/member(s) physician communication;
  6. Minimal extrusion on physician's time; and
  7. Regular updates on high and moderate risk insured/member(s).
  1. Outcomes Measurement

Outcomes for each Disease Management Program are measured on an annual basis. They include:

    1. Analysis of Utilization/Resources
  1. Inpatient Admission
  2. ER Visits
  3. Office Encounters
  4. Pharmacy usage ( as appropriate)
  1. Quality of Life/Functional Status
  2. Clinical Outcomes
  3. Insured/member(s) and Provider Satisfaction
  1. Program Evaluation

On an annual basis, each Disease Management Program is formally evaluated to identify opportunities for improvement and program revision as necessary. Findings from this evaluation are presented to the appropriate Quality Committee for review, input and approval.



HIPAA and Medical Records

BCNEPA would like to clarify its policy regarding access to medical records within the realm of the Health Insurance Portability and Accountability Act (HIPAA). The HIPAA Privacy Rule, effective April 14, 2003, permits a health care covered entity, such as BCNEPA, to request health care information about its insured/member(s) for purposes of treatment, payment, and/or health plan operations without the insured/member's consent/authorization. This includes access to an insured/member's medical records when necessary and appropriate.

The HIPAA Privacy Rule allows a covered entity access to insured/member(s) records for purposes of treatment, payment, and /or health plan operations which includes, but is not limited to, the following:

Providers Who Use Outside Billing Agencies

If you use an outside company to perform insurance billing and follow-up, please be advised that in order to comply with the HIPAA Privacy Regulations, which took effect on April 14, 2003, FPLIC will not release any claim information to these companies unless written authorization is received from you to do so. FPLIC reserves the right to require specific information as verification of caller's authority to request Protected Health Information (PHI).

A "Notice of Provider's Agency Arrangement" form must be completed and returned to BCNEPA in order to release any information to these agents. Please complete all requested information and return to BCNEPA at the address below or fax to the Provider Relations Department at fax number 570-200-6880.

Please see Section J "Forms" for a copy of the "Notice of Provider's Agency Arrangement" form or it is available on the BCNEPA Provider Center.


Provider Relations Department
19 North Main Street
Wilkes-Barre, PA 18711

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


NaviNetSM is the web-based system that enables access to a wide variety of information via a HIPAA secure computer connection. Through secure access, providers can obtain and submit key information including, but not limited to:

There are various options to acquire FPLIC information:

BCNEPA Provider Center is a wealth of information for providers and is accessible via NaviNet. To gain access to the Provider Center using NaviNetSM, click on the BCNEPA Provider Center found on the left side of the Plan Central screen. From your internet browser screen, type in and click on the Provider tab. From either access method, you will be taken to the BCNEPA Provider Center Page, which contains various building icons. Hover the cursor over the building of interest and a drop down menu will appear. Left click on the item of interest. Information that is available from the Provider Center includes, but is not limited to; Provider Relations, Pharmacy Information, Quality Management Information, Provider Manuals, issues of Provider Bulletins and important forms.

BCNEPA Service Representatives are dedicated to address provider specific issues. Please refer to the Telephone Directory (Section B, page 1) for the appropriate BlueCare service representative phone number to verify insured/member(s) benefits, eligibility, claims status and enrollment information.

BCNEPA Provider Bulletin is a monthly publication from BCNEPA specifically for the provider network. It contains key information on policy, procedure and reimbursement updates and changes. It serves as an extension of your contract. One copy is mailed to each clinical site and key facility departments. Issues of the Bulletin are also available via the BCNEPA Provider Center.

Infofax is an option via the fax machine to receive information on the status of a claim, benefits and enrollment. Infofax requires that you enter patient information into the system via your touch-tone phone. Instead of the information being read back to you, the response will be faxed directly to you in minutes.

Infofax is available from 7:00 a.m. 9:00 p.m. Monday - Friday and 7:00 a.m. - 2:00 p.m. on Saturdays. A provider must be authorized prior to receiving patient information. To register to become an authorized user, please complete a "Fax Location Authorization" form and fax to our partner, Highmark Blue Shield at 1-800-985-6275. Once authorized, a confirmation along with a User Guide will be faxed to you.

Please note that BlueCare products are processed on Highmark systems, thus any information on BlueCare faxed via Infofax will originate from Highmark. Providers must utilize Highmark's internal system identifier when using Infofax. Please contact the Infofax Help Line with questions or concerns at 1-800-985-2032.

BCNEPA Provider Relations is always available to assist you with complex issues or concerns. Your respective consultant can be contacted via e-mail or phone, as listed on the BCNEPA Provider Center or in any issue of the Provider Bulletin. If you are not sure who your consultant is, please call the Provider Relations Department at 1-800-451-4447 or 570-200-4700 Monday Friday, 8:00 a.m. 5:00 p.m. for assistance.



BlueCare insured/member(s) are responsible for understanding their benefits and exclusions as stated in their contract.

Identification Cards All BlueCare insured/member(s) receive an identification card, which must be presented at the time of service. A separate card is issued for each family insured/member(s).


Identification cards will vary based on group benefit information


The purpose of the BlueCare Service Representatives is to communicate with and to educate insured/member(s), employer groups, and providers, whether by telephone, walk-ins, written or faxed correspondence.

If an insured/member(s) is questioning his/her eligibility, benefits, claims status or enrollment information, please refer him/her to the number on the back of his/her identification card or please see the Telephone Directory (Section B, page 1) for the appropriate BlueCare service representative phone number. The BlueCare service representative can also assist in filing complaints and appeals.

All inquiries to the BlueCare service representatives will be documented on-line to maintain consistency and meet reporting purposes. This measure will ensure that our providers and insured/member(s) receive quality service and timely responses. The BlueCare service representatives are specially trained to answer questions concerning all phases of BlueCare product operations and to provide assistance to providers and insured/member(s).

For a detailed description of benefits, insured/member(s) should consult their handbook or contact their employer.


To obtain information on the various Acts by year, please refer to



BCNEPA, on behalf of FPLIC, contracts directly with hospitals, rehabilitation centers, skilled nursing facilities and other health care providers to render and/or coordinate health care services to BlueCare insured/member(s). This system of health care delivery provides quality care that is consistent with current professional knowledge, improves health outcomes, and promotes a healthy lifestyle for BlueCare insured/member(s).

The purpose of the Quality Management Department within BCNEPA is to evaluate the quality of services provided to BlueCare insured/member(s) by FPLIC facilities.

Another objective is to facilitate Continuous Quality Improvement (CQI) processes within the department and among other Blue Cross departments. In operationalizing CQI concepts, the Quality Management Department is challenged to:


Diagnosis Related Group

The DRG Review Unit performs on-site retrospective review to determine if the admission was medically necessary and appropriate. It also verifies that the diagnostic and procedural information that led to the DRG assignment is accurate and substantiated by documentation in the medical record.

Clinical Code Editor

The DRG Review Unit utilizes a computer software program to evaluate the clinical accuracy and completeness of the hospital claim. The program uses a set of comprehensive edits to evaluate a patient's principal diagnosis, secondary diagnosis, surgical procedure, age, sex and discharge status to determine whether these elements are clinically consistent.

DRG Review Process

A focused DRG validation review is performed on a retrospective basis at the facility site to verify the following:

  1. Medical necessity and appropriateness of the service/admission
    1. "Medical necessity" is defined as services or supplies rendered by a facility that BCNEPA determines are:
  1. Validity and accuracy of diagnosis, procedure and DRG codes
  1. Validity of attested conditions and procedures
  1. Accuracy of other pertinent data

DRG Validation (Post Payment Review)

A post-payment audit sampling will be conducted by the staff nurses of the Retrospective Review Department based on focused sample selection of claims. The purpose of the audit is:

DRG/Per Case Payment Validation Procedure

The DRG/per case payment validation procedure consists of four (4) parts:

  1. Sample selection focuses on error-prone areas as determined by previous audit studies and an analysis of utilization trends. Sample selection is under constant review with appropriate revisions on a continuing basis.
  2. Hospitals are notified at least eighteen (18) days before the audit dates and are supplied with an advance listing of the medical records to be reviewed. Hospitals are expected to retrieve all records requested and to provide suitable private accommodations for the review.

    Should a hospital fail to locate medical records on the advance listing, a second request will be made at a subsequent date. Failure to provide requested records after the second request will result in adjustment of payment for the services in question. This adjustment is final and not subject to reconsideration at a later date.

  3. Case Review is performed on-site at the hospital using the source medical record and, when necessary, in the Plan using copies of pertinent aspects of the provider medical record.
  4. If the BlueCare pre-admission certification is not supported by documentation within the medical record, and it has been determined that the inpatient admission was not medically appropriate, the admission will be reviewed and payment may be adjusted.

    All admissions, when the patient remains after the day outlier threshold is attained, will be reviewed by Retrospective Review Department to determine the appropriateness of the length of stay (applicable to DRG validation only). If the length of stay is considered to be medically inappropriate, no additional payments will be made.

    Readmissions within thirty (30) days of a preceding discharge will be reviewed to determine the medical appropriateness of the initial discharge. If the initial discharge is determined to be inappropriate, payment will be adjusted.

  5. Validation Report to the hospital is a direct result of the case review analysis and is a compilation of proposed changes to information originally submitted by the hospital. The findings are forwarded to the hospital and a written response is required within forty-five (45) days.

  6. Finalization begins when the hospital responds, in writing, to the Retrospective Review Department indicating either agreement or disagreement with the audit findings. When the hospital appeals a validation review report, additional documentation from the medical record, or from other sources, must be forwarded to the Plan to unequivocally support the appeal. These cases are reviewed by the DRG review nurses who consult with the medical director and respond to the hospital in a final report. This report can indicate agreement based upon additional supporting documentation or continued disagreement with the hospital and the reasons for disagreement.

If no response is received from the hospital or if additional supporting documentation is lacking or insufficient, claims will be adjusted. There will be no appeal to these cases and the decision will be final.


The Utilization Review Unit reviews pre-authorization requests and performs retrospective review of BlueCare claims to determine medical necessity, appropriateness of charges and contractual eligibilities. In addition, the Utilization Review Unit performs hospital bill audits on select claims and as requested by internal departments. All determinations are completed within timeframes, compliant with state and federal mandates.

In order to determine whether services are medically necessary, excluded under the member's agreement, or pre-existing, it is often necessary for the Utilization Review Unit to request medical records.

This is accomplished by written request to the provider. A prompt response will ensure timely adjudication of all claims. Complete professional confidentiality is always maintained, in accordance with the Health Insurance Portability and Accountability Act (HIPAA) regulations.



Blue Cross of Northeastern Pennsylvania (BCNEPA)/First Priority Health (FPH)/First Priority Life Insurance Company (FPLIC) will not honor any provider (professional/organizational) adjustment requests nor will initiate adjustments if the date of the requested adjustment is:

  1. Greater than four years from claim receive date, or
  2. Ninety days from the last processed date, provided, however, that no less than four years has elapsed from the original claim receive date.
  3. Processing associated with Coordination of Benefits (COB), subrogation, fraud investigations are exempt from this policy.

Effective July 1, 2004, BCNEPA implemented the claim adjustment policy for all product lines. This process will be applicable to provider initiated and BCNEPA/FPH/FPLIC initiated adjustments.


Satellite clinics are determined to be extensions of hospital outpatient departments by an on-site review process. BlueCare, through the Blue Cross network, provides for outpatient hospital benefits in its insured/member(s) agreements when: medically necessary, regularly billed for by a hospital, and provided in the outpatient department of a hospital.

However, the fact that an entity or arrangement is established as a satellite of a hospital does not automatically mean that it must also be considered an outpatient department of the hospital for reimbursement purposes. Such an entity or arrangement may entail either hospital staffed diagnostic clinics or purchase/lease arrangements of private physician practices for which the hospital is seeking reimbursement of services.

Please refer to your FPLIC agreement for specific reimbursement details.


First Priority Life Insurance Company (FPLIC) strives to build a supportive relationship with our providers. Issues are addressed in a professional manner and as timely as possible. Unfortunately, terminations may take place, whether voluntary or involuntary.

  1. Voluntary - In accordance with the executed agreements, terminations require a ninety (90) day written notice of reason for the termination. The termination will be effective 90 days from the date of receipt of the written notice. This time frame is important for FPLIC to address many issues, including membership notification. Please mail the termination letter certified return receipt to:

Provider Relations Department
Blue Cross of NEPA
19 North Main Street
Wilkes-Barre, PA 18711-0302

  1. Involuntary FPLIC may initiate termination, pursuant to the termination section of the provider agreement for circumstances, including, but, not limited to:
  1. Provider no longer satisfies the FPLIC participation criteria for continuing participation;
  2. Loss of state licensure;
  3. Providing inadequate or poor quality care or is found to be harming insured/member(s);
  4. Provider is sanctioned by federal and/or state agencies;
  5. Loss of malpractice insurance coverage;
  6. Failure to comply with the recredentialing process.

The effective date of the involuntary termination is to be determined by FPLIC in accordance with contractual provisions and policies and procedures.


Blue Cross of Northeastern Pennsylvania, Highmark Blue Shield, First Priority Health, and First Priority Life Insurance Company would like to remind the provider networks that services performed by a provider with the same legal residence as an insured/member(s) OR who is an immediate relative of an insured/member(s) are not reimbursable. These services are excluded from coverage.

"Immediate Relative" is defined as follows:

In this situation, denial of claims may occur. Should you have any questions regarding this information, contact your Provider Relations Consultant.